Unit 1 ( vital) Flashcards
Thermoregulation
maintaining a stable internal body temp.
Components of vital signs (5)
Temperature: internal body temperature
Pulse: rate in which the heart is pumping
Respirations: rate in which the body is breathing
Blood Pressure: rate that the heart is working and resting
Pain: the level of comfort felt by the patient
Vital signs
are measurements of the body’s most basic functions.
Core Temp
body temperature deep within the body
Where measurement are used to represent CORE temperature ?
rectal
What measurement are used to represent SURFACE temperature ? (2)
oral and axillary
Pilorection
Hairs standing on end
If the body is overheating, it will compensate with?
A. Vasodilation
B. Vasoconstriction
Vasodilation
Define temperature
the degree of hotness or coldness of a substance
Define Hyperthermia
& Hypothermia
An increase above normal body temperature.
A decrease below normal body temperature.
- Mr. Lu is admitted with an abdominal pain. His oral temperature is 100.4°F (38°C), pulse is 88 beats/min, respirations are 18 breaths/min, and blood pressure is 118/78 mm Hg. These findings are:
A. Abnormal
B. Normal
abnormal
temp - 98.6°F
The average normal oral temperature is 98.6°F (37°C).
Ms. Martin vomited 200 mL of stomach contents after breakfast. Her vital signs include tympanic temperature, 97.6°F (36.4°C); pulse, 99 beats/min; respirations, 16 breaths/min; and blood pressure, 104/67 mm Hg. These findings are:
A. Normal
B. Abnormal
normal
Oral temp higher than 37.8 C or 100 F/ and rectal 101F is ________
fever/pyrexia
hyperpyrexia
fever over 105.8 F/dangerous/can lead to seizures/coma
pyrogens
fever producing substances
4 names of types of fever
d. the name says what it does.
a. “I” for my ex lol
Intermittent - alternates between regularly . drops to normal
Remittent- Fluctuations in temp during 24 hrs. Never normal
Constant - may fluctuations but Always above normal
Relapsing - short episodes of fever alternating with periods of normal temp lasting 1-2 days. Goes away then comes back
During hyperthermia the elevated body temp is the same as the set point?
T or F
F.
The body temp is overwhelmed and does not reset the set point.
Sites for temp (5)
-mouth
- rectum
- axillae
-tympanic
-skin
Sites for core temp ( 3) (how do they do this) (which one is the gold standard ) * invasive*
-pulmonary artery (gold )
- esophagus
-bladder
Surgery & Intensive care
Points for assessing the pulse (6)
- radial (common)
- brachial ( infants)
- TEMPORAL (head)
- Dorsalis (pedal pulse/posterior for feet n legs)
- Femoral ( legs for children)
- Popliteal ( lower leg)
Pulse deficit
difference between the apex beats not transferring to your artery
dysrhythmia
abnormal rhythm
irregularly irregular vs regular irregular
- unpredictable
- irregular but forms a pattern
Korotooff Sounds ( five)
Phase 1 is a sharp tapping sound and indicates the systolic blood pressure.
Phase 2 is a swishing sound associated turbulence .
Phase 3 rhythmic tapping/ SHARP
Phase 4 is soft and thump that becomes muffled.
The diastolic blood pressure is determined when all sound ceases at Phase 5.
Apical pulse
(located )
is the most accurate measurement of the heart’s frequency and rhythm.
Located at the 5th intercostal space on the midclavicular line.
Peripheral pulses are found away
from the heart, such as the wrist, foot, knee, and groin.
afebrile
not feverish/ free from fever
What is in charge of heat production and loss?
Hypothalamus
Basal metabolic rate (BMR)
break down of food into energy to maintain essential activities of life. Example: breathing
When we increase cellular metabolisms it has increase in
HEAT
How to newborns regulate heat?
Non-shivering thermogenesis …..Use brown fat to generate heat.
