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204 Exam 1 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Heat produced - heat lost

A

Body temperature

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2
Q

Acceptable temp for Fahrenheit

A

96.8° F to 100.4° F

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3
Q

Acceptable temp for Celsius

A

36° C to 38° C

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4
Q

What controls body temp like a thermostat?

A

Hypothalamus

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5
Q

What 5 things regulate body temperature?

A 
Neural and vascular control
Heat production
Heat loss (radiation, conduction, convection, evaporation)
Skin temperature regulation
Behavioral control
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6
Q

7 Factors that affect body temperature

A 
Age
Exercise
Hormone level
Circadian rhythm
Stress
Environment
Temperature alterations
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7
Q

Heat-loss mechanisms are unable to keep pace with excessive heat production

A

Fever (pyrexia)

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8
Q

Have fever

Do not have fever

A

Febrile

Afebrile

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9
Q

hypothalamus isn’t working correctly

A

Hyperthermia

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10
Q

Acceptable pulse rate

A

60-100bpm

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11
Q

Acceptable respirations

A

12-20bpm

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12
Q

Acceptable blood pressure

A

120/80 mm Hg

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13
Q

Risk for Imbalanced Body Temperature
Hyperthermia
Hypothermia
Ineffective Thermoregulation

A

Examples of nursing diagnosis for pt with body temperature alterations

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14
Q

How to reduce fever (6)

A 
Antipyretics (meds)
obtain blood cultures
minimize heat production
Maximize heat loss 
increase metabolic rate (oxygen levels)
pt comfort
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15
Q

When do you want to draw a culture?

A

Before starting antibiotics

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16
Q

Palpable bounding of blood flow noted at various points on the body
The indicator of circulatory status

A

Pulse

HR (same thing as pulse)

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17
Q

Number of pulsing sensations in 1 minute

A

Pulse rate

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18
Q

Electrical impulses

A

originate from the sinoatrial (SA) node

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19
Q

Characteristics of Pulse (4 things)

A

Rate (# per minute)
Rhythm (intervals)
Strength (0-4) volume of blood ejected
Equality (compare sides)

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20
Q

Factors that affect pulse (7 things)

A 
Exercise
Temperature
Emotions
Medications
Hemorrhage
Postural changes
Pulmonary conditions
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21
Q

difference b/w peripheral & apical pulses

A

pulse deficit

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22
Q 
0
1
2
3
4
strength of pulse is recorded as
A 
0= absent
 1= weak or thready
2=normal
3 =full or strong
4= bounding
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23
Q

Sites for pulse (10 sites)

A 
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
Popliteal
Post. tib
Dorsal pedis
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24
Q

7 things that determine what the pulse will be like

A

Activity intolerance

Anxiety

Acute Pain

Decreased cardiac output

Deficient/excess fluid volume

Impaired gas exchange

Ineffective peripheral tissue perfusion

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25
Q

Movement of gases into and out of the lung.

A

Ventilation

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26
Q

Movement of oxygen and carbon dioxide between alveoli and red blood cells.

A

Diffusion

27
Q

Distribution of red blood cells to and from the pulmonary capillaries.

A

Perfusion

28
Q

What is involved with respiration?

A

Ventilation, Diffusion, Perfusion

29
Q

During the mechanics of inspiration what happens?

A

abdomen moves downward & forward

Chest wall moves up

30
Q

During the mechanics of expiration what happens?

A

diaphragm relaxes
abdomen returns to normal position
chest wall relaxed position

31
Q

When assessing respiration you need to assess

A

diffusion & perfusion

32
Q

Assessing ventilation

A

Respiratory Rate: breaths/minute
Depth: deep, normal, shallow
Rhythm: regular/irregular

33
Q

Assessment of diffusion & perfusion

A

Measure: oxygen saturation of blood & arterial oxygen saturation

34
Q

8 Factors affecting respiration

A 
exercise 
acute p!
anxiety
smoking
body position
medications
neurological injury
Hemoglobin function
35
Q

Force exerted on the walls of an artery by pulsing blood under pressure from the heart

A

BP

36
Q

Maximum peak pressure during ventricular contraction, squeezing ventricle to get blood out

A

Systolic

37
Q

Minimal pressure during ventricular relaxation

A

Diastolic

38
Q

Difference between systolic and diastolic pressures

A

pulse pressure

39
Q

Physiology of Arterial BP

A 
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
40
Q

is the resistance to blood flow determined by the tone of the vascular musculature and diameter of the blood vessels

A

Peripheral Resistance (PVR)

41
Q

8 factors influencing BP

A 
Age
Stress
Ethnicity 
Gender 
Daily Variation
Meds
Activity, weight
Smoking
42
Q

Thickening of walls
Loss of elasticity-makes it ridged
Family history

A

Hypertension

43
Q

6 Risk factors for hypertension

A 
obesity
cigarette smoking
heavy alcohol consumption
high sodium intake
sedentary life-style
stress
44
Q

Systolic <90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs

A

Hypotension

45
Q

Korortkoff phase 1

A

sharp thump

46
Q

Korortkoff phase 2

A

blowing or whooshing sound

47
Q

Korortkoff phase 3

A

crisp, intense tapping

48
Q

Korortkoff phase 4

A

softer blowing sound that fades

49
Q

Korortkoff phase 5

A

silence

50
Q

when do we need to do BP manually? (7 things)

A 
Hyper & hypotensive pt
 irregular HR
Peripheral vascular obstructions (clots)
Shivering
Seizures
Excessive tremors
Inability to cooperate
51
Q

Characteristics of pain

A

Quality
Aggravating and precipitating factors
Relief measures

52
Q

Effects of pain on the patient

A

Behavioral effects

Influence on activities of daily living (ADLs)

53
Q

Concomitant (secondary) symptoms

A

Usually increases pain severity

54
Q

ABCDE of P! assessment

A 
Ask
Believe
Choose
Deliver
Empower
55
Q

Type of pain scales

A

Wong-Baker Faces

Oucher

56
Q

Cuff is too small, release to slow

A

will cause a high reading

57
Q

If the arm is low

A

high reading

58
Q

Cuff is too big, above the heart

A

low reading

59
Q

Systolic <90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs

A

Hypotension

60
Q

The measure of HR & rhythm

A

Pulse

61
Q

Bodys mechanism for exchanging oxygen & carbon dioxide

A

Respiration

62
Q

Core temp sites

A 
rectum
tympanic membrane
temporal artery
pulmonary artery
esophagus
urinary bladder
63
Q 
Pulses for 
infants
toddler
preschooler
school age child
adolescent
adult
A 
Infants 120-160
toddler- 90-140
Preschooler- 80-110
School age child- 75-100
Adolescent- 60-90
Adult - 60-100

204 Exam 1 (7 decks)

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