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