Heat production in adults and children occur(s) during? Select all that apply.
a. Non shivering thermogenesis
b. Involuntary shivering
c. Voluntary movements
d. Rest
b. Involuntary shivering ( muscle movements)
c. Voluntary movements (ex: gym)
d. Rest (BMR)
When does the Nurse obtain Vital Signs? ( 7)
- At admission – obtaining baseline
- Before and after surgery or invasive procedures
- Beginning of a shift
- Medications – before and after some meds
- Changes in client condition
6.Gut feeling - Before and after any nursing intervention that could affect the vital signs
Mechanism that effect the exchange of heat between body and the environment? (4) * third one is from 4th grade song*
WE JUST TALKED ABOUT THIS
- Radiation- loss of heat through electromagnetic waves emitting from surfaces that are warmer than the air. (ex. Skin is warmer than air)
- Convection- transfer of heat through current of air or water. (ex: use of a fan to cool a body, immersion in bath)
- Evaporation- occurs when water is converted to vapor and lost from the skin(perspiration) or mucous membranes(through the breath)
- Conduction- process whereby heat is transferred from a warm to a cool surface by direct contact. (ex: sitting on cold chair, heat from yourself transfers to the chair)
Tympanic Temp (ear) Ranges
97.8 – 100.6 F (36.6-38 C)
Oral Temp Ranges
96.8 - 100 F (36 -37.8 C)
diaphoresis
(heavy sweating)
Heat exhaustion (temp/symptoms /treatment )
occurs with core temperature 98.6 to 103F (36-39.4C).
nausea, vomiting, tachycardia,
Treatment – place in cool environment, administer fluids, use of fan or cooling towels, cool sponge bath
Pulse
Wave of blood created by contraction of the left ventricle of the heart and ends when it relaxes
Tachycardia =
Bradycardia =
= heart rate greater than normal (above 100 in adults)
= heart rate below normal (less than 60 in adults)
If apical is lower than peripheral…
error was made. Apical rate is never lower than peripheral
- What is the primary purpose of initially assessing an apical pulse?
A. Assessment of the patient’s cardiac function
B. Establishment of a baseline as part of the patient’s vital signs
C. Assessment of the patient’s risk for cardiovascular disease
D. Determination of oxygen saturation
B. Establishment of a baseline as part of the patient’s vital signs
REMEMBER WHAT BREATH SUFFIX IS
=slow rate, less than 10 breaths/min
=fast rate, greater than 24 breaths/min
= Absence of breathing (remember when its an “a” present its absence)
= normal rate/depth, 12 -20 breaths/min
Bradypnea
Tachypnea
Apnea
Eupnea
____________ rapid and shallow respirations with periods of apnea (DEFINE)
Cheyne-Stokes respirations
is the mechanical movement of air in and out of the lungs
Pulmonary Ventaltion
_______________(O2) and carbon dioxide (CO2) between the alveoli and the pulmonary blood supply (RBCs)
The exchange of oxygen
_____________is the distribution of blood to periphery and vital organs
Perfusion
______ increased depth and rate leads to excessive intake of O2 and loss of CO2
_________decreased depth with build up of CO2 in blood, low blood oxygen levels occur
Hyperventilation
Hypoventilation
What other things beside rate, pattern, and depth tells the nurse that the patient is in respiratory distress? (4 )
(hint one is what we used to measure in clinical )
-Assessment of color of skin, nailbeds, and oral mucous membranes
-Level of consciousness
-Emotional state/Anxiety
-Assessment of adequate oxygenation: Pulse oximeter
is the pressure within the arteries of the body (not a trick question..)
Blood pressure
= heart at work
= heart at rest
Systolic pressure
Diastolic pressure
Pre-hypertension:
having a systolic pressure from 120–139 (mm Hg) or a diastolic pressure from 80–89 mm Hg.
Hypertension is diagnosed when readings at 2 different intervals are elevated:
Systolic greater
Diastolic greater
than 140
than 90
MULTIPLE TIMES
ORTHOSTATIC hypotension ( think what orthostatic means)
when the patient sits or stands with complaints of feeling dizzy or lightheaded from a lying position.
