Week 2 Flashcards
Why are vital signs important ?
They determine a baseline for future assessments
what are the guidelines for vital sign measurements ?
1) unregulated care providers may measure the vital sigs and the nurse responsible has to interpret and act on these measurements
2) use equipment that is functional and appropriate for the size and age of the patient
3) select equipment based on the persons conditions and characteristics
4) minimize environmental factors that may affect vital signs
5) use an organized step by step approach
6) approach patient in calm, caring manner while demonstrating profiency
7) use vital signs to determine indications for prescribed medication administration
8) Analyze vital sign measurement results
9) when vital signs appear abnormal, have another nurse take the vital signs
10) involve in the patient/and or caregiver in the vital sign assessment and finding
What is core temperature ?
temperatures of structures deep within the body
what do temperature control mechanisms do?
They keep the core temperature constant
normal body temperature range
36C to 38C - body surface temperatures fluctuate depending on blood flow to the skin and amount if heat lost to the external environment
thermoegulation
the balance between heat lost and heat produced
what is the role of the hypothalamus ?
To control body temperature - it sense changes in the body temperature - when its too hot the nerve cells in the anterior hypothalamus go above the set point, impulses are then sent to reduce body temp - the posterior hypothalamus senses the temp is below the set point then impulses are sent to increase the body temp
what is a set point
A comfortable temperature
which part of the hypothalamus recognize an increase in body temp above set point
the anterior hypothalamus
which part of the hypothalamus recognizes a decrease in body temp below the set point
the posterior hypothalamus
what mechanisms are used to increase body temp
Vasoconstriction of blood vessels to decrease flow to skin and the extremities - muscle shivering
what mechanisms are used to decrease body temperature when its too high
sweating, vasodilation, inhibition of heat production
Which process produces heat ?
metabolism - as metabolism increases more heat is produced and when metabolism decreases heat production decreases
when does heat production occur ?
rest, voluntary movement, involuntary shivering, non-shivering thermogenesis
Basal metabolic rate
heat produced at absolute rest
which hormone affects BMR ? how does it affect BMR?
the thyroid hormone affects bmr by promoting the breakdown of body glucose and fat
male sex hormone
testosterone increases BMR- men have a higher BMR than women
Exercise
exercise increases BMR and heat production
Shivering
is an involuntary body movement - significant energy is required for shivering which increases body temp - this heat equalizes body temperatures
Why are babies and older individuals at risk for hypothermia
they are less likely to generate heat via shivering or preserve heat via vasoconstriction which puts them at risk for hypothermia
Non shivering thermogenesis
main source of heat generation in newborns - sympathetic nerve ending release norepinephrine to respond to chilling which stimulates fat metabolism in richly vascularized brown adipose tissue to produce internal heat that is then conducted to the surface
how is heat lost
conduction, evaporation, convection, radiation
Radiation
transfer of heat from the surface of one object to the surface of another without direct contact - radiation increases as the temp difference increases - if the environment is hotter than person we absorb heat - radiation can increase through removing clothing patients position enhances radiation - standing more SA to radiate heat - fetal position covered by something decreases heat
Conduction
transfer of heat from direct contact - touch colder surface you will lose heat - touch a hotter surface the body gains heat
Convection
transfer of heat away from body by air movement
Evaporation
transfer of heat when liquid is changed to gas - sweat
Diaphoresis
visible perspiration which occurs primarily on the forehead and upper thorax - excess evaporation can cause skin scaling and itching, as well as drying of the nares and pharynx
what determines a persons ability to control body temperature
1) the degree of temp extreme 2) the persons ability to sense feeling comfortable or uncomfortable 3) though processes or emotions 4)the persons mobility or ability to remove or add clothes
Factors affecting body temperature ?
