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NUR 126 > Wk 6 Vital Signs > Flashcards

Wk 6 Vital Signs Flashcards

1
Q

Define respirations

A

exchange of oxygen and carbon dioxide during cellular metabolism

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2
Q

Describe 3 areas of respiration are included in your assessment

A

Rate: breaths per minute
Depth: deep, normal or shallow
Rhythm: regular or irregular

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3
Q

Normal range of respiration’s for adult

A

12-20 per minute

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4
Q

Factors influencing respiration

A 
Exercise
Acute pain
Anxiety
Smoking
Body position
Medications
Neurological injury
Hemoglobin function
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5
Q

Hypernea

A

Labored respiration, increased depth, increased rate above 20 per min

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6
Q

Eupnea

A

Normal respiration

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7
Q

Define arterial oxygen saturation and describe how it is measured

A

Measure O2 saturation in blood
Detects amount of O2 bound to hemoglobin
Reliable SaO2 higher than 70%
Normal 95-100% saturation

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8
Q

Define pulse

A

Palpable bounding of blood flow noted at various points of the body = circulatory status

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9
Q

Four measurements that are included when assessing the radial pulse

A

Rate
Rhythm
Strength
Quality

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10
Q

Normal heart rate for adule

A

60-100

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11
Q

Factors that can influence pulse rate

A

Exercise, temp, emotions, medications, postural change, hemorrhage, pulmonary condition

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12
Q

Define blood pressure

A

Normal adult: 120/80

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

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13
Q

Systolic defined

A

Max peak pressure during ventricle contraction

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14
Q

Diastolic defined

A

Min pressure during ventricle relaxation

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15
Q

Define pulse pressure

A

Difference between systolic and diastolic readings

120/80 = 40 pulse pressure

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16
Q

Factors that influence blood pressure

A 
Age
Stress
Ethnicity
Gender
Medication
Activity
Weight
Smoking
17
Q

Concepts that have interrelationships that compose the blood pressure

A

???

18
Q

Define hypertension

A

More common, thickening of walls, loss of elasticity, family history, risk factors, systolic over 130

19
Q

Define hypotension

A

Systolic less than 90, dilation of arteries, loss of blood volume, decrease of blood flow to vital organs, orthostatic

20
Q

Common errors in BP assessment

A 
bladder/cuff too wide: false low
bladder/cuff too narrow: false high
cuff too lose: false high
deflating cuff to slowly: false high
arm above heart: false low
arm below heart: false high
repeating too quickly: false high systolic
21
Q

Define orthostatic hypotension

A

Decrease of systolic reading of 20mm Hg per normal (norm 120)
Decrease of diastolic reading of 20mm Hg per normal (norm 80)
**within 3 min of rising to upright

22
Q

Korotkoff sounds (five phases)

A

1: sharp thump
2: blowing or whooshing sounds
3: crisp, intense tapping
4: softer blowing sound that fades
5: silence

23
Q

Explain the two korotkoff sounds that are recorded for BP

A

1: systolic BP, phase 1
2: diastolic BP, phase 5

24
Q

Determine when the nurse should assess an apical pulse instead of a radial pusle

A

The nurse should take an apical pulse when radial pulse is weak or irregular, the rate is <60 beats per minute or >100 beats per minute

25
Q

Identify the average temperature for their route

A

Oral: 96.8-100.4 (36-38c)
Tympanic:
Rectal: 98.6 (37.5c)
Axillary: 97.7 (36.5c)

26
Q

Normal adult core temperature

A

??

27
Q

Factors that influence body temperature

A 
Age
Exercise
Hormone levels
Circadian rhythm
Stress
Environment
Temperature alternations
28
Q

Five sites to measure temperature

A 
Oral:
Tympanic:
Rectal:
Axillary:
Skin/Temporal artery:
29
Q

Four nursing diagnosis related to body temperature changes

A

Risk for imbalance body temperature
Hyperthermia
Hypothermia
Ineffective thermoregulation

30
Q

Nursing interventions for hypothermia

A 
Prevent further temp loss
Remove wet clothes, replace with dry clothes
Blankets
Keep head covered
Heating pad by neck/head
Drink hot liquids
Avoid ETOH/caffiene
31
Q

Nursing interventions for hyperthermia

A

Obtain blood cultures
Minimize heat production (reduce activities that increase oxygen demand)
Maximize heat loss (reduce external covering)
Provide supplemental O2, stimulate appetite, offer meals, increase fluids
Promote patient comfort
Identify onset and duration
Control environmental temp

32
Q

Hypothalmaic temperature control

CHILLS

A

Vasoconstriction
Piloerection
Epinephrine secretion
Shivering

NUR 126 (23 decks)

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