NursingTest 4 Flashcards
What are the 6 vital signs that are taken to give some indication of a person’s state of health
temperature pulse respiration blood pressure pain level oxygen saturation
define metabolism
cellular chemical reactions in the body
what causes a fever and what are agents that cause fever
when metabolism increases, more heat is produced
pyrogens are agents that cause fever
what is acts as a thermostat and controls body temperature by a feedback mechanism
hypothalamus, located btw the cerebral hemispheres
when the body heat rises above normal, the hypothalamus sends out a signal through the nervous system that cause ___ ___ and ___
vasodilation
sweating
inhibition of heat production
heat loss occurs through what four ways
radiation
conduction
convection
evaporation
define pyrexia
fever
occurs when normal mechanisms of the body cannot keep up with the excessive heat production and body temperature rises
Temp rises above 100.2 or 37.9 C
define stroke volume
the volume of blood pushed into the aorta per heartbeat
define systolic pressure
the maximum pressure exerted o the artery during left ventricular contraction
define diastolic pressure
the lower pressure exerted on the artery when the heart is at rest btw contractions
What is the range of normal body temperature and what is the average temp of a young healthy adult
- 5-99.5 AND 36.4-37.5
98. 6 OR 37
what temperature usually indicates a fever
100.2 OR 37.9
during pregnancy, how different in the average temp and why
may stay at a high normal because of an increase in the patients metabolic rate
what are the stages of fever
onset=maybe be gradual/suddenly
febrile=body temp rises
defervescence=lowering of body temp
fevers are classified into what four categories
constant=continuously elevated
intermittent=temp alternates rising and falling
remittent=temp falls in morning, then rises later on in day
relapsing=temp falls to normal and then rises again in a repeated pattern
what are some common pulse points
radial temporal carotid femoral apical, over the apex popliteal pedal posterior tibial
the apical, rather than the radial pulse, is taken on children younger than ____
2 years
what are the average pulse rates for: normal pulse range some althletes adult male adult female child age 5 child age 1 newborn
normal pulse range=60-100 some althletes=45-60 adult male=72 adult female76-80 child age 5=95 child age 1=110 newborn=120-160
what are some factors that affect pulse rate
age body build and size blood pressure drugs emotions blood loss exercise increased body temp pain
while taking the pulse, what else should be noted
rate
rhythm
volume
What are the normal range of respirations for the age groups: elderly healthy adult adolescent child age 3 child age 1 newborn
elderly=16-20 healthy adult=12-20 adolescent=16-20 child age 3=20-30 child age 1=20-40 newborn=30-80
what are some symptoms of hypoxia that may be noted as a result of low oxygen supply in the blood
apprehension and restlessness
confusion, dizziness
change in the level of consciousness
cyanosis particularly around the mouth and in nail beds
define eupnea
normal, relaxed breathing pattern
effortless, evenly spaced, regular, automatic
define dyspnea
difficult and labored breathing
define tachypnea
increased or rapid breathing
define bradypnea
slow and shallow breathing
define hyperventilation
a pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled
causing blood level of carbon dioxide to fall
define kussmaul respirations
increased rate and depth with panting and long, grunting exhalation
seen in pt with diabetic acidosis and renal failure
define biot respirations
shallow for two or three breaths with a period of variable apnea (absence of breathing)
occur in pt with increased intracranial pressure
define Cheyne-Stokes respirations
- pattern of dyspnea followed by a short period of apnea
- respirations are faster and deeper, then slower and are followed by a period of no breathing
- pt who is critically ill, brain conditions, heart or kidney failure, drug overdose
define crackles
abnormal, nonmusical sound heard on auscultation
also called rales
define rhonchi
continuous dry, rattling sounds caused by partial obstruction
define stertor
snoring sound produced when pt is unable to cough up secretion from the trachea or bronchi
define stridor
crowing sound on inspiration caused by obstruction of the upper air passages as occurs in croup or laryngitis
define wheeze
whistling sound of air forced pas a partial obstruction
found in asthma or emphysema
what is pulse pressure
the difference between systolic and diastolic pressure
EX: 120/80=120-80=40
why should a pt not cross their legs when a blood pressure is being taken
it cause an elevation in systolic and diastolic pressure
prolonged hypertension can cause permament damage to the __, __, __, and __ of the eye.
brain
kidneys
heart
retina
what are some causes of shock
hemorrhage vomitting diarrhea burns myocardial infarction
what are some signs of shock
decrease in BP increase in HR cold and clammy skin dizziness blurred vision apprehension
pain assessment must include
location intensity character frequency duration
temperature measurement through ___ is the closest to core body temperature
tympanic
a CNA reporst to the nurse that the T of a pt who is 1st day postoperative is 100.2F. Which action should the nurse take?
tell CNA to take T again in 2 hours
T greater than 105.8 should be treated promptly to reduce the fever because of what?
potential damage to the cells of the CNS
a newly admitted pt has a respiratory rate of 16/minute. which action should the nurse take
note the rate on the chart, respiratory rate is normal
a pt who makes harsh high sounds on inspiration has what kind of respiratory condition
stridor
what are the physical examination techniques
inspection and observation palpate percussion auscultation olfaction
define lordosis
exaggerated lumbar curve
define kyphosis
increased curve in the thoracic area
define scoliosis
pronounced lateral curvature of the spine
when documenting pupils, what does PERRLA mean
pupils equal round reactive light accommodation
define nystagmus
jerky movements
in Glasgow coma scale, what is highest possible score, and what indicates a coma
15
7
when assessing a complaint of bloating and gas, you would assess for air within the intestines by ___
percussion
wet, crinkly sounds heard on auscultation of the lungs are referred to as _____ and indicate ___
crackles
moisture in the lungs
