Quiz 2 ; Ch. 24 Flashcards
How often are vital signs checked for higher risk patients?
4 hours min.
What are vital signs?
Vital signs are a persons temp, pulse, respiration, and BP
Pain is often included as the fifth vital sign
What’s the definition of body temp?
Body temperature is the difference between the amount of heat produced by the body and the amount of heat lost to the environment measured in degrees.
Core body temp is usually between 97.0-99.5
Core temperatures are measured by nurses at tympanic or rectal site but they may also be measured in the esophagus, pulmonary artery, or bladder.
What is the primary source of heat in the body?
Metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions.
When additional heat is required to maintain balance, epinephrine and norepinephrine are released to rapidly alter metabolism so that energy production decreases and heat production increases.
What is the primary site of heat loss?
The skin
What is convection?
The dissemination of heat by motion between areas of unequal density
Ex: an oscillating Fan blows currents of cool air across the surface of a warm body
What is conduction?
The transfer of heat to another object during direct contact
Ex: The body transfers heat to an ice pack, causing the ice to melt
Febrile vs. Afebrile
The person with the normal body temperature is referred to as Afebrile
A person with a fever is said to be febrile
What is Hyperpyrexia?
A very high fever, usually above 105.8 F
What are some physical effects of having a fever?
Patients may experience loss of appetite, headache, hot, dry skin, flush face, thirst, muscle aches, and fatigue. Respirations and pulse rate increase
What does antipyretic mean?
Antipyretics are fever reducing drugs, such as aspirin or acetaminophen. These drugs reset the elevated setpoint regulated by the hypothalamus.
What happens if your temp falls below 93.2?
Your severely hypothermic and will most likely die
How do you convert Celsius to Fahrenheit and vice versa
Celsius to Fahrenheit = multiply by 9/5 and add 32
Fahrenheit to Celsius = subtract 32 and multiple by 5/9
What are the sites most commonly used to assess body temperature?
Oral, anal, axillary, tympanic (ear)
How to take someone’s pulse
The peripheral pulses a throbbing sensation that can be palpated over a peripheral artery,such as the radial artery or the carotid artery.
The normal pulse rate for adolescents and adults ranges from 60-100 beats a minute
What is stroke volume?
The quantity of blood forced out of the left ventricle with each contraction
What is cardiac output?
The cardiac output is amount of blood pumped per minute, and averages from 3.5 L to 8.0 L in a healthy adult. This volume is determined by using the following formula, cardiac output = stroke volume x heart rate.
Ex: The cardiac output of an adult with a stroke volume of 70 mL and a heart rate of 70 bpm is 4.9 L/min
What is the pulse regulated by?
The pulse is regulated by the autonomic nervous system through the SA node (pacemaker of the heart). Parasympathetic stimulation of the SA node via the Vegas nerve decreases the heart rate, sympathetic stimulation of the SA node increases the heart rate and force of contraction
What is bradycardia?
Bradycardia is a pulse rate below 60 beats per minute. The pulse rate is normally slower during sleep, and men, and in people who are thin
What are dysrhythmias?
An irregular pattern of heartbeat
Describe respiration
Respiration involves ventilation, diffusion, and perfusion. Ventilation or breathing is movement of gases in And out of the lungs. Diffusion is exchange of oxygen and carbon dioxide between the alveoli of the lungs and the circulating blood. Perfusion is the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells.
What is normal respiration called?
Eupnea
Under normal conditions, healthy adults breathe about 12 to 20 times each minute
What is tachypnea ?
And increased respiratory rate, may occur in response to an increased metabolic rate when the person has a fever.
What is bradypnea?
A decrease in respiratory rate
Apnea vs. dyspnea
Apnea refers to periods during which there’s no breathing. If apnea last longer than 4 to 6 minutes, brain damage and death might occur.
Dyspnea Is difficult or labored breathing. A dyspenic patient usually has rapid, shallow respirations and appears anxious. Dyspenic people can often breathe more easily in an upright position, a condition known as Orthopnea
Describe blood pressure
Blood-pressure refers to the force of moving blood against arterial walls. Maximum blood pressure is exerted on the walls of arteries when left ventricle of the heart contracts and pushes blood through the aortic valve into the aorta at the beginning of systole. The pressure rises of the ventricle contracts (systole) and falls of the heart relaxes. (Diastole)
Systolic vs. diastolic
The highest pressure is the systolic pressure. When the heart rest between beats during diastole, the pressure drops. The lowest pressure present on arterial walls at this time is diastolic pressure. The difference between the systolic and diastolic pressure is called the pulse pressure
What is hypertension?
