week one Flashcards
when to measure vital signs
- on admission
- per physician
- changes in patients condition
- before and after major procedure
- during blood transfusion
- after medications or interventions that affect vitals
normal temp ranges for adult
96.8-100.4
normal oral/tympanic temp range
97.6-99.6
normal rectal temp
98.6-100.4 (most accurate)
normal axilla temp
96.6-98.6
normal pulse range
60-100 bpm
normal respiration rage
12-20 bpm
normal blood pressure range in adults
less than 120/80 mmHg
what range is considered pre-hypertensive blood pressure
systolic 120-139
diastolic 80-89
what range is considered hypertensive blood pressure
systolic > 140
diastolic > 90
what range is considered hypotensive
systolic < 90 and symptomatic!
what are the temperature sites
oral rectal axillary tympanic temporal artery esophageal pulmonary artery urinary bladder
what is our thermostat controlling temperature
hypothalamus
what does BMR and shivering show
heat production
what does radiation, diaphoresis (sweating), conduction (touching) show
heat loss
what affects body temp
age hormonal level environment exercise circadian rhythm temp alterations
what does pyrexia mean
fever
when is a fever not harmful
below 102.2
if fever is present when should you check temp
several times throughout day
inability to promote heat loss or reduce production
hyperthermia
what is it called with a body temp of 104 F or more
heatstroke
signs and symptoms of heatstroke
dry hot skin
excess thirst, muscle cramps
no sweating
vital signs; increased heart rate, decreased BP
prolonged exposure to cold decreases body ability to produce heat
hypothermia
what is it called whit a body temp of < 86-96.8
hypothermia
fehrenheit to celsius conversion
(F-32) x 5/9
celsius to fahrenheit conversion
(9/5 x C) + 32
most frequently used methods of attaining temp
oral
approx. one degree lower than core temp
oral
easily influenced by hot or cold foods
oral temp
most reliable measure or core temp
rectal
where do you place rectal thermometer in adults
1 1/2 in
where do you place a rectal thermometer in child
1 in
where do you place the rectal thermometer in infant
1/2 in
when taking rectal temp what should you check before taking
when was their last bowel movement because it could affect readings
what is the safest method of temperature taking
axillary
how long must you keep axillary thermometer in place
5-10 minutes
what is the most rapid means of temp measurment
tympanic
what is the diaphragm of stethoscope used for
high pitch sounds
what is the bell of stethoscope used for
low pitch sounds
what are the sites to access pulse
radial
apical
corotid
dorsalis pedis
when should you take apical pulse (2)
if radial is abnormal and if taking meds that affect HR
what site do you NOT measure pulse bilaterally
carotid because patient will pass out
when checking pulse in dorsalispedis what is important
don’t have to count pulse this just tells us there is circulation status to the foot
what are the 4 characters of assessment of pulse
rate, rhythm, strength, and equality
how is pulse deficit found
one person taking radial and another taking apical for full minute then find the difference = pulse deficit
what is ventilation
movement of gases into and out of the lung
what is diffusion
movement of oxygen and carbon dioxide between alveoli and red blood cells
what is perfusion
distribution of red blood cells to and from the pulmonary capillaries
how many breaths/minute
rate
regular/irregular
rhythm
deep, normal, shallow
depth
ventilation of normal rate and depth
eupnea
rapid breathing then slow breathing then one last breath
cheyne-stokes respiration
SpO2 is
arterial saturation
what is the acceptable range of SpO2
95%-100%
light absorption with phot detector
pulse oximetry
SpO2 level below 90%
hypoxemia
force exerted against the blood vessels by the blood
blood pressure
major factor underlying stroke and frequently has NO symptoms
hypertension
symptoms including skin mottling, clamminess, confusion, increased heart rate, or decreased urine output is
hypotension
what is ideal when taking blood pressure
same arm every reading
avoid IV sites
ask patient not to speak
rest 5 min before assessing
symptoms of hypertension
thickening of walls
loss of elasticity
family history
symptoms of hypotension
90 mmHg
dilation of arteries
loss of blood volume
decrease of blood flow to vital organs
alternate blood pressure sites
thigh and arterial line
what is considered the 5th vital sign
pain
what should you remember about vital sign of pain
PQRST provokes quality region severity timing
when should you always reassess pain when giving medication for it
30 minutes after medication is given
what is the complete cycle of vital signs
temperature blood pressure respirations pulse pain
when should vital signs be taken
same time everyday
febrile
feverish; pertaining to fever
afebrile
without fever
FUO
fever of unknown origin
conduction
transfer of heat from one object to another with direct contact
evaporation
transfer of heat energy when a liquid is changed to a gas
radiation
transfer of heat from surface of one object to surface of another without direct contact between the two
convection
transfer of heat away by air movement
diaphoresis
visible perspiration
tympanic
ear canal
dyspnea
the sensation of difficult or labored breathing
orthopnea
sensation of breathlessness in the recumbent position
hyperthermia
inability to promote heat loss or reduce production
hypothermia
prolonged exposure to cold decreases bodys ability to produce heat
temporal
forehead
