QUIZ 1 QTR 2 Flashcards by chloe ortega

________ are a person’s temperature, pulse, respiration, and blood pressure, abbreviated as T, P, R, and BP

Vital signs

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____ is often called the fifth vital sign

Pain

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______, the noninvasive measurement of arterial oxyhemoglobin saturation of arterial blood, is also often included with the measurement of vital signs

Pulse oximetry

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the result of the amount of heat produced and the amount of heat lost by the body

Body temperature

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Purposes
To obtain baseline information

Body temperature

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Purposes
To assess the progression of an illness

Body temperature

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Purposes
To monitor a response to therapy

Body temperature

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5 ways of assessing body temp

Oral temperature
Ear temperature
Rectal temperature
Axillary temperature
Temporal artery temperature

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TYPE OF BODY TEMPERATURE

Sites: rectum, tympanic membrane, oral cavity

Core temperature

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TYPE OF BODY TEMPERATURE

Sites: skin and axillae (skin or outside)

Surface temperature

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controls heat loss; nerve sensors send out signals that initiate sweating peripheral vasodilation and inhibition of heat production.

Anterior hypothalamus

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the number of calories you burn as your body performs basic (basal) life-sustaining function Sometimes, when you are cold, it’s because you are kulang sa calorie intake

Basal metabolic rate

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controls heat production; nerve sensors send out signals that initiate shivering vasoconstriction and release of epinephrine.

Posterior hypothalamus

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_______, one of the presenting symptoms is hotness or warm feeling. This is because too much thyroxine is produced.

Hyperthyroidism

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(4) FACTORS THAT PROMOTE HEAT LOSS

Conduction
Radiation
Convection
Vaporization (evaporation)

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changes throughout the day

Because of the mechanisms that take place in your body, your signs aren’t the same the whole day.

Diurnal variations

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DISADVANTAGE

Contraindicated in children below 3 y/o
Seizure-prone client
Confused, irrational, and unconscious clients
Clients who experience nausea and vomiting
Contraindicated after oral and nasal surgery

ORAL ROUTE

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ADVANTAGE

Most accessible and convenient

Reflects rapid change in core temperature

ORAL ROUTE

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ADVANTAGE

Safest and non-invasive; accessible

Can be used for newborns and uncooperative clients

AXILLARY ROUTE

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DISADVANTAGE
Thermometer must remain in place for long periods; approx. 8 minutes (not that long lagi)

Not as accurate as rectal route

AXILLARY ROUTE

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ADVANTAGE

Easily accessible
Reflects results within seconds
Unaltered by eating, smoking, drinking, and oxygen administration
Can be used for infants, unconscious, and dyspneic clients

TYMPANIC ROUTE

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DISADVANTAGE

Equipment is expensive
Can be uncomfortable
Contraindicated for clients with ear infections and those who underwent ear surgery
Earwax may result to inaccurately low result

TYMPANIC ROUTE

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ADVANTAGE

Same with tympanic
Easily accessible
Reflects results within seconds
Unaltered by eating, smoking, drinking, and oxygen administration
Can be used for infants, unconscious, and dyspneic clients

TEMPORAL ROUTE

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DISADVANTAGE

Head covering, hair or temporal area against a high pillow or mattress can cause inaccurately high results

Influenced by perspiration

TEMPORAL ROUTE

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Hypothermia - Body temperature _____

< 36°C

Severe hypothermia - body temperature _____

< 28°C

Hyperthermia - Body temperature ____

> 40.5°C

Heat stroke - Caused by exercise in hot weather

Heat stroke

- caused by excessive envionmental heat and dehydration

Heat exhaustion

Clinical indicators: Weakness, muscle aches, headache, syncope, N/V pallor, dizziness, diaphoresis

Heat exhaustion

Clinical indicators: Flushed, hot and dry skin, throbbing headache; rapid, strong pulse WOF: impaired judgment, delirium, unconsciousness and seizure

Heat stroke

Fever (pyrexia, febrile) - temperature ____°C (orally) or ____°C (rectally).

37.8 (orally) 38.3 (rectally)

Hyperpyrexia - temperature of __°C or more.

Clinical indicators: Agitation Confusion Stupor and may progress to coma

Hyperpyrexia

Wave of blood created by contraction of the left ventricles of the heart Regulated by autonomic nervous system

PULSE

- amount of blood that enters the aorta with each ventricular contraction.

Stroke volume

- amount of blood pumped by the heart in one full minute.

Cardiac output

DISADVANTAGE Inconvenient and difficult to clients who are unable to turn to sides Presence of stool may interfere with thermometer placement May cause ulcerations and rectal perforations in children and infants contraindicated to client with diarrhea, after recall and prostatic surgery or injury, recent myocardial infarction and post head injury. May embarrass the client; requires privacy Contraindicated for newborns, client with hemorrhoids, or a fragile rectal mucosa and those who underwent colon and rectal surgery, clients with heart conditions

RECTAL ROUTE

- discrepancy between the two pulse rates

Pulse deficit

ADVANTAGE Most accurate and reliable measurement of temperature

RECTAL ROUTE

Act of not breathing Movement of gases into and out of the lungs, promoting an exchange of gases between the atmosphere and the capillary beds in the alveoli

