Unit 3: Chapters 12 & 13 Flashcards
Vital signs
- temperature
- pulse
- respirations
- blood pressure
- pain
When should you take vital signs?
- admission
- according to medical orders
- once per day if pt is stable
- every 4 hrs when 1 or more vital signs are abnormal
- every 5 to 15 min when pt is unstable
- when there is a significant difference from previous measurement
What produces temperature in the body?
hypothalamus
Shell temperature
warmth at the skin surface
Core temperature
warmth at deeper sites within the body (heart, brain)
Factors that affect body temperature
- age
- gender
- exercise
- time of day
- emotions
- illness
- drugs
Normal body temperature
96.6 - 99.3 degrees F
Sites for assessing body temp
- temporal artery
- oral
- rectal equivalent
- axillary equivalent
- tympanic membrane
Different types of thermometers
- electronic
- infrared
- infrared temporal artery
- glass
- chemical
- digital
Fever
elevated body temperature 99.3
Signs/symptoms associated with elevated temp
flushed skin, restlessness, irritability, poor appetite, glassy eyes, increased perspiration, headache, above normal pulse, disorientation, convulsions, fever blisters
Phases of the fever
- prodromal phase
- onset or invasion phase
- stationary phase
Prodromal phase
nonspecific symptoms just before temp rises
Onset or invasion phase
obvious mechanisms for increasing body temp
Stationary phase
fever is sustained
Resolution
temp returns to normal
Pulse
sensation felt as the heart forces blood into the arteries,causing arterial walls to expand and distend
Pulse rate
of pulsations palpated in 1 minute
Factors affecting the pulse rate
- age
- circadian rhythm
- gender
- body build
- exercise
- stress/ emotions
- elevated body temp
- blood volume and components
- drug
Tachycardia
100 to 150 bpm
Palpation
awareness of ones own heart contraction
Bradycardia
less than 60 bpm
Pulse rhythm
pattern of the pulsations and the pauses between them
Arrhythmia or dysrhythmia
irregular pattern of heartbeats
Pulse volume
quality of palpated pulsations
Apical pulse
of ventricular contractions per minute
Landmark for locating the apical pulse
apex
Process of taking an apical-radial pulse
separate nurses at the same time using one watch or clock
Pulse deficit
difference between the radial and apical rates
When it is difficult to hear/feel/find a pulse what can you use?
Doppler ultrasound device
Respiration
exchange of oxygen and carbon dioxide
Ventilation
movement of air in and out of the chest
Normal adult respiratory rate
Men: 14-18
Women: 16-20
Bradypnea
slower that normal respiratory rate
Hyperventilation
rapid and or deep breathing
Hypoventilation
diminished breathing
Dyspnea
difficult or labored breathing
Orthopnea
breathing facilitated by sitting up or standing
Apnea
absence of breathing
Stertorous breathing
noisy ventilation
stridor
high pitched sound heard on inspiration when there is laryngeal obstruction
Blood pressure
force that the blood exerts within the arteries
Preload
volume of blood that fills the heart and stretches the heart muscle fibers during its resting phase
Cardiac outputs
volume of blood ejected from the left ventricle per minute
Afterload
force against which the heart pumps when ejecting blood
Factors that affect blood pressure
- age
- circadian rhythm
- gender
- exercise
- emotions and pain
- miscellaneous factors
Blood pressure is written as a
fraction
Systolic pressure
pressure within the arterial system when the heart contracts
Diastolic pressure
pressure within the arterial system when the heart relaxes and fills with blood
Pulse pressure
difference between systolic and diastolic blood pressure measurements
Assessment sites for blood pressure
- popliteal artery behind the knee
- lower arm use radial artery
Equipment needed to measure blood pressure
- sphygmomanometer
- inflatable cuff
- stethoscope
Korotkoff sounds
sounds that result from the vibrations of blood within the arterial wall or changes of blood flow
Average adult blood pressure
120/80
Palpating blood pressure
- apply blood pressure cuff
- position fingers over the artery while releasing cuff pressure ( instead of a stethoscope)
Doppler stethoscope
helps to detect sounds created by the velocity of blood running through a blood vessel
automatic blood pressure monitoring
- blood pressure cuff attached to a microprocessing unit
- diagnosis unusual fluctuations in blood pressure
Hypertension
high blood pressure
White coat hypertension
blood pressure is elevated when taken by a health care provider but normal at other times
Diseases associated with hypertension
- anxiety
- obesity
- vascular diseases
- stroke
- heart failure
- kidney diseases
Hypotension
low blood pressure
Postural hypotension
temporary drop in blood pressure when rising from a reclining position after 3 to 5 minutes of rest
Where do you document vital signs?
