Unit 3: Chapters 12 & 13 Flashcards
(123 cards)
1
Q
Vital signs
A
- temperature
- pulse
- respirations
- blood pressure
- pain
2
Q
When should you take vital signs?
A
- 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
3
Q
What produces temperature in the body?
A
hypothalamus
4
Q
Shell temperature
A
warmth at the skin surface
5
Q
Core temperature
A
warmth at deeper sites within the body (heart, brain)
6
Q
Factors that affect body temperature
A
- age
- gender
- exercise
- time of day
- emotions
- illness
- drugs
7
Q
Normal body temperature
A
96.6 - 99.3 degrees F
8
Q
Sites for assessing body temp
A
- temporal artery
- oral
- rectal equivalent
- axillary equivalent
- tympanic membrane
9
Q
Different types of thermometers
A
- electronic
- infrared
- infrared temporal artery
- glass
- chemical
- digital
10
Q
Fever
A
elevated body temperature 99.3
11
Q
Signs/symptoms associated with elevated temp
A
flushed skin, restlessness, irritability, poor appetite, glassy eyes, increased perspiration, headache, above normal pulse, disorientation, convulsions, fever blisters
12
Q
Phases of the fever
A
- prodromal phase
- onset or invasion phase
- stationary phase
13
Q
Prodromal phase
A
nonspecific symptoms just before temp rises
14
Q
Onset or invasion phase
A
obvious mechanisms for increasing body temp
15
Q
Stationary phase
A
fever is sustained
16
Q
Resolution
A
temp returns to normal
17
Q
Pulse
A
sensation felt as the heart forces blood into the arteries,causing arterial walls to expand and distend
18
Q
Pulse rate
A
of pulsations palpated in 1 minute
19
Q
Factors affecting the pulse rate
A
- age
- circadian rhythm
- gender
- body build
- exercise
- stress/ emotions
- elevated body temp
- blood volume and components
- drug
20
Q
Tachycardia
A
100 to 150 bpm
21
Q
Palpation
A
awareness of ones own heart contraction
22
Q
Bradycardia
A
less than 60 bpm
23
Q
Pulse rhythm
A
pattern of the pulsations and the pauses between them
24
Q
Arrhythmia or dysrhythmia
A
irregular pattern of heartbeats
25
Pulse volume
quality of palpated pulsations
26
Apical pulse
of ventricular contractions per minute
27
Landmark for locating the apical pulse
apex
28
Process of taking an apical-radial pulse
separate nurses at the same time using one watch or clock
29
Pulse deficit
difference between the radial and apical rates
30
When it is difficult to hear/feel/find a pulse what can you use?
Doppler ultrasound device
31
Respiration
exchange of oxygen and carbon dioxide
32
Ventilation
movement of air in and out of the chest
33
Normal adult respiratory rate
Men: 14-18
Women: 16-20
34
Bradypnea
slower that normal respiratory rate
35
Hyperventilation
rapid and or deep breathing
36
Hypoventilation
diminished breathing
37
Dyspnea
difficult or labored breathing
38
Orthopnea
breathing facilitated by sitting up or standing
39
Apnea
absence of breathing
40
Stertorous breathing
noisy ventilation
41
stridor
high pitched sound heard on inspiration when there is laryngeal obstruction
42
Blood pressure
force that the blood exerts within the arteries
43
Preload
volume of blood that fills the heart and stretches the heart muscle fibers during its resting phase
44
Cardiac outputs
volume of blood ejected from the left ventricle per minute
45
Afterload
force against which the heart pumps when ejecting blood
46
Factors that affect blood pressure
- age
- circadian rhythm
- gender
- exercise
- emotions and pain
- miscellaneous factors
47
Blood pressure is written as a
fraction
48
Systolic pressure
pressure within the arterial system when the heart contracts
49
Diastolic pressure
pressure within the arterial system when the heart relaxes and fills with blood
50
Pulse pressure
difference between systolic and diastolic blood pressure measurements
51
Assessment sites for blood pressure
- popliteal artery behind the knee
| - lower arm use radial artery
52
Equipment needed to measure blood pressure
- sphygmomanometer
- inflatable cuff
- stethoscope
53
Korotkoff sounds
sounds that result from the vibrations of blood within the arterial wall or changes of blood flow
54
Average adult blood pressure
120/80
55
Palpating blood pressure
- apply blood pressure cuff
| - position fingers over the artery while releasing cuff pressure ( instead of a stethoscope)
56
Doppler stethoscope
helps to detect sounds created by the velocity of blood running through a blood vessel
57
automatic blood pressure monitoring
- blood pressure cuff attached to a microprocessing unit
| - diagnosis unusual fluctuations in blood pressure
58
Hypertension
high blood pressure
59
White coat hypertension
blood pressure is elevated when taken by a health care provider but normal at other times
60
Diseases associated with hypertension
- anxiety
- obesity
- vascular diseases
- stroke
- heart failure
- kidney diseases
61
Hypotension
low blood pressure
62
Postural hypotension
temporary drop in blood pressure when rising from a reclining position after 3 to 5 minutes of rest
63
Where do you document vital signs?
