perfusion and vital signs

Question 1

vitals signs

Answer 1

indicators of health status- effectiveness of circulatory, respiratory, neural and endocrine systems

Question 2

name vital signs

Answer 2

temp, pulse, respiration, bp, oxygen saturation, (pain)

Question 3

temp can be affected by

Answer 3

age, exercise, hormone level, circadian rythm, environment, temp alterations

Question 4

radial pulse measurement includes

Answer 4

rate, rhythm, and quality; 30 sec if reg, 1 min if irregular

Question 5

apical pulse

Answer 5

rate and rhythm, always 1 min

Question 6

respiration affected by

Answer 6

exercise, smoking, pain, anxiety, meds, body position, neurological injury, hemoglobin fn

Question 7

bp affected by

Answer 7

age, stress, ethnicity, gender, daily variations, meds, activity, weight, smoking

Question 8

hypertension - physiological changes

Answer 8

thickening of walls, less elastic; family hx, risk factors

Question 9

hypotension -physiology and effects

Answer 9

dilation of arteries, loss of blood volume, dec blood flow to organs; systolic < 90mm Hg

Question 10

normal temp range

Answer 10

36-38 C (96.8-100.4 F)

Question 11

average oral / tympanic temp for adult

Answer 11

37 C (98.6F)

Question 12

average rectal temp

Answer 12

37.5 C (99.5F)

Question 13

average axillary temp

Answer 13

36.5 C (97.7F)

Question 14

average pulse - adult

Answer 14

60-100 beats/ min

Question 15

average respirations adult

Answer 15

12-20 breaths/ min

Question 16

average pulse pressure adult

Answer 16

30-50 mm Hg

Question 17

pulse pressure

Answer 17

difference between systolic and diastolic pressure, normally 30-40 mm Hg

Question 18

newborn body temp

Answer 18

35.5-37.5 C (95.9-99.5F)

Question 19

progesterone levels effect on temp

Answer 19

decreased levels during menstrual fluctuations cause baseline temp to decrease few tenths of a degree

Question 20

when body temps is too low, the hypothalamus initiates

Answer 20

vasoconstriction - blood flow to the skin is decreased to preserve heat

Question 21

physical and emotional stress - effect on body temp

Answer 21

increased - via hormonal and neural stimulation

Question 22

fever is usually not harmful if stays below

Answer 22

39 C (102.2F)

Question 23

fever

Answer 23

alteration in the hypothalamic set point

Question 24

pyrogens

Answer 24

bacteria and viruses that elevated body temp; act as antigens stimulating an immune response

Question 25

patterns of fever

Answer 25

sustained, intermittent, remittent, relapsing

Question 26

sustained fever

Answer 26

continued temp above 38C (100.4F), little fluctuation

Question 27

intermittent fever

Answer 27

fever spikes interspersed with normal temp (temp normal at least once in 24 hr)

Question 28

remittent fever

Answer 28

fever spikes and falls without return to normal temp

Question 29

relapsing fever

Answer 29

periods of febrile and afebrile episodes; febrile and normothermia episodes often longer than 24 hr

Question 30

hypothermia classification

Answer 30

mild, moderate, severe

Question 31

mild hypothermia

Answer 31

34-36 C(93.2-96.8)

Question 32

moderate hypothermia

Answer 32

30-34 C (86- 93.2F)

Question 33

severe hypothermia

Answer 33

>30 C (86F)

Question 34

body metabolism increases during fever by

Answer 34

10% for every degree C

Question 35

hyperthermia

Answer 35

body temp exceeds set point; inability of the body to promote heat loss or inhibit heat production

Question 36

malignant hyperthermia

Answer 36

due to certain anesthetic drugs; hereditary condition of uncontrolled heat production

Question 37

heat stroke

Answer 37

body temp of 40C or more (104F); heat depresses hypothalamic function; high mortality