RESPIRATION

Involves inhalation and exhalation

RESPIRATION

External intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles

COSTAL BREATHING

The contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen

DIAPHRAGMATIC BREATHING

Exercise (increases metabolism) Stress (readies the body for “fight or flight”) Increased environmental temperature Lowered oxygen concentration at increased altitudes

INCREASES RESPIRATORY RATE

Decreased environmental temperature Certain medications (e.g., narcotics) Increased intracranial pressure

DECREASES RESPIRATORY RATE

Eupnea - _____

normal

Bradypnea - ____

slow

Tachypnea - _____

fast

______ - absence of breathing

Apnea

______ - labored respiration normally occurring during exercise

Hyperpnea

______ - difficulty in breathing

Dyspnea

Pressure exerted by blood against the walls of the arteries

BLOOD PRESSURE

Indirect measurement of the flow of blood against arterial walls during cardiac contraction and cardiac relaxation

BLOOD PRESSURE

Numerous factors influence blood pressure, including physiological factors such as cardiac output, and blood volume, and personal factors like age, lifestyle, etc.

BLOOD PRESSURE

_____ pressure - ventricular contraction

Systolic

______ pressure - ventricular relaxation

Diastolic

When the pumping action of the heart is weak, less blood is pumped into the arteries (lower cardiac output), and the blood pressure decreases When the heart’s pumping action is strong and the volume of blood pumped into the circulation increases (higher cardiac output), the blood pressure increases.

PUMPING ACTION OF THE HEART

_______ - the difference between systolic and diastolic pressure

Pulse pressure

The volume of the blood that is pumped from the heart in 1 minute (about 5.6L) The cardiac output increases as a result of an increase in heart rate, heart contractility, and circulating blood volume. Therefore, when the heart contractility or the circulating blood volume increases, we expect an increase in the cardiac output.

CARDIAC OUTPUT

true or false The cardiac output is indirectly proportional to the heart rate, heart contractility, and circulating blood volume.

false The cardiac output is directly proportional to the heart rate, heart contractility, and circulating blood volume.

The amount of blood within the intravascular compartment.

BLOOD VOLUME

Therefore the blood volume is _____ proportional to the circulating blood volume.

directly

Amount of friction between blood flow and vessel walls.

PERIPHERAL VASCULAR RESISTANCE

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - Older people have higher blood pressure due to decreased elasticity of blood vessels

Age

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - Physical activity increases the cardiac output and hence the blood pressure

Activity / Exercise

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - Stimulation of the sympathetic nervous system increases the blood pressure reading

Stress

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - African Americans over 35 years tend to have higher blood pressures than European Americans of the same age

Ethnicity / Race

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - pain, anxiety, and fear stimulate the sympathetic nervous system causing BP to rise. A full bladder can increase sympathetic stimulation, elevating BP.

Sympathetic stimulation

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - After puberty, females usually have lower blood pressure than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher blood pressure than before.

Sex

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - Many medications, including caffeine, may increase or decrease the blood pressure

Medications

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - Both childhood and adult obesity predisposed to hypertension

Weight / Obesity

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - a diet low in sodium and high in potassium can reduce BP. vegetarian diets and limited alcohol consumption (lower than two drinks per day for men and one per day for women) are associated with low BP.

Diet

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - results in vasoconstriction, a narrowing of blood vessels.

Smoking

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - Pressure is usually lowest early in the morning when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening.

Diurnal variations

TYPE OF PERSONAL DETERMINANTS OF BLOOD PRESSURE - - Any conditions affecting the cardiac output, blood volume, blood viscosity, and/or complaint of the arteries have a direct effect on the blood pressure.

Medical conditions

TRUE OR FALSE In assessing blood pressure, you can use lower arm, upper arm, thigh, leg

true

in taking BP, if the arm is positioned above heart level, the reading will be:

falsely low BP

in taking BP, if the arm is positioned below heart level, the reading will be:

falsely high BP

The _______ are generated when the blood pressure changes the flow of blood through the artery.

Korotkoff sounds

These sounds are heard through the stethoscope or a Doppler placed distal to the blood pressure.

Korotkoff sounds

Phase _: A sharp thump

Phase _: a crisp intense tapping

Phase _: a blowing or whooshing sound

Bladder cuff too narrow =

Erroneously high

Phase _: a softer blowing sound that fades

Phase _: Silence

Bladder cuff too wide =

Erroneously low

Arm unsupported=

Erroneously high

Insufficient rest before the assessment=

Erroneously high

Repeating assessment to quickly =

Erroneously high systolic or low diastolic readings

Cuff wrapped too loosely or unevenly =

Erroneously high

Defaulting cuff too quickly =

Erroneously low systolic or high diastolic readings

Deflating cuff too slowly =

Erroneously high diastolic reading

Failure to use the same arm consistently =

Inconsistent measurements

Arm above level of the heart =

Erroneously low

An arterial blood oxygen saturation level provides vital information about the person's cardiopulmonary status and is now considered as one of the vital signs

OXYGEN SATURATION

An unpleasant and highly personal experience that may be imperceptible to others while consuming all parts of the person’s life.

PAIN

Assessing immediately after a meal or while client smokes or has pain =

Erroneously high

Failure to identify auscultatory gap =

Erroneously low systolic pressure and erroneously low diastolic pressure

Oxygen entering the body binds with hemoglobin in the RBC and is transported via the circulation to your body cells.

OXYGEN SATURATION

A _____ is a noninvasive device that estimates a client’s arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client’s finger

pulse oximeter