Temperature, Pulse & Respiration Flashcards
Define afebrile
without fever
Define febrile
with fever
Define hyperthermia
unusually high fever - greater than 38.5 degrees
Define hypothermia
core body temperature below 35 degrees
When is someone considered having a fever?
when temperature reads over 38 degrees
Define hyperpyrexial
hyperthermia greater than 41.5 degrees
Define pulse
throbbing caused by the regular contraction and alternate expansion of an artery as the wave of blood passes through the vessel as a result of each heart beat
Define bradycardia
slow heartbeat - pulse rate below 60bpm in an adult
Define apnea
temporary cessation of breathing and therefore decrease body’s intake of oxygen and release of carbon dioxide
Define bradypnea
abnormally slow breathing
Define cheyne stokes
breathing pattern marked by a period of apnea lasting 10-60 sec, followed by increased depth and frequency of respirations
Define eupnea
unimpaired respiration
Define hyperventilation
increased minute volume ventilation, which results in lowered C02 levels
Define hypoventilation
reduced rate and depth of breathing that causes increased C02
Define tachycardia
abnormally rapid heart beat - greater than 100 bpm
What is the average oral or tympanic temperature for a healthy adult?
37.0 degrees
What are 3 factors that can significantly alter a patients pulse rate?
- pain
- blood loss
- infection
What is a nurse referring to when she states a patient’s pulse as bounding?
the strength of a pulse
What are two factors to observe when assessing a clients respiration?
- rate, depth, rhythm and character
- note the patients skin colour and level of consciousness
Where is an apical pulse best heard?
over the 5th intercostal space, 7-9cm left of mid-sternum, just below left nipple
When is an apical pulse used?
when pulse rate is noted as being irregular for one minute or if there is any double of pulse assessment
Why are respirations assessed unobtrusively?
because people tend to find it hard to breath normal when they know they’re being assessed
Name 7 factors that could influence temperature.
- diurnal cycle
- menstruation cycle
- activity level
- age
- stress
- environment
- fever
What are the 5 possible routes for taking temperature?
- oral
- rectal
- tympanic
- axilla
- temporal artery
What must you remember when taking a tympanic temperature for an adult vs. a child?
- adults pull ear up
- children pull ear down
When should you not take oral temperatures? (8 answers)
- disorientated
- confused
- unconscious
- seizuring
5, mouth infections or mouth surgery - very young children
- after hot/cold drinks
- smoking
What is the purpose of a pulse assessment?
indicates hearts function and tissue circulation
What is the normal pulse range?
6–100 beats per minute in adults
What does PMI stand for?
point of maximum impulse
What are some things to consider before taking a pulse?
- asepsis - handwashing and is stethascope cleaned in between patients
- person centered care - introduce and ask patient if it is a good time for them
- organization
- pulse site to be assessed
What are 4 characteristics to take into account when taking a pulse?
- rate (60-100 beats per minute)
- rhythm (regular or irregular)
- strength (strong, bounding, weak, thready)
- bilateral equity (both radial pulses for example)
Name 9 factors that can affect a pulse
- age
- exercise
- temperature
- pain
- emotions
- hemorraging
- medications
- posture change
- manner of approach
What is the purpose of evaluating respirations?
to evaluate the exchange of oxygen and carbon dioxide
What is the normal respiratory rate?
12-20 rpm
What are 4 characteristics to watch for when assessing respirations?
- rate (number of breath cycles per minute)
- depth (estimate by observing, deep, normal or shallow)
- rhythm (regular or irregular)
- effort (easy or laboured)
What are 9 factors affecting respiration?
- exercise
- acute pain
- illness
- anxiety/stress
- smoking
- body position
- meds
- neurological injury
- hemoglobin