Question 38

symptoms of heat stroke

Answer 38

delirium, thirst, muscle cramps, nausea, visual disturbance, incontinence, inc HR, low BP

Question 39

MOST important sign of heat stroke

Answer 39

hot, dry skin- no sweat due to electrolyte loss and hypothalamic malfunction

Question 40

progression of heat stroke

Answer 40

unconscious, fixed nonreactive pupils; permanent neurological damage

Question 41

heat exhaustion

Answer 41

diaphoresis results in electrolyte and water loss

Question 42

hypothermia

Answer 42

heat loss due to prolonged exposure to cold overwhelms ability to produce heat; can be intentionally induced during surgical procedures

Question 43

accidental hypothermia

Answer 43

develops gradually, can go unnoticed for hours; when temp drops below 35C / 95F uncontrollable shivers, memory loss, depression, poor judgment

Question 44

if body temp falls below 34.4 C (94F)

Answer 44

HR, resp, and BP fall; cyanotic skin, dysrhythmias, loss of consciousness, unresponsive to pain

Question 45

severe hypothermia symptoms

Answer 45

similar to death - lack of response to stimuli, extremely slow resp and pulse

Question 46

frostbite

Answer 46

ice crystals form inside the cell; permanent circulatory and tissue damage; area becomes white, waxy and firm to touch; sensation loss

Question 47

areas susceptible to frostbite

Answer 47

earlobes, tips of nose, fingers ad toes

Question 48

frostbite tx

Answer 48

gradual warming, analgesia, protect tissues

Question 49

compare oral, rectal and axillary temp

Answer 49

rectal usually .5C (.9F) higher than oral, axillary .5C lower than oral

Question 50

convert C to F

Answer 50

``` F = 9/5C +32 C= (F-32) x 5/9 ```

Question 51

advantage of oral temp

Answer 51

easily accessible,comfortable, shows rapid change in core temp; provides accurate surface temp reading; reliable for intubated patients

Question 52

oral temp limitations

Answer 52

delay if patients smoked, ate cold/ hot, or receiving oxygen by mask / cannula; not for patients with oral surgery, hx of epilepsy, shaking chills; risk of fluid exosure

Question 53

don't use oral temp with

Answer 53

infants, small children, confused, unconscious or uncooperative

Question 54

tympanic temp benefits

Answer 54

if patient has tachypnea - does not disturb breathing; provides accurate core temp - close to hypothalamus; sensitive to core temp changes; rapid measurement (2-5s), unaffected by oral intake, smoking

Question 55

tympanic temp used with newborns why?

Answer 55

reduce infant handling and heat loss

Question 56

tympanic temp disadvantages

Answer 56

more variability than other core temp devices, requires removing hearing aid; disposable cover available in only 1 size; otis media and cerumen distorts reading; not accurate for core temp changes before / after exercise; affected by fans, incubators; incorrect handling of device = errors

Question 57

rectal temp benefit

Answer 57

more reliable if can't get oral temp

Question 58

rectal temp disadvantages

Answer 58

lags behind during rapid core temp changes; requires lubrication, not usually for newborns

Question 59

axillary temp often used for

Answer 59

newborns and unconscious patients

Question 60

axillary temp limitations

Answer 60

underestimates core temp; time consuming, needs continuous positioning by nurse; requires exposure to thorax - heat loss (esp newborns); affected by environment including time to place thermometer

Question 61

axillary temp not recommended for fever detection in

Answer 61

infants and young children

Question 62

skin temp benefit

Answer 62

noninvasive, safe, continuous reading; used in neonates

Question 63

skin temp limitations

Answer 63

lags behind during core temp changes - esp hyperthermia; sweat affects adherence, affected by environmental temp; can have allergy

Question 64

temporal artery benefit

Answer 64

rapid, used in premature infants, newborns, children; reflects rapid change in core temp change; sensor cover not required

Question 65

temporal temp affected by

Answer 65

sweat, moisture, hair on forehead