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NRS Therapeutics 1 > Vital Signs TPR & BP (ch29) > Flashcards

Vital Signs TPR & BP (ch29) Flashcards

1
Q

What do Nurses use Vital Signs for?

A

To implement prescribed treatment and notify physician of sig. changes

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2
Q

When are vitals taken?

A

On admission, B/A invasive procedures, with blood transfusions and medications, condition changes, or patient reports specific/non-specific symptoms.

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3
Q

Temperature Definition and normal range

A

Heat produced- heat lossed. Normal range is 96.8-100.4 degrees F (36-38 degrees C)

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4
Q

What is thermoregulation?

A

regulation of body temp., done by balancing heat lost and heat produced.

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5
Q

What’s the hypothalamus responsible for?

A

it is the body’s thermostat. Causes vasoconstriction and shivering to conserve heat. Causes vasodilation/sweating to release heat.

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6
Q

Basal Metabolic Rate (BMR)

A

heat produced by the body at absolute rest, affected by thyroid hormones that control metabolism. Men have higher BMRs.

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7
Q

How is heat released/lost from the body?

A

lost from the skin surface via radiation (bl vessels constric/narrow) conduction (direct contact), evaporation, convection (air, fans), and sweating.

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8
Q

Name factors that influence body temperatures?

A

Age, Exercise, Hormone Lvl (menstrual cycle), Stress, Environment, Diseases, Circadian Rhythm (lowest at 1-4am, high 6pm).

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9
Q

Oral Thermometers

A

Accessible, comfortable, placed in post. sublingual pocket, affected by food, fluids, and smoking, not for infants/children, electronics take 20-50 sec

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10
Q

Afebrile

A

without fever, have normal temperature

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11
Q

How is heat produced by the body?

A

Voluntary movements (exercise), Involuntary “ (shivering), Nonshivering thermogenesis (newborns), and even at rest (BMR).

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12
Q

Contrast Newborn/children temp ranges with Adult temps. Why variation?

A

Adults are normally 96.8-100.4F or 36-38C, whereas children are nmlly 95.9-99.5F or 35.5-37.5C. Variation due to immature thermoregulation.

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13
Q

Rectal Temperatures

A

Patient in sims position, red tipped probe, use water based lubricant, insert 1-1.5 inches, clean anus with tissue after.

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14
Q

Temporal temperatures

A

measures cutaneous blood flow (of temporal artery). swipe center of forehead to hairline and over temporal artery, then place on mastoid process behind ear. Affected by moisture.

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15
Q

List signs and symptoms of fever

A

chills, diaphoresis, weakness, warm temp. flushed skin, rapid pulse and respiratory rates.

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16
Q

What can Nurses do to bring fever down?

A

Obtain ordered blood cultures for antibiotics, minimize physical activity/position changes, provide 02 therapy, offer meals and increase fluid intake, apply damp cloth to pat’s forehead, control environmental temp.

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17
Q

Define pulse

A

palpable bounding of blood flow through arteries as blood is pumped from left ventricle. Good indicator of circulatory status.

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18
Q

Pulse rate

A

The amount of beats palpated per minute. be aware of influencing factors

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19
Q

Tachycardia

A

abnormally high pulse rate. In adults= above 100 beats/min.

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20
Q

Bradycardia

A

abnormally low pulse rate. In adults= below 60 beats/min.

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21
Q

Pulse dysrhythmia

A

Abnormal rhythm of heartbeats from early, late or missed beats. Irregular beats produce pulse deficits

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22
Q

Pulse volume (strength)

A

volume of blood ejected against arterial walls, noted as bounding (4+), strong (3+), Normal (2+), diminished (1+), or absent (0).

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23
Q

Character (Equality) of the Arteries

A

Pulses on both sides of the body should be equal in rate and strength.

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24
Q

What can cause unequal, asymmetric pulses?

A

blood clot formation, aberrant blood vessels, and aortic dissection.

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25
Q

Apical/Radial pulse deficit

A

difference between the apical and radial pulses when measured simultaneously by 2 colleagues. often associated with abnormal rhythms.

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26
Q

Name factors that can affect pulse

A

Exercise, Temperature (fever, heat increase), Emotions, Shock (low HR), Drugs( epinephrine/tobacco increase, beta blockers, digitalis decrease), Hemorrhage (increases), Posture, Pulmonary conditions (COPD, emphysema increase)

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27
Q

Normal Adult pulse range

A

60-100 bpms

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28
Q

Normal Children pulse range

A

Toddlers-school age children= 75-140bpms, infants 120-160bpms. Normally higher than adults.

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29
Q

Name 3 major observations you make when taking radial pulse?

A

Note the rate in bpms, rhythm (regular intervals), and strength (0-4 scale).

30
Q

Apical pulses

A

locate the point of maximal impulse (PMI) by finding the the 4th or 5th intercostal space at mid-clavicular line. Auscultate and count.

31
Q

Name 10 arterial pulses

A

Apical, Temporal, Carotid, Brachial (antecubital fossa), radial, ulnar, femoral (below inguinal ligament), popliteal (behind knee), posterior tibial (inner side of ankle), dorsalis pedis (top of foot).

32
Q

Name 2 reasons for taking arterial pulse

A

When checking for impaired peripheral blood flow, When assessing affects of medications or exercise.

33
Q

Respiration

A

includes one inhalation and expiration. the exchange of 02 and C02 in lungs to provide adequate oxygen to body.

34
Q

hyperpnea

A

resps are labored, increased in depth, and increased in rate (above 20 rpms)

35
Q

Cheyne-stokes

A

irregular rate and depth of resps. with alternating apnea and hyperventilation periods.

