Week 5 Flashcards
what is Autologous Donation
when pt donates their own blood for their surgery
what are the 5 vital signs
- Respiratory rate (oxygen saturation)
- Temperature
- Blood pressure
- Pulse
- Pain rating 0-10
Steps for taking pulse
- Put index and middle finger on radial artery (on wrist)
- Count for 30 seconds
- Multiply by 2 and find the pulse
What is a normal pulse range
60-99 beats/min
Why is it important to keep record of vitals
to have a baseline to compare with at each visit
Body temperature is regulated by what
the part of the brain called the hypothalamus
What is the temperature that is considered critical?
106 degrees and above, also
96 degrees or below
Mercury is no longer used becasue
It is extremely toxic to the human body and very hard to clean up
What is the name of ear thermometers we use
Tympanic (fast and accurate reading)
what is Febrile
When a fever is present, must be over 100
also called Pyrexia
What is Afebrile
no fever present
What is Hypothermia
Decreased core body temp
What is Onset
When the fever began
Antipyretic
Agent to reduce fever
Lysis is what
body temp gradually returns to normal after a period of fever
What is a pulse
the two phases of the heart action that can be felt when compressing the artery
Most common areas to take a pluse
radial artery (on the wrist thumb side)
apical artery (Draw a straight line from the left nipple to the fifth intercostal space to identify the area of the apical pulse.)
NR baby pulse rate at birth
130-160
NR infant pulse rate
110-130
NR child 1-7 pulse rate
80-120
NR child over 7 pulse rate
80-90
NR Adult pulse rate
60-100
When do you take Respirations
after taking pulse, don’t tell pt you’re counting the breaths to avoid erroneous results
What makes us breath
the buildup of CO2 not the absence of O2 is what makes us spontaneously take a breath
What part of the brain measures blood levels of CO2
Medulla oblongata
What is the normal respiratory rate to pulse ratio
1 breath:4 pulse beats
When taking respirations what are you looking for
- The rhythm if it is regular or irregular
2. The depth (the amount of air that is inspired and expired)
What causes elevated respiratory rate
Excitement emotions fever lung disease pain shock hemorrhage drugs exercise nervousness
What can cause decreased respiratory rate
Sleep coma drugs pressure on the brain kidney disease
One inspiration and one expiration is equal to what
one respiration
NR for BP
less than 120 SBP
Less than 80 DBP
High BP (hypertension stage 1) range
140-159 SBP
90-99 DBP
Prehypertension BP range
120-139 SBP
80-89 DBP
High BP (hypertension stage 2)
160 & Higher SBP
110 & Higher DBP
Hypertensive crisis
Higher than 180 SBP
Higher than 110 DBP
Blood pressure is measuring what?
the force of blood exerted on the peripheral arteries during the cardiac cycle
What is the name of the type of BP device used in health care today
sphygmomanometer
Can be electric or manual,
Manual is called Aneroid Manometer
What is the Korotkoff Sounds
blood flow sounds that healthcare providers observe while taking blood pressure with a sphygmomanometer over the brachial artery in the antecubital fossa. These sounds appear and disappear as the blood pressure cuff is inflated and deflated.
Phase 1 Korotkoff
K-1 (Phase 1): The appearance of the clear “tapping” sounds as the cuff is gradually deflated. The first clear “tapping” sound is defined as the systolic pressure.
Phase 2 Korotkoff
K-2 (Phase 2): The sounds in K-2 become softer and longer and are characterized by a swishing sound since the blood flow in the artery increases.
Phase 3 Korotkoff
K-3 (Phase 3): The sounds become crisper and louder in K-3 which is similar to the sounds heard in K-1.
Phase 4 Korotkoff
K-4 (Phase 4): As the blood flow starts to become less turbulent in the artery, the sounds in K-4 are muffled and softer. Some professionals record diastolic during Phase 4 and Phase 5
Phase 5 Korotkoff
K-5 (Phase 5): In K-5, the sounds disappear completely since the blood flow through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.
If hypertension goes untreated it will cause damage to what
the heart, kidneys, eyes, and arteries
it takes how many dr visits to diagnose hypertension
3 separate visits
How many types of HTN (hypertension)
4 types
- Primary
- Secondary
- Benign
- Malignant
Primary HTN
No apparent cause or cure, most common type, tx is life long
Secondary HTN
results of another medical condition such as pregnancy, renal disease, obesity. When underlying problem resolved BP returns to normal
Benign HTN
HTN that has a slow progression, most primary is benign
Malignant HTN
Very rare, progresses rapidly, damages cardiovascular system
HT (hypotension) NR
Usually below 90/60
seen with hemorrhage, shock, CNS (central nervous system) disorders and treatabe
Pulse oximetry
Can measure the O2 saturation continuously and accurately to detect a drop in saturation before a Pt becomes cyanotic
Cyanosis
a bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.
Dyspnea
difficulty breathing a s/s of a decline in O2 saturation
Orthopnea
in ability to breath in any position other than sitting straight up or standing
Diaphoresis
extreme perspiration
What is a pulse omimetry
it measures both )w saturation and the pulse rate.
What is a normal O2 saturation level
95%-100% if lower alert the nurse or MD
What is O2 saturation mean
the bodies hemoglobin molecules are bound to an O2 molecules and if every hemoglobin were attached to an O2 then the body would be at 100% saturation
If O2 saturation is below 90% what can happen
it could be life threatening situation
Can you apply an oximetry to the same hand of an arm that has a pressure cuff on it
NO
Dysrhythmias is a oximetry limitation becasue
the abnormal heart rhythms (dysrhythmias) can cause inadequate perfusion and lead to falsely decreased O2 stats.
Perfusion
the process of oxygenated blood being delivered to the tissues of the body. … Perfusion of the body’s tissue occurs during Systole. The chambers contract and the oxygenated blood is forced into the arteries. These arteries carry the blood to the tissues where the oxygen is removed from the blood.
Oximetry can have skewed results from what
Nail polish
acrylic nails
intravenous dyes (especially dark colors)
