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Nursing, LPN, Year 1 > X Foundations - Chp 4, Vital Signs > Flashcards

X Foundations - Chp 4, Vital Signs Flashcards

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1
Q

How is heat produced in the body

A
  • muscles, shivering

- metabolism (burn ATP)

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2
Q

When vessels DILATE

A

more blood to an area, more heat to an area

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3
Q

Excitement stimulates what gland?

A

Adrenal. Epinephrine squirted out to cause vasomotor changes

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4
Q

*** Body’s Thermostat controlled by

A

Hypothalamus (core body temp 98.6F/37C

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5
Q

*** Ways that heat is lost in body

A

1) Conduction (contact w cold surface)
2) Convection (layers of heat, clothing, hair etc)
3) Radiation (body heat radiates)
4) Evaporation (sweat, cooling process)

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6
Q

Axillary Temps

A

still used by least accurate. usually ~1* off

-in documentation, make sure to note HOW you took the temp

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7
Q

LABILE body temp

A

Baby’s up to 6 months have labile body temps that go up and down easily and quickly

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8
Q

Baby’s increased surface area to mass casuses

A

LABILE body temp

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9
Q

what method of temp taking is closest to core temp

A

Tympanic

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10
Q

Vegus Nerve

A 
The vagus nerve supplies motor parasympathetic fibers to all the organs except the suprarenal (adrenal) glands, from the neck down to the second segment of the transverse colon. The vagus also controls a few skeletal muscles, notable ones being:
Cricothyroid muscle, 
Levator veli palatini muscle
Salpingopharyngeus muscle
Palatoglossus muscle
Palatopharyngeus muscle

Superior, middle and inferior pharyngeal constrictors
Muscles of the larynx (speech).
This means that the vagus nerve is responsible for such varied tasks as heart rate, gastrointestinal peristalsis, sweating, and quite a few muscle movements in the mouth, including speech (via the recurrent laryngeal nerve). It also has some afferent fibers that innervate the inner (canal) portion of the outer ear (via the auricular branch, also known as Alderman’s nerve) and part of the meninges. This explains why a person may cough when tickled on the ear (such as when trying to remove ear wax with a cotton swab).

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11
Q

8 Pulse Sites

A

1) Temporal (not greatest, ensures blood going to head)
2) **Carotid (quickest, in emergency)
3) ** Radial (most common)
4) Brachial (mostly babies/toddlers)
5) Femoral (waist)
6) Popliteal (behind knee)
7) Tibialis Anterior (inner ankle)
8) Dorsalis