36
Q

Respiratory Rhythm

A

assesses the interval between each resp. cycle. Either regular or irregular

37
Q

Pallor

A

whiteness in skin of face, lips, conjunctivae, nail beds, palms or soles. due to decreased oxyhemoglobin from anemia or shock

38
Q

dyspnea

A

difficulty/abnormal breathing, clinical sign for hypoxia

39
Q

stridor

A

wheezing sound due to turbulent airflow in the upper resp. tract.

40
Q

Cyanosis

A

bluish color due to increased deoxygenated hemoglobin, hypoxia. Caused by heart, lung diseases or cold temps. Look at nail beds, lips, mouth, and general skin

41
Q

Name factors that affect respiration

A

Exercise, Acute pain (shallow), Anxiety, Smoking, Body position, medications, neurological injury, hemoglobin function

42
Q

Normal repiratory ranges

A

Adults= 12-20rpms, Children= 20-30rpms. Children are normally higher (smaller lungs)

43
Q

Major observations made when assessing respiration

A

Rate, Rhythm (intervals regular or not), Depth (shallow, deep)

44
Q

Muscles normally used in respiration?

A

diaphragm contracts during inspiration, causing the abdomal cavity to rise and the chest wall gently rises. During expiration, diaphragm relaxes, chest wall and abdominal cavity fall.

45
Q

Kussmaul’s respiration

A

Respirations that are abnormally deep, regular, and increased in rate

46
Q

Biot’s respiration

A

Respirations are abnormally shallow for 2-3 breaths followed by irregular period of apnea

47
Q

What accessory muscles might be used to assist some ill people respirate?

A

Contraction of the neck and shoulder muscles, or the intercostal muscles between the ribs may help ill people.

48
Q

How does assessing skin color relate to respiratory assessment?

A

Abnormal skin color relates to circulatory system abnormalities. For instance cyanosis and pallor both result from levels of oxygenated hemoglobin. Erythema is caused by dilated vessels and increased oxyhemoglobin

49
Q

Erythema

A

red color caused by increased visibility of oxyhemoglobin, dilated vessels, increased blood flow. Causes= fever, direct trauma, alcohol intake. Look at face, sacrum, shoulders

50
Q

What factors affect the accuracy of assessing skin color?

A

if the person works outside (skin exposed to sun more pigmented), cosmetics, tanning agents, Age (elderly have uneven/increased pigmentation), Darker skinned patients (harder to view pallor and cyanosis). Areas of hyperpigmentation and hypopigmentation (normal).

51
Q

Pallor in dark-skinned patients

A

face, buccal mucosa, conjunctiva, nail beds. brown skin appears yellow brown, black appears ashen gray. mucous membranes will be gray

52
Q

Cyanosis in dark-skinned patients

A

observe least pigmented areas; lips, tongue, conjunctivae, palms, soles, nail beds.

53
Q

Erythema in dark-skinned patients

A

not easily observed so have to feel area for heat, warmth and inflammation

54
Q

T or F: If a person has dyspnea, he/she may also tend to have tachycardia?

A

True

55
Q

Amphetamines and cocaine ______ respirations?

A

increase

56
Q

Naroctics ______ respirations?

A

decrease

57
Q

Systolic pressure

A

peak of maximum pressure when ejection of blood occurs

58
Q

dystolic pressure

A

minimum pressure against arteries when the ventricles relax.

59
Q

pulse pressure

A

difference b/w the systolic and diastolic BP. example- BP= 120/80, PP=40

60
Q

Korotkoff sounds

A

sounds heard when auscultating bp, caused by vibration of the arterial wall as the artery distends from BP cuff. 1st sound= systolic pressure, 2nd sound= diastolic.

61
Q

auscultatory gap

A

usually with hypertensive patients, when lub dub temporarily disappears when cuff pressure is reduced, and then sound reappears at lower level.

62
Q

Hypotension

A

low BP, when systolic pressure falls below 90mmHg. Due to hemorrhaging, heart failure, myocardial infarction.

63
Q

Hypertension

A

Diastolic readings above 90mmHg and systolic readings above 140mmHg. Due to thickening and loss of elasticity in arterial walls.

64
Q

orthostatic hypotension

A

patient experiences low BP and symptoms when moving to an upright position. Can be from meds, dehydration, anemia and prolonged bedrest

65
Q

What five physiological factors control BP?

A

Cardiac output (HRxSV), Peripheral Resistance, Blood Volume, Viscostiy of blood, Elasticity of arteries.

66
Q

Name 6 factors that can affect BP

A

Age, Stress, Race (higher in africans), Gender, Medications (Narcotics and analgesics decrease), Time of day (diurnal variation)

67
Q

Does BP normally increase or decrease with age? why?

A

Increases, during childhood to compensate larger body size/weight, and during adulthood due to decreased elasticity of arteries

68
Q

Does BP tend to be higher or lower in the sitting/standing positions compared to lying position? Why?

A

BP is higher when sitting/standing because of increased peripheral resistance.

69
Q

Describe 3 sounds of normal BP

A

Sharp thump, 1st sound heard= systolic pressure, then a gradually softening thumps as cuff deflates, then last fading thump= diastolic pressure

70
Q

Normal BP range for adults

A

less than 120/80mmHg

71
Q

Normal BP range for children

A

87-117/48-64mmHg

72
Q

Normal BP range for infants

A

65-115/42-80 mmHg

NRS Therapeutics 1 (1 decks)

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