1) age - infants lose 30% of there heat from there heads - temp regulation is unstable until children hit puberty
2) exercise
3) hormone level - women have greater body fluctuations than men - progesterone increases body temp - menopause causes hot flashes which is caused the instability of the vasomotor controls
4) Circadian Rhythm - lowest between 0100 and 0400 hours - body temp rises steadily to about 1800 hours then declines back down to early morning levels
5) stress
6) environment (poikilothermia - depends on the level of the injury, high cervical injuries have a greater loss of ability to regulate temperature
7) temperature alterations ( Fever or pyrexia - the heat loss mechanisms cannot keep up with the rise in body temp - below 39C its ok) - pyrogens can cause a rise in body temperature - pyrogens are antigens, triggering the immune system responses - during the period the person may experience chills and shivers even though body temp is rising - once the chill phase subsides a new set point of high temp is achieved - the person feels dry and warm - once the pyrogens are removed the third phase of febrile (showing symptoms of fever) occurs (white blood production is stimulated, increased temp decreases iron in blood plasma which suppresses bacteria growth ) - when the fever breaks someone becomes afebrile (not showing symptoms of fever)
why are fever patterns important ?
helps with making diagnosis - fever pattern differ depending on the pyrogen - fever of unknown pyrogen refers to a fever that does not have a determined cause
risks of fever
during fever cellular metabolism increases ad oxygen consumption rises - energy use increases due to increase in metabolism - increases metabolism required an increase in oxygen - risks of myocardial hypoxia produces angina (chest pain) - cerebral hypoxia produces confusion - oxygen therapy may be needed - water loss is excessive which causes dehydration
hyperthermia
body temperature that is elevated as a result of the body inability to promote heat loss or reduce heat production which results from an overload of the body’s thermoregulatory mechanisms
Heatstroke
prolonged exposure to the sun or high environmental temperatures can overwhelm the bodies heat loss mechanisms - people old, very young, alcoholism, spinal cord injury, diabetes, cardiovascular disease, hypothyroidism - symptoms are confusion, delirium, excess thirst, nausea, muscle cramps, visual disturbances, giddiness, hot dry skin, vital signs as high as 45C increase HR and low BP
Heat Exhaustion
profuse diaphoresis results in excessive water and electrolyte loss - fluid volume deficit
Hypothermia
heat loss prolonged exposure to cold overwhelms body’s ability to produce heat - loss of memory, depression, poor judgement, uncontrollable shivering - severe hypothermia causes death - 35C or less
Frostbite
ice crystals form inside cells can result in circulatory and tissue damage (earlobes, tip of the nose, fingers, and toes) white, waxy, firm to touch, loss of sensation
where are core temperatures measured ?
pulmonary artery, esophagus, urinary bladder
intermittent temperatures are measured from ?
mouth, rectum, tympanic membrane
Types of thermometers
1) electronic thermometer
2) clinical strip thermometers - remove after 60sec tend to overestimate
3) glass thermometers
during acute care, how may a health care provider try t0 intervene ?
the healthcare provider may try to find the cause by isolating the pyrogen via lab analysis - once the lab results are available the prescribed healthcare provider with give the correct antibiotics for the pyrogen
What happens when children get fevers ?
children usually get fevers from viruses - they immature temperature control mechanisms - febrile seizures are uncommon for children older than 6 years of age - children are also at risk of losing large amounts of water in proportion to there BW
what medications can be given to decrease fever ?
Antipyretics example:
nonsteroidal (acetaminophen, salicylates, indomethacin, and ketorolac) by increasing heat loss
corticosteroids reduce heat production
nonpahrmalogical methods would be via conduction, evaporation, convection, or radiation (hypothermia blankets, tepid sponge baths, bathing with alcohol water solution, ice packs, cooling fans)
what are the solution for heatstroke ?
moving patient to cooler environment - reducing clothing - placing cool wet towels over skin -
what are the solutions for hypothermia ?
removing wet clothes, wrapping patient in blanket, forced air warming blankets, placed under blanket next to warm person in non healthcare setting, drink hot liquids - keep patients head covered
AVOID ALCOHOL AND CAFFIENE
stroke volume
60 to 70 ml of blood enters the aorta with each ventricular contraction
what happens with each stroke volume ejection ?
blood is pushed out of the heart - the walls of the aorta distend - this creates a pulse wave which reaches the peripheral arteries
Pulse Rate
is the number of pulsing sensations occurring in one minute
Cardiac output
the volume of blood pumped by the heart during 1 minute
how do you determine how much ml of blood is pumped out of the heart per minute ?
beats per minute (pulse rate) x stroke volume (ex: 70bpm x 70ml = 4900 ml per min)
As heart rate increase…..
the heart has less time to fill - without a change in stroke volume - bp decreases
as the heart slows….
filling time increases - blood pressure increases
which artery is mainly used for the assessment of pulse ?
