Unit I: Ch. 29 Flashcards
what are the traditional vital signs, plus two others
Traditional: body temp, pulse, respiration, & blood pressure
two additional: pain and oxygen saturation
Checking patients vital signs shouldn’t be automatic or routine procedures, but ……
a thoughtful, scientific assessment
UAP may measure, record, and report vital signs, but what responsibilities rest with the registered nurse
the real assessment/interpretation of the measurements
what is body temperature
balance between heat lost and produced by body
what is the core temperature
temp of deep tissues of body, which are usually relatively constant
what is the surface temperature
temp of skin, SQ tissue, & fat, which will rise and fall with external temps
what are the five most important factors that affect the body’s heat production
- ) basil metabolic rate
- ) muscle activity
- ) thyroxine output
- ) epinephrine, norepinephrine, & sympathetic stimulation/stress response
- ) fever
what are the four ways heat is lost from the body
radiation, convection, conduction, evaporation
how is heat lost by radiation
heat transfer from one object to another without contact
how is heat lost by conduction
heat transfer from one molecule to a another molecule of lower temperature
how is heat lost by convection
heat dispersion by air currents
how is heat lost by evaporation
vaporization of moisture from skin, respiratory tract, & mucosa of mouth
what are the three physiological processes used to increase body temperature
- ) shivering increases body temp
- ) Inhibition of sweating to decrease heat loss
- ) vasoconstriction decreases heat loss
what are factors that affect body temperature
age, diurnal variations (circadian rhythms), exercise, hormones, stress, environment
what is the normal range for body temperature for adults
96.8ºF – 99.5ºF (36ºC – 37.5ºC)
three terms for a body temp above usual range
pyrexia, hyperthermia, or fever
term for a very high fever, 105ºF (41ºC)
hyperpyrexia
term for an extremely low body temp, 95ºF (35ºC)
hypothermia
someone who has a fever is referred to as
febrile
someone w/o a fever is referred to as
afebrile
what are the four common fever types
intermittent, remittent, relapsing, constant
what are two examples of elevated body temps that are not considered fevers
heat exhaustion and heat stroke
what is an intermittent fever
when body temp alternates at regular intervals of high, normal, and subnormal temps
what is a remittent fever
when body temp fluctuates over a wide range of temps, all of which are above normal
what is a relapsing fever
short febrile periods for a few days with periods of 1-2 days of normal temp
what is a constant fever
when body temp fluctuates minimally but remains above normal
what are the most common sites for measuring body temperatures
oral, rectal, axillary, tympanic membrane, temporal artery
what is a pulse
wave of blood created by contraction of the left ventricle of the heart
what is cardiac output
the volume of blood pumped into the arteries by the heart and equals the result of the SV x HR/min
what is a peripheral pulse
a pulse located away from the heart
what is the apical pulse
the central pulse located at the apex of the heart
what are the nine pulse sites
temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, pedal (dorsalis pedis)
what are the common methods for assessing pulse
palpation (feeling) or auscultation (hearing by stethoscope)
what is tachycardia
heart rate that exceeds 100 bpm
what is bradycardia
heart rate that’s below 60 bpm
what is the pulse rhythm
pattern of beats and intervals between the beats
what is dysrhythmia or arrhythmia
an irregular heart rhythm
the force of blood with each beat is known as
pulse volume
what is the apical-radial pulse assessment
when the apical & radial pulse is take simultaneously, typically by two nurses
inhalation refers to what act
the intake of air into the lungs
exhalation refers to what act
breathing air out of the lungs
what are the two types of breathing
costal (thoracic) and diaphragmatic (abdominal) breathing
breathing that involves the external intercostal muscles as well as other accessory muscles is what type of breathing
costal (thoracic) breathing
breathing that involves the contraction and relaxation of the diaphragm is known as what type of breathing
diaphragmatic (abdominal) breathing
what qualities of breathing should be assessed when looking at respiration
rate, depth, rhythm, quality, and effectiveness
what is bradypnea
abnormally slow respiration
what tachypnea
abnormally fast respirations
what is systolic pressure
the pressure of blood as a result of ventricles contracting
what is diastolic pressure
pressure of blood when the ventricles are at rest
pulse pressure is the term that describes what
the difference between the diastolic and systolic pressures
when a blood pressure is persistently above normal its called
hypertension
what does hypotension refer to
blood pressure that’s below normal
a client that experiences a fall in blood pressure when they sit or stands has what
orthostatic hypotension
the five phases of blood pressure sounds are called what
Korotkoff’s sounds
the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high followed by the reappearance of sounds at a lower level is called what
an auscultatory gap
a noninvasive device that estimates a client’s arterial blood oxygen saturation by a sensor is known as what
pulse oximeter
what does an oxygen saturation value signify
the percent of all hemoglobin binding sites that are occupied by oxygen