- medical record for analysis of patterns and trends
- clients record
Physical assessment
systematic examination of body structures
Purposes of physical assessment
- evaluate client’s current physical condition
- detect early signs of developing health problems
- establish baseline
- evaluate the clients responses to medical and nursing interventions
Inspection
purposeful observation
Percussion
- least used assessment technique
- striking or tapping with finger tips to produce vibratory sounds
Palpation
lightly touching or applying pressure to the body
light palpation
using the fingertips, the back of the hand, or the palm of the head
Deep palpation
depressing tissue approximately 1 inch with the forefingers of one or both hands
Auscultation
listening to body sounds
Equipment
gloves, examination gown, cloth or paper towels, scale, stethoscope, sphygmomanometer, thermometer, pen light, tongue blade
Environment
assessment location
Drape
sheet of soft cloth or paper
Head-to-toe approach
assessing the client from the top of the body to the feet
Body systems approach
assessing the client according to the functional systems of the body
Mental status assessment
technique for determining the level of a pts cognitive function
Opthalmoscope
tool used to examine structures within the eye
Visual acuity
ability to see both near and far
Snellen eye chart
tool for assessing far vision
Jaeger chart
visual assessment tool with small print or newsprint with varying sides
What is the size of each pupil measured in under normal light conditions?
millimeters
Pupil shape
normal pupils are round and equal in size
Consensual response
a brisk,equal, and simultaneous constriction of both pupils when one eye and then the other is stimulated with light
accommodation
ability to constrict when looking at a near object and dilate when looking at an object in the distance
PERLA
pupils equally round and react to light and accommodation
Extraocular moments
eye movements
Visual field examination
assessment of peripheral vision and continuity in the visual field
Cerumen
ear wax
hearing acuity
ability to hear and discriminate sound
Weber test
determining equality or disparity of bone-conducted sound
Rinne test
comparing air versus bone conduction of sound
Audiometry
measures hearing acuity at various sound frequencies
Smelling acuity
ability to smell and identify odors
Wound
break in the skin
Ulcer
open, crater-like area
abrasion
area that has been rubbed away by friction
Laceration
torn, jagged would
Fissure
crack in the skin (especially on or near mucus membranes )
Macule
freckles
Papule
wart
Vesicle
blister
Wheal
hives
Pustule
boil
Nodule
enlarged lymph node
Cyst
tissue growth
Turgor
resiliency of the skin (fullness or lack thereof )
Lordois
exaggerated natural lumbar curve
Kyphois
increased thoracic curve
Scoliosis
lateral curvature of the spine
Two normal heart sounds
-S1 and S2
“lub dub”
Capillary refill time
the time it takes blood to resume flowing in the base of the nail bed
Tracheal sounds
- loud and coarses
- equal in length and separated by a brief pause
Bronchial sounds
- heard over the upper sternum anteriorly & between the scapulae posteriorly
- harsh and loud
- shorter on inspiration than expiration
- pause between them
Bronchovesicular sounds
- either side of the central chest or back
- equal in length during inspiration and expiration
- no noticeable pause
Vesicular sounds
- periphery of all the lung sounds
- longer on inspiration than expiration
- no bause between
Normal capillary refill time
2 seconds or less
Assessing the abdomen
always inspect and then auscultated
Assessing bowel sounds
- place diaphragm lightly in the right lower quadrant
- move the chest piece over all four quadrants in clockwise pattern
Normal bowel sounds
resemble clicks or gurgles and occur 5 to 34 times a minute
frequent bowel sounds
hyperactive
hypoactive
if bowel sounds occur after long intervals of silence
Absent
if no bowel sound is heard for 2 to 5 minutes
