NOTES_1 Ch 30: Vital Signs - Temperature and Heart Flashcards
What is the acceptable temperature range for adults?
96.8-100.4
What is the acceptable respiration range for adults?
12-20 breaths/min
What is the acceptable pulse rate range for adults?
60-100 bp/min
What an acceptable blood pressure for adults?
<120/<80
Average oral/tympanic temp in adults is…
98.6
Average rectal temp in adults is…
99.5
Average axillary temp in adults is…
97.7
What are the four main vital signs?
- Temperature
- Pulse
- Blood Pressure
- Respiratory Rate / Oxygen Saturation
What is the occasional fifth vital sign?
Pain
How do we take a temperature?
With a thermometer
How do we take a pulse?
Palpate and count for 60 seconds
How do we take a respiration rate?
Count the number of breaths for 1 minute
With what do we take a blood pressure reading?
Sphygmomonometer
Temperature control is regulated by…
the hypothalamus
The anterior hypothalamus controls heat _____.
loss
The posterior hypothalamus controls heat _____.
production
Radiation is the transfer of…
heat from one surface to another
Convention is the transfer of heat by…
air.
A fan blowing on a surface promotes…
heat loss.
Conduction is the transfer of heat from…
one molecule to another of lower temperature
Dispursion of heat through air current is known as…
convection.
The continuous evaporation of moisture from the respiratory tract, oral mucosa and skin is known as…
insensible heat/water loss
What is Pyrexia?
A fever
Acetametaphin is a(n)…
antipyretic
An antipyretic works against…
fever
Name 5 methods of assessing temperature and the cautions of each.
- Orally; wait 20-30 mins after eating/drinking
- Temporal; Forehead, not reliable due to variables
- Tympanic Membrane; Watch for cerumen, eardrum and redness (indicating possible infection)
- Axillary; Surface reading, caution of seat, add 1 degree to reading
- Rectal; Contraindictions (should be used with those who have diarareah, rectal surgery, etc. Could effect cranial nerve 10
A.B.C. is an acronym for
Airway
Breathing
Circulation
A pt presenting a temp of 104°F with no diaphorisis may be symptomatic of
heatstroke
A pt presenting with high temp and profuse diaphoresis may be symptomatic of
heat exhaustion
Name ten heatstroke symptoms:
- giddiness
- confusion
- delerium
- excessive thirst
- nausea
- muscle cramps
- visual disturbances
- elevated temperature
- elevated heart rate
- low blood pressure
Someone with low blood volume is…
hypovolemic
Someone who is hypovolemic needs…
water & electrolytes
(Sugar/salt water)
What is cardiac output and how is it calculated?
- Total amount of blood pumped in 1 minute
- HR x SV (Heart Rate x Stroke Volume)
If someone is Tachycardic, that means
they have a HR of 120 or more
What is arythmia?
This is when the heart beats too quickly, too slowly, or with an irregular pattern
What is dysrhythmia?
An abnormal heartbeat
Where are all the places you can take a pulse?
- Temporal (temples of head)
- Carotid (at neck)
- Apical (on chest surface)
- Brachial (at bend of elbow)
- Radial (wrist at thumb)
- Femoral (where leg meets torso, toward groin)
- Popliteal (behind knee)
- Posterior tibial (inside of ankle bone)
- Dorsalis pedis (top of foot)
When listening to the “lub, dub” of the heartbeat, the “lub” is known as __ and represents the closure of the ___ valves known as the _____ and the _____.
S1, AV, Tricuspid, Mitral/bicuspid
When listening to the “lub, dub” of the heartbeat, the “dub” is known as __ and represents the closure of the ___ valves known as the _____ and the _____.
S2, Semilunar valves, pulmonic, aortic
The five points at which to listen to the heart are represented by what acronym?
Describe each point
All Patients Take Medicine
- A= Aortic; Right sternal border at 2nd intercostal space
- P= Pulmonic; Left sternal border at 2nd interncostal space
- T= Tricuspid; Left sternal border at 4th intercostal space
- M= Mitral; Left sternal border at 5th intercostal space at midclavicular line
PMI stands for…
Point of Maximal Impulse
Where do we take the apical pulse?