Hypertension, one of the most common health problems, is blood pressure that is above normal for a sustained period. A diagnosis of hypertension is made when the systolic pressure is 140 MM HG or higher or the diastolic pressure is 90 MM hg or higher
What is hypotension?
Hypertension is below normal blood pressure. A consistently low blood pressure (eg. A systolic reading of 90-115 mm hg) Is normal in some adults, such as trained athletes. However most cases of hypertension are the result of pathology. Pathologic hypotension my results from vasodilation of the arterials, failure of the heart to function as an effective pump, or loss of blood pressure.
What is Orthostatic hypotension?
Orthostatic hypotension (postural hypotension) is a drop in systolic blood pressure of a number equal to or greater than 20 mm hg or in diastolic blood pressure of a number equal to or greater than 10 MM HG within three minutes of standing
What are the korotkoff sounds?
The series of sounds a nurse listens to when assessing the blood pressure. These sounds are only heard when using a stethoscope to assess blood pressure.
1st sound : systolic
2nd : diastolic
What is pulse oximetry?
Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (Sao2 or Spo2) of arterial blood. A sensor, or probe, uses a beam of red and infrared light that travels through tissue and blood vessels. One part of the sensor emits the light and another part receives the light. The oximeter then calculates the amount of light that has been absorbed by arterial blood. Oxygen saturation is determined by the amount of each light absorbed; unoxygenated hemoglobin absorbs more red light and oxygenated hemoglobin absorbs more infrared light. Sensors are available for use on a finger, a toe, a foot (infants), an earlobe, forehead, and the bridge of the nose. It is important to use the appropriate sensor for the intended site; use of a sensor on a site other than that for what it is intended can result in inaccurate or unreliable readings (Haynes, 2007). Circulation to the sensor site must be adequate to ensure accurate readings. Pulse oximeters also display a measured pulse rate.
Pulse oximetry cont..
It is important to know the patient’s hemoglobin level before evaluating oxygen saturation because the test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a patient with low hemoglobin level could appear to have a normal Spo2 because most of that hemoglobin is saturated. However, the patient may not have enough oxygen to meet body needs. Also, take into consideration the presence of preexisting health conditions, such as COPD. Parameters for acceptable oxygen saturation readings may be different for these patients. Be aware of any medical orders regarding acceptable ranges and/or check with the patient’s physician. A range of 95% to 100% is considered normal Spo2; values less than or equal to 90% are abnormal, indicate that oxygenation to the tissues is inadequate, and should be investigated for potential hypoxia or technical error (Booker, 2008a; DeMeulenaere, 2007).
Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. Pulse oximetry does not replace arterial blood gas analysis. Desaturation indicates gas exchange abnormalities
What is the core body temp?
36-37.5 Celsius
97-99.5 Fahrenheit
Where are core temperatures usually measured at?
Tympanic or rectal sites
What is radiation?
The diffusion or dissemination of heat by electromagnetic waves
Ex: the body gives off waves of heat
What is convection?
The dissemination of heat by motion between areas of unequal density
Ex: an oscillating fan blows currents of cool air across the surfaces of a warm body
What is evaporation?
The conversion of a liquid to a vapor
Ex: body fluid in the form of perspiration is vaporized
What is conduction?
The transfer of heat to another object during direct contact
Ex: the body transfers heat to an ice pack
What is the purpose of a fever?
To signal infection and increase immune function
Types of fever
Neurogenic: is the result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial pressure, or increased intracranial pressure. This type of fever does not respond to antipyretic meds.
FUO/fever of unknown origin: a fever of 38.3 c or 101F or higher that lasts for 3 weeks or longer
Where is the primary source of heat from?
Metabolism
Piloerection and shivering increase body temp
What is thermogenesis ?
It’s generation of heat from chemical reactions in the cellular activity
What is thermolysis ?
Dispersing heat through radiation, conduction, convection, and evaporation
What is thermoregulation?
The balance between heat production and heat loss
What time of day is your body temp highest?
Between 4-7 pm
How long should you wait to take temp if someone has had something to drink or eat?
15-30 min
Heat stroke vs. heat exhaustion
Heatstroke: lose heat loss mechanism, hot dry skin
Heat exhaustion: loss of body fluids in attempt to lower temp causing electrolyte imbalance (profuse diaphoresis)
Measuring pulse: sympathetic vs parasympathetic actions
Parasympathetic stimulation: decreases heart rate
Sympathetic stimulation: increases heart rate
What is a normal pulse?
60-100 beats a minute
What is bradycardia?