- medical record for analysis of patterns and trends
| - clients record
64
Physical assessment
systematic examination of body structures
65
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
66
Inspection
purposeful observation
67
Percussion
- least used assessment technique
| - striking or tapping with finger tips to produce vibratory sounds
68
Palpation
lightly touching or applying pressure to the body
69
light palpation
using the fingertips, the back of the hand, or the palm of the head
70
Deep palpation
depressing tissue approximately 1 inch with the forefingers of one or both hands
71
Auscultation
listening to body sounds
72
Equipment
gloves, examination gown, cloth or paper towels, scale, stethoscope, sphygmomanometer, thermometer, pen light, tongue blade
73
Environment
assessment location
74
Drape
sheet of soft cloth or paper
75
Head-to-toe approach
assessing the client from the top of the body to the feet
76
Body systems approach
assessing the client according to the functional systems of the body
77
Mental status assessment
technique for determining the level of a pts cognitive function
78
Opthalmoscope
tool used to examine structures within the eye
79
Visual acuity
ability to see both near and far
80
Snellen eye chart
tool for assessing far vision
81
Jaeger chart
visual assessment tool with small print or newsprint with varying sides
82
What is the size of each pupil measured in under normal light conditions?
millimeters
83
Pupil shape
normal pupils are round and equal in size
84
Consensual response
a brisk,equal, and simultaneous constriction of both pupils when one eye and then the other is stimulated with light
85
accommodation
ability to constrict when looking at a near object and dilate when looking at an object in the distance
86
PERLA
pupils equally round and react to light and accommodation
87
Extraocular moments
eye movements
88
Visual field examination
assessment of peripheral vision and continuity in the visual field
89
Cerumen
ear wax
90
hearing acuity
ability to hear and discriminate sound
91
Weber test
determining equality or disparity of bone-conducted sound
92
Rinne test
comparing air versus bone conduction of sound
93
Audiometry
measures hearing acuity at various sound frequencies
94
Smelling acuity
ability to smell and identify odors
95
Wound
break in the skin
96
Ulcer
open, crater-like area
97
abrasion
area that has been rubbed away by friction
98
Laceration
torn, jagged would
99
Fissure
crack in the skin (especially on or near mucus membranes )
100
Macule
freckles
101
Papule
wart
102
Vesicle
blister
103
Wheal
hives
104
Pustule
boil
105
Nodule
enlarged lymph node
106
Cyst
tissue growth
107
Turgor
resiliency of the skin (fullness or lack thereof )
108
Lordois
exaggerated natural lumbar curve
109
Kyphois
increased thoracic curve
110
Scoliosis
lateral curvature of the spine
111
Two normal heart sounds
-S1 and S2
| "lub dub"
112
Capillary refill time
the time it takes blood to resume flowing in the base of the nail bed
113
Tracheal sounds
- loud and coarses
| - equal in length and separated by a brief pause
114
Bronchial sounds
- heard over the upper sternum anteriorly & between the scapulae posteriorly
- harsh and loud
- shorter on inspiration than expiration
- pause between them
115
Bronchovesicular sounds
- either side of the central chest or back
- equal in length during inspiration and expiration
- no noticeable pause
116
Vesicular sounds
- periphery of all the lung sounds
- longer on inspiration than expiration
- no bause between
117
Normal capillary refill time
2 seconds or less
118
Assessing the abdomen
always inspect and then auscultated
119
Assessing bowel sounds
- place diaphragm lightly in the right lower quadrant
| - move the chest piece over all four quadrants in clockwise pattern
120
Normal bowel sounds
resemble clicks or gurgles and occur 5 to 34 times a minute
121
frequent bowel sounds
hyperactive
122
hypoactive
if bowel sounds occur after long intervals of silence
123
Absent
if no bowel sound is heard for 2 to 5 minutes