___________ is BP that is below normal
Systolic reading consistently <90 mmHg and diastolic <60 mmHg in patient whose pressure is normally higher than this.
hypotension
The first sound of Series of sounds that correspond to heart beats? And the the sounds stops is ?
systolic and diastolic
______________ is anecdotal information that comes from opinions, perceptions or experiences.
subjective
Which disorder can cause an increase in the basal metabolic rate (BMR) and thus raises body temperature?
Hypertension
Hyperlipidemia
Hypothyroidism
Hyperthyroidism
Hyperthyroidism
In which clients would the nurse find elevated pulse rates? Select all that apply.
A 3-month-old infant
A client with hypothyroidism
a client taking digoxi
A client with a temperature of 101
A client with chronic obstructive pulmonary disease (COPD)
everyone but 2 & 3
Place in order the steps required to obtain a manual blood pressure:
deflate the cuff, and note the top number of the blood pressure when the first sound is auscultated for the systolic blood pressure.
Insert the ear pieces of the stethoscope into ears.
Place the cuff about 1 inch above the antecubital space with the center over the brachial artery.
Release the air from the cuff, and record the findings
Gather and sanitize the stethoscope and sphygmomanometer
let the air out of the cuff and wait 1 to 2 minutes
determine when the last sound is auscultated for the diastolic blood pressure.
Inflate the cuff until the brachial pulse is no longer palpated
reinflate the cuff to about 20 mm HG above the number previously palpated
1 Gather and sanitize the stethoscope and sphygmomanometer
2 Insert the ear pieces of the stethoscope into ears.
3 Place the cuff about 1 inch above the antecubital space with the center over the brachial artery.
4 Inflate the cuff until the brachial pulse is no longer palpated
5 let the air out of the cuff and wait 1 to 2 minutes
6 reinflate the cuff to about 20 mm HG above the number previously palpated
7 deflate the cuff, and note the top number of the blood pressure when the first sound is auscultated for the systolic blood pressure.
8 determine when the last sound is auscultated for the diastolic blood pressure.
9 Release the air from the cuff, and record the findings
A client visits an urgent care center while on vacation in Colorado. The client reports difficulty breathing since arriving. Which factor most likely explains the client’s dyspnea?
The client is experiencing a sickle cell crisis.
The high altitudes prevent oxygen from binding to hemoglobin.
the client has consumed large amounts of caffeinated coffee.
The client has underlying chronic obstructive pulmonary disease (COPD)
b
What should the nurse do when obtaining a client’s orthostatic blood pressure (BP)?
Take the standing BP first
Perform these readings prior to the client eating.
Wait 1 to 3 minutes in between each reading
Document the lowest BP reading.
Wait 1 to 3 minutes in between each reading
orthostatic
erect postion
Which is the best term for the nurse to include in his or her assessment documentation to note that a client is unable to lie flat without becoming short of breath?
Wheezes
Crackles
Dyspnea
Orthopnea
Orthopnea
__________ labored breathing that occurs when lying flat but improves when standing or sitting.
Orthopnea
Which gases are primarily exchanged during repiration? Select all that apply.
Oxygen
Chloride
Nitrogen
Hydrogen
Carbon Dioxide
1 and 5
The nurse is working at a health fair providing blood pressure and pulse screenings. The nurse finds a young adult client has an apical pulse of 44 bpm. What would be the nurse’s first action?
Call 911 and notify emergency medical service (EMS)
Have the client drink some water, then recheck the apical pulse.
Ask the client if he or she is an athlete or runs every day.
Instruct the client to make an appointment to see his or her health-care provider.
Ask the client if he or she is an athlete or runs every day.
Which physiological processes occur when the hypothalamus is stimulated due to a client being warm? Select all that apply.
Epinephrine release
Peripheral vasodilation
Perspiration
Piloerection
Shunting of blood away from the periphery
2 & 3
relationship between height and weight
Increased metabolic demand results in a decrease in oxygen consumption. T or F
F
Increased metabolic demand results in a increase in oxygen consumption. Pulse and respirations:
