Wk 6 Vital Signs Flashcards
Define respirations
exchange of oxygen and carbon dioxide during cellular metabolism
Describe 3 areas of respiration are included in your assessment
Rate: breaths per minute
Depth: deep, normal or shallow
Rhythm: regular or irregular
Normal range of respiration’s for adult
12-20 per minute
Factors influencing respiration
Exercise Acute pain Anxiety Smoking Body position Medications Neurological injury Hemoglobin function
Hypernea
Labored respiration, increased depth, increased rate above 20 per min
Eupnea
Normal respiration
Define arterial oxygen saturation and describe how it is measured
Measure O2 saturation in blood
Detects amount of O2 bound to hemoglobin
Reliable SaO2 higher than 70%
Normal 95-100% saturation
Define pulse
Palpable bounding of blood flow noted at various points of the body = circulatory status
Four measurements that are included when assessing the radial pulse
Rate
Rhythm
Strength
Quality
Normal heart rate for adule
60-100
Factors that can influence pulse rate
Exercise, temp, emotions, medications, postural change, hemorrhage, pulmonary condition
Define blood pressure
Normal adult: 120/80
Force extended on walls of an artery by blood pulsing under pressure from heart
Systolic defined
Max peak pressure during ventricle contraction
Diastolic defined
Min pressure during ventricle relaxation
Define pulse pressure
Difference between systolic and diastolic readings
120/80 = 40 pulse pressure
Factors that influence blood pressure
Age Stress Ethnicity Gender Medication Activity Weight Smoking
Concepts that have interrelationships that compose the blood pressure
???
Define hypertension
More common, thickening of walls, loss of elasticity, family history, risk factors, systolic over 130
Define hypotension
Systolic less than 90, dilation of arteries, loss of blood volume, decrease of blood flow to vital organs, orthostatic
Common errors in BP assessment
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
Define orthostatic hypotension
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
Korotkoff sounds (five phases)
1: sharp thump
2: blowing or whooshing sounds
3: crisp, intense tapping
4: softer blowing sound that fades
5: silence
Explain the two korotkoff sounds that are recorded for BP
1: systolic BP, phase 1
2: diastolic BP, phase 5
Determine when the nurse should assess an apical pulse instead of a radial pusle
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
Identify the average temperature for their route
Oral: 96.8-100.4 (36-38c)
Tympanic:
Rectal: 98.6 (37.5c)
Axillary: 97.7 (36.5c)
Normal adult core temperature
??
Factors that influence body temperature
Age Exercise Hormone levels Circadian rhythm Stress Environment Temperature alternations
Five sites to measure temperature
Oral: Tympanic: Rectal: Axillary: Skin/Temporal artery:
Four nursing diagnosis related to body temperature changes
Risk for imbalance body temperature
Hyperthermia
Hypothermia
Ineffective thermoregulation
Nursing interventions for hypothermia
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
Nursing interventions for hyperthermia
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
Hypothalmaic temperature control
CHILLS
Vasoconstriction
Piloerection
Epinephrine secretion
Shivering