Left midclavicular line at the fifth intercostal space.
Orthostatic hypotension is defined as a decrease in systolic blood pressure of __ mm Hg or a decrease in diastolic blood pressure of __ mm Hg within __ minutes of standing when compared with blood pressure from the sitting or supine position
20, 10, 3
If a patient presents with orthostatic hypotension, the priorty is ____ and what should you do with the pt?
safety, lay them back down
What are the four characteristics of the pulse?
- Rate
- Rhythm
- Strengh
- Equality
How do we determine heart rhythm?
With an EKG
What is meant by pulse equality?
Is it the same on both sides of the body
How is a pulse documented?
- Bounding = 4+
- Strong = 3+
- Normal and expected = 2+
- Diminished or barely palpable = 1+
- Abscent = 0
When does exercise increase pulse rate?
during short-term exercise
When does exercise result in a decreased pulse rate?
When the heart is conditioned to long-term exercise and results in a lower resting pulse rate and quicker return post exercise.
How does internal temperature effect pulse rates?
fever and heat = increase
hypothermia = decrease
What effect do emotions have that increase pulse rate?
Acute pain or anxiety can stimulate the sympathetic nervous system resulting in increased pulse rate.
When would emotions decrease pulse rate?
Unrelieved severe pain can cause a parasympathetic reaction slowing heart rate
Do positive chronotropic drugs increase or decrease pulse rate?
increase
Do negative chronotropic drugs increase or decrease pulse rate?
Decrease
A pulse deficit is when…
Apical pulse is greater than radial pulse
A pusle deficit can indicate…
- The thrust of blood from heart is too feeble for wave to be felt at peripheral site
- May indicate vascular disease is preventing impulses from being transmitted
- Can also result from disrythmia
What does A/O stand for?
Alert and Oriented
How is A/O assessed?
If the patient can name
- person (who they are)
- place (where they are)
- time (date)
You can also add
- Current event
What is meant by A/Ox3
Patient is fully alert and oriented
Answered:
Person, Place, Time
What is meant by A/Ox2
They got two of the A/O assessment questions correct
What are the two tupes of body temperature?
Core: deep tissue (constant)
Surface: varies pending blood flow to skin and heat lost to environment
A pulse rate > than 100 bpm is known as…
tachycardia
A pulse rate < than 60 bpm is known as…
Bradycardia
How do the following effect pulse rate?
- Sort-term Exercise
- Long-term Exercise
- Fever and Heat
- Hypothermia
- Sort-term Exercise = increases hr
- Long-term Exercise = Decreases hr
- Fever and Heat = Increase hr
- Hypothermia = Decreases hr
How do the following effect pulse rate?
- Hemorrhage
- Standing or sitting
- Lying down
- Acute pain and anxiety
- Diseases causing poor oxygenation such as asthma, COPD
- Hemorrhage = Increase
- Standing or sitting = Increase
- Lying down = Decrease
- Acute pain and anxiety = Increase
- Diseases causing poor oxygenation such as asthma, COPD = Increase
What is orthoscopic hyotension?
Sudden low blood pressure caused by elevation changes in Standing, sitting, or lying down
Orthostatic hypotension signs and symptoms include:
- Feeling lightheaded or dizzy after standing up
- Blurry vision
- Weakness
- Fainting (syncope)
- Confusion
- Nausea
A discrepancy between AP and Radial pulse is indicitive of…
a pulse deficit
What causes a pulse deficit?
The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral site.
Pulse deficit is indicative of
vascular disease that is preventing impulses from being transmitted
Pulse deficits can be associated with
abnormal rhythms
Describe how an Apical-Radial Pulse is performed
- 2 nurses
- Start and stop is called by radial nurse
- Counted for 60 seconds
- Document each pulse
True or False
Radial pulse can never be greater than apical pulse
True
An irregular pulse or heart rate should be doublechecked at what pulse site?
Apical
or
PMI (Point of Maximal Impulse)
If an auto BP is abnormal, you should…
double check it manually
