QUIZ 1 QTR 2 Flashcards
________ are a person’s temperature, pulse, respiration, and blood pressure, abbreviated as T, P, R, and BP
Vital signs
____ is often called the fifth vital sign
Pain
______, the noninvasive measurement of arterial oxyhemoglobin saturation of arterial blood, is also often included with the measurement of vital signs
Pulse oximetry
- the result of the amount of heat produced and the amount of heat lost by the body
Body temperature
Purposes
To obtain baseline information
Body temperature
Purposes
To assess the progression of an illness
Body temperature
Purposes
To monitor a response to therapy
Body temperature
5 ways of assessing body temp
Oral temperature
Ear temperature
Rectal temperature
Axillary temperature
Temporal artery temperature
TYPE OF BODY TEMPERATURE
Sites: rectum, tympanic membrane, oral cavity
Core temperature
TYPE OF BODY TEMPERATURE
Sites: skin and axillae (skin or outside)
Surface temperature
- controls heat loss; nerve sensors send out signals that initiate sweating peripheral vasodilation and inhibition of heat production.
Anterior hypothalamus
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
- controls heat production; nerve sensors send out signals that initiate shivering vasoconstriction and release of epinephrine.
Posterior hypothalamus
_______, one of the presenting symptoms is hotness or warm feeling. This is because too much thyroxine is produced.
Hyperthyroidism
(4) FACTORS THAT PROMOTE HEAT LOSS
Conduction
Radiation
Convection
Vaporization (evaporation)
- 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
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
ADVANTAGE
Most accessible and convenient
Reflects rapid change in core temperature
ORAL ROUTE
ADVANTAGE
Safest and non-invasive; accessible
Can be used for newborns and uncooperative clients
AXILLARY ROUTE
DISADVANTAGE
Thermometer must remain in place for long periods; approx. 8 minutes (not that long lagi)
Not as accurate as rectal route
AXILLARY ROUTE
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
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
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
DISADVANTAGE
Head covering, hair or temporal area against a high pillow or mattress can cause inaccurately high results
Influenced by perspiration
TEMPORAL ROUTE
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.
41
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
1
Phase _: a crisp intense tapping
3
Phase _: a blowing or whooshing sound
2
Bladder cuff too narrow =
Erroneously high
Phase _: a softer blowing sound that fades
4
Phase _: Silence
5
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