Radial artery - when a patient suddenly worsen the carotid artery is used - if the radial pulse cannot be used then the apical pulse can be assessed
when should apical pulse be assessed ?
when patient takes medication that affects heart rate - apical pulse is more accurate assessment of cardiac function - infants an young children the apical or brachial pulse should be checked
heart sounds to focus on….
a normal slow rate (S) is low pitched and dull “lub” - higher pitched and shorter “dub” - count the number of lub dubs
Tachycardia
abnormally fast heart rate, more than 100bpm
Bradycardia
slow heart rate, less than 60 bpm
what is a pulse deficit ?
an inefficient contraction of the heart rate that fails to transmit a pulse wave to the peripheral pulse site
how to detect a pulse deficit ?
two people are req - one to asses the radial (brachial pulse) and the other to assess the radial pulse - the difference between the two is the pulse deficit ( radial pulse is 78 bpm and apical is 92 bpm the difference is 14 which is the pulse deficit
Dysrythmia
an interval between each pulse or heartbeat that is early, late, or missed beat - if detected an EMG needs to be done
what is the strength of a pulse
the strength of a pulse reflects the volume of the blood ejected against the arterial wall with each heart contraction
what is the equity of pulses
pulses on both sides of the body need to be assessed to compare their characteristics - carotid pulse should not be assessed simultaneously b/c excessive pressure
Ventilation
the movement of gases in and out of the lungs
Diffusion
the movement of oxygen and CO2 between the RBCs and alveoli
Perfusion
the distribution of RBCs to and from the pulmonary capillaries
adult breathing pattern
12 to 20x per minute
elevation in co2 levels
causes the respiratory control system in the brain to increase the rate and depth of breathing - this is done to remove excess co2 (hypercarbia) increased exhalation
what happens when arterial O2 levels drop….
chemoreceptors in the carotid artery and the aorta become sensitive to HYPOXEMIA (low O2 levels) - the receptors send signals to the brain tp increase the rate and depth of ventilation
what happens during inhalation ?
the respiratory center sends impulses along the PHRENIC NERVE, causing the diaphragm to contract - abdominal organs move downward and forward
Tidal Volume
the amount of air that moves in and out of the lungs with each respiratory cycle (normal person inhales 500ml of air)
Eupnea
is the normal rate and depth of ventilation
why does sighing happen ?
eupnea is interrupted by sighing - sigh is prolonger deeper breathe which is a protective physiological mechanism for expanding small airways and alveoli that were not ventilated during normal breath
why should you not let the patient know that you are assessing breathing ?
they may alter there breathing rate and depth - its better to measure respiration when measuring pulse
what is apnea monitor
An apnea monitor is a respiratory monitoring device- used frequently with infants
what is ventilatory depth
depth of respiration is assessed by observing the degree of excursion or movement in the patients chest wall - deep respiration is the full expansion with full exhalation
Arterial Blood gases
pH: 7.35–7.45 mm Hg
PaCO2: 35–45 mm Hg
PaO2: 80–100 mm Hg
SaO2: 95%–100%
Pulse oximetry (SpO2)
normal levels are 95 - 100% less than 85% is abnormal
Specific tests of the complete blood cell count (CBC)
Hemoglobin: 135–180 g/L in male patients; 120–160 g/L in female patients
Hematocrit: 0.43–0.49 in male patients; 0.38–0.44 in female patients
Red blood cell count: 4.7–5.74 × 1012/L in male patients; 4.2–4.87 × 1012/L in female patients
how is ventilatory rhythm assessed ?
the best way is to observe the abdominal movements -women’s abdominal movements are best observed from there upper chest because they use their thoracic muscles
what happens when there is foreign body that interferes with the movement of air in and out of the lungs ?
the intercoastal spaces in the rib cage retract during inspiration
what does a long expiration phase indicate ?
the outward flow is obstructed
what is SaO2 ?
it is the saturation of hemoglobin (SaO2) - which is the percentage of Hemoglobin that is bound with oxygen in the arteries- normal range is 95 to 100%
what is SvO2?
it is the saturation of venous blood - which is lower the SaO2 value - the normal value is 70%
what is a pulse oximeter ?
permits the indirect measurement of oxygen saturation - an LED emits light wavelengths that are absorbed differently by oxygenated and deoxygenated hemoglobin molecules
what is blood pressure ?
it is the force exerted on the walls of an artery by the pulsing blood under pressure from the heart
what is systolic blood pressure ?
is it the maximum pressure when ejection occurs
What is diastolic blood pressure ?
it is the minimal pressure exerted against the arterial walls - when the ventricles relax and the blood remaining in the arteries exert diastolic pressure
how is blood pressure measured ?
mmHg is the unit used - systolic/diastolic
what is pulse pressure ?
it is the difference between systolic and diastolic pressure
relation of cardiac output and blood pressure ?
when the cardiac output increases - more blood is being pumped against arterial walls causing the blood pressure to rise- a greater heart increases the cardiac output
what happens when heart rate increases rapidly ?
when heart rate increases rapidly than it decreases the hearts ability to fill, resulting in bp decreasing
relation of blood pressure & peripheral resistance ?
the size of arteries and arterioles remain partially constricted to maintain constant blood flow - the local arteries and arterioles change size to adjust blood flow to local tissues - peripheral vascular resistance is the resistance to blood flow
relation of blood volume and pressure ?
the volume of blood circulating within the vascular system affects blood pressure - more volume increases than more pressure is exerted against the arterial walls ( when circulation BV decreases due to hemorrhaging or dehydration than bp decreases)
relation of blood pressure & viscosity ?
the thickness of the blood does affect the pressure - HEMATOCRIT (% of red blood cells in the blood) determines the blood viscosity - when hematocrit rises, the heart has to pump more forcefully to pump the viscous fluid which causes an increase in BP
relation of elasticity and Blood pressure ?
walls of the artery normally are elastic to accommodate pressure changes but when certain diseases like arteriosclerosis where the arteries lose there elasticity the resistance to blood flow is greater - systemic pressure rises - systolic pressure is greater than diastolic pressure-
relation of blood pressure & age ?
blood pressure varies throughout age - children have increasing (infant 65 to 115 mmHg systolic/42 to 80 diastolic) - adults bp increases with advanced age normal would be (l140/90 mmHg) - people with diabetes (130/80 mmHg)
why would older people have higher systolic pressure ?
this is due to decrease elasticity in the vessels - bp higher than 140/90 is HYPERTENSION
relation between stress and BP?
anxiety, fear, pain and emotional stress cause a stimulation of the Sympathetic nervous system
Heart Rate, Cardiac Output, Ventricular Resistance Increase
BP increases
does ethnicity affect blood pressure ?
hypertension is higher in ethnic groups - environmental factors may be a contributing factor
gender differences between blood pressure ?
men have higher BP after puberty and women have higher BP during menopause than men of a similar age
does blood pressure vary throughout the day ?
yes, bp rises in the late afternoon and evening and declines in the early morning
do medications affect blood pressure ?
yes, medications can indirectly and directly affect bp - antihypertensive drugs and other cardiac medications may lower bp
what other factors affect blood pressure ?
- activity ( bp drops several hours after exercise and during exercise bp rises to meet oxygen demands)
- eating (bp rises in older people 1 hour after eating)
- obesity (factor in hypertension)
- smoking ( bp rises and drops back to normal 15 min after smoking)
what is white coat hypertension?
bp rises during visit to health care provider
what is masked hypertension ?
bp reading is normal with HCP but elevates when at home
what is cardiovascular disease ?
people with a family history of hypertension have a risk of getting cardiov. disease - risk factors are obesity, smoking, salt intake, lifestyle, alcohol consumption, sedentary lifestyle)
what is hypotension ?
the dilation of the arteries in the vascular bed, loss of substantial blood volume, or the failure of the heart muscle to pump adequately
what symptoms are associated with hypertension ?
pallor, skin mottling, clamminess, confusion, increased HR, decreased urine output
what is orthostatic hypotension (postural hypotension) ?
when a normotensive person develops symptoms of low blood pressure when rising to an upright position - when volume depleted person stands, bp drops significantly, HR increases to compensate for the drop in CO
who is at risk for orthostatic hypotension ?
dehydrated individuals, anemic, prolonged bed rest or recent blood loss
what is Sphygmomanometer ?
cloth or occlusive vinyl, pressure manometer,
what are the two types of sphygmomanometer ?
aneroid (glass enclosed circular gauge - require regular calibration) & mercury
how should blood pressure reading be done ?
when the patient is supine sitting position or standing position -
what is an auscultatory gap ?
the temporary disappearance of sound -
Define Disease ?
an objective state of health of ill health - the pathological process can be detected by medical science
Define Illness ?