Pulse: less than 60 beats a minute
What is tachycardia ?
Pulse: more than 100 beats a minute
What are areas pulses can be felt?
Carotid Brachial Radial Ulnar Femoral Popliteal Dorsalis pedis Posterior tibia Apical
How do you find the apical pulse?
Find the supra sternal notch
Locate the 5th intercostal
Left of the midclavicular line
Measuring respirations: what is normal for an adult?
12-20 breaths per minute
Normal respiration is called eupnea
Tachypnea vs. Bradypnea
Tachypnea: is more than 20 breaths per minute
Bradypnea: is less than 12 breaths per minute
What is dyspnea?
Difficulty breathing
What is Cheyne strokes?
Periods of apnea and hyperventilation
What does Kussmauls mean?
Abnormally deep, regular, and increased RR ( hyperglycemia leading to acidosis)
What is Biots respiration?
Abnormally shallow breathing followed by irregular periods of apnea (damage to the medulla oblongata)
What is Orthopnea?
Client finds it easier to breathe sitting up or in an upright position
What is pulse oximetry?
Measures % of O2 carried by hemoglobin
Normal range: 95-100%
Abnormal: less than 90%
What is the peripheral pulse?
The peripheral pulse is a throbbing sensation that can be palpated over a peripheral artery such as the radial artery or the carotid artery.
What is stroke volume?
The quantity of blood forced out of the left ventricle
What is cardiac output?
The amount of blood pumped per minute
Avg. 3.5-8 L
How do you determine blood volume?
Cardiac output= stroke volume X heart rate
What is the cardiac output of an adult with a stroke volume 70ml and a heart rate of 70 beats per min?
4.9 Liters a minute
What system regulates the pulse?
The autonomic nervous system through the SA node
The vagus nerve: systems
Parasympathetic stimulation of the SA node via the vagus nerve DECREASES the heart rate
Sympathetic stimulation of the SA node via the vagus nerve INCREASES the heart rate
What is the pulse amplitude?
The pulse amplitude describes the quality of the pulse in terms of its fullness and reflects the strength of left ventricular contraction
What is the most powerful respiratory stimulant?
An increase in carbon dioxide, which would cause an increase in resp. Rate and depth
Blood pressure cont..
Blood pressure refers to the force of the moving blood against arterial walls.
The pressure rise as the ventricle contracts (systole) and falls as the heart relaxes
What is systolic and diastolic pressure?
Systolic: highest pressure
Diastolic: lowest pressure
The difference between the systolic and diastolic pressure is called the pulse pressure
Examples of systolic and diastolic BP
120/80
The numerator 120 is systolic pressure
The denominator 80 is diastolic pressure
The pulse pressure is 40 mm hg
What are baroreceptors?
Baroreceptors are pressure sensitive receptors that are stimulated by changes in stretch of the blood vessel as BP changes and send impulses to the cardiovascular center to intimate the appropriate changes in heart rate and vascular smooth muscle
What could cause a false high BP reading?
Applying a cuff that is to narrow
Releasing the valve to slowly
Viewing the meniscus from below eye level
Rein flaring the bladder during auscultation
What would cause a false low BP reading?
Applying to wide of a cuff
Releasing the valve rapidly
Failure to pump 20-30 above disappearance of pulse
Viewing the meniscus from above eye level
What is the normal pulse rate range?
60-100 beats a minute
How do you find the apical pulse?
Go to the suprasternal notch
go down to to the 5th intercostal
Left of the midclavicular line
What does eupnea mean?
Easy breathing at rest/rate
12-20 breaths
True or false women have a higher average temp
True, due to estrogen and progesterone
True or false low temp causes vasodilation
True
High temp causes vasoconstriction
What physiological processes are responsible for the appearance of the cardinal signs?
The vascular and cellular stages
What happens in the vascular stage?
Initially, in the vascular stage, small blood vessels constrict the area followed by vasodilation of arterials and venules that supply the area. This increasing blood flow results and redness and heat in the area. Once histamine is released swelling, pain and loss of function can occur
What happens during the cellular stage?
White blood cells move quickly into the area. Neutrophils, the primary phagocytes, engulf the organism and consume cell debris and foreign material. Exudate composed of fluid, cells, and inflammatory byproducts is released from the wound. The exudate maybe clear(serous), contain red blood cells(sanguinous) or contain pus (purulent). The damaged cells are then repaired or scar tissue forms
What might inserting a rectal thermometer do?
Stimulate the vagus nerve, which would decrease the heart rate
What is the difference between the apical and radial pulse called?
Pulse deficit