Is a subjective experience of the loss of health
Define Health ?
Objective process of characterized by functional stability, balance and integrity
Define Wellness ?
Subjective experience
What are the different Health Conceptualizations ?
- Health as Stability: maintenance of physiological, functional, and social norms
- Health as Actualization: Actualization of human potential
- Health as Actuslization and Stability
- Health as Resource
- Health as Unity
What is Labonte’s multidimensional conceptualization view of health ?
- feeling vitalized and full of energy
- Having satisfying social relationships
- Having feeling of control over ones life and living condition
- being able to do things that one enjoys
- having a sense of purpose
- feeling connected to community
In modern times, what are the three approached to health ?
- Medical Approach: represents a stability orientation to health - health problems are defined as Physiological risk factors which are physiologically defined characteristics that are precursors to or risk factors for diease
- Behavioural Approach: lifestyles, environment, human biology and the organization of health care - this health field concept was widely used - the behavioural approach places responsibility for health on the individual which favours health promotion strategies
- Socioenvironmental Approach: health is closely tied to social structures such as air pollution and poor water quality
What are the major determinants of health ?
- Income and social status: people with lower income have ower life expectanices, more likely to have chronic health problems, lower self esteem, lower sense of self - children born into low income families have low birth weights and are more likely to have chronic diseases
- Social Support Networks: social suppot affects health behaviours, health, and healthcare utilization, - studies have found that higher levels of support and mastery were associated with lower psychological stress
- Education and Literacy: literacy can affect both directly or indirectly - education increases job oppurtunity and income security - people with higher education smoke less, are more physically activem and have healthier foods
- Employment and working conditions: workplace stress is associated with physical injuries, high blood pressure, Cardiovascular disease, depression, and an increase in tobacco and alcohol use
- Physical Environments: lack of adequate housing is a concern and affects health directly, food security, second hand soke increases suddent infant death syndrome
- Biological and Genetic Endowment: hereditary is strongly ifluenced, age is also a social determinant of health
- Individual Health practice and Coping skills: Physical inactivity, poor nutrition, tobacco use
- Healthy Child Development (early life)
- Health services
- Gender
- Culture
- Social Environments: the array of values and norms of a society that influence in varying ways the health and well being of populations
Define Health Promotions ?
is directed toward increasing the level of well being and self actualization
Define disease prevention ?
action to avoid or forestall illness/disease
what are the three levels of disease prevention ?
- Primary Prevention: activities that protect against disease before sigs and symptoms occur
- Secondary Prevention: activities that promote ealy detection of disease once pathogenesis has occured so that prompt treatment can be initiated (ex: prevention screening for cancer)
- Teritary Prevention: activities that are intiated in the convalescence stage of disease and are directed toward minimizing residual disability and helping people live productively with with limitations
What are the different health promotion strategies?
- Build Healthy Public Policy
- Create supportive environments
- Strengthen Community Action
- Develop personal skills
- Reorient Health services
What is the Indian Act ?
identified the federal governments role in providing health care services to first nations inuit
treaties were signed before the confedarion of with the british government and after with the government of Canada
These treaties enabled the direct delivery of healthcare to indigeneous people regardless of where they live in Canada including Primary Health Care (PHC) and emergency services o remote and isolated reserves
What is the Truth and Reconciliation Commission (TRC) ?
considered and brough attention to the events and impacts of indian residential schools - TRC merged both truth and reconciliation in order to repair bonds and relationshios between Canadas indigineous and non indigineous people
What are inpatients and outpatients ?
Inpatients who stay at an institution for diagnosis, treatmen, rehabilition and outpatients are ones who visit an institution for select services
What are the different institutional sectors ?
- Hospitals: major healthcare agencies - most specializing in acute care services
- Long term care Facilities: 24 hour immediate and custodial care for residents of any age with chronic or debilitating illness or disabilities
- Psychiatric Facilities
- Rehabilitation centres
What are the different Community Sectors ?
- Public Health: public health is committed to ensuring conditions and circumstances in which people can be healthy through appropriate screening, assessment, developement, monitoring and support
- Physician Offices
- Community health centres ad Clinics
- Assisted Living
- Home Care: provision of health care services and equipment to patients and families in their homes, residential settings, hospitals and ambulatory clinics
- Adult Day Support Programs: is an alternative to hospitalization
- Community and volunteer agencies
- Hospice & pallative care
- Occupational Health
What are the levels of care ?
- Level 1: Health promotion
- Level 2: Disease and Injury prevention
- Level 3: Diagnosis and Treatment: which contains three subleves (Primary care which is the first contact the patient makes with the health care system that leads to decision making regarding a course of action - Secondary Care usually occurs in hospital or home settings and involves specialized medical service - Tertiary Care is specialized care in diagnosing and treating complicated health problems, tertiary care occurs in regional, teaching, university, or specialized hospitals
- Level 4: rehabilitation - the aim of rehabilitation is to improve the health and quality of life of those facing life altering conditions regardles of age of circumstances
- Level 5 Supportive Care: consists of health, personal, and social services provided over a prolonged period to people who are disabled, who do not functional independtly or have a terminal disease
What is Critical Thinking ?
it is defined as a process and a set of skills
critical thinking requires purposeful and reflective reasoning to examine these ideas, assumptions, beliefs, principles, conclusions and actions within the context of the situation
The use of Evidence informed Knowledge which is knowledge based on research or clinical expertise which makes you an informed clinical thinker and improves patient outcomes
Critical thinking not only requires cognitive skills but also requires a nurses habit to ask questions, to be well informed, to be honest in facing personal biases, and always being able to reconsider and think differentlly about issues
Learning to apply these skills and establish critical thinking required time and practice
What are the levels of critical thinking in nursing ?
- Level 1 Basic: thinking is concrete and based on a set of rules and priciples
- Level 2 Complex: you begin to seperate your thinking process from those of expert others and to analyze and examine choices more independently - consider other options
- Level 3 Commitment: assuming responsibility and accountability for your choices
What are the components of critical thinking ?
- Specific Knowledge Base: knowledge base includes information and theory from the basic sciences, humanities, behavioural scieneces, and nursing - Building sound knowledge base demands that you also develope Information Literacy Skills which indicates proficency in knowing when information is needed and how to affectively find, retrieve, evaluate, and apply research findings
- Experience
What are the critical Thinking competencies ?
- Scientific Method: is a systemic ordered approach to gathering data and solving problems that is used in nursing, medecine, and various other disciplines - consists of five steps (Identification of the problem, collection of data, formulation of reseacrh questions or hypothesis, testing of the question or hypothesis, evalution of the results of the test or study
- Problem Solving: imvolves evaluating the solution over time to be sure that it is still effective
- Decision Making: is a product of critical thinking that focuses on problem resolution
What are Specific Critical Thinking Competencies in clinical situations ?
- Diagnostic Reasoning and Clinical Inference: Diagnostic reasoning is a process of determining the patients jealth status after you make physical and behavioural observations and after you assign meanings to the behaviours, physical signs, and symptoms exhibited by the patient - Clinical Inference is the process of drawing conlcusions from related pieces of evidence - Clinical Reasoning is a term used to describe the cognitive process of thinking about patients issues, making inferences, and deciding on the action to be implemented on a particular situation
- Clinical Decision Making: focuses on defining patient problems and selectiong appropriate interventions - clinical judgement consists of 4 components (noticing and grasping the situation, interperting or developing a sufficent understanding of the situation to respond, responding or deciding on a course of action, reflecting on the actions and the outcomes
What are the standards for critical thinking ?
- Intellectual Standards: guideline or principle for rational thought
- Professional standards: consists of a ethical criteria - the code of ethics for registered nurses are based on core values that serve as a guide to ethical decision making
What are the ways of developing critical thinking skills ?
- Case Based Learning: allows you to explore problems and engage in decision making w.o harming the patient
- Reflective Writing: uses the process of reflection - reflection allows you to examine your assumptions
- Concept Mapping: visual representation of patient problems ad interventions that depicts there relationship with one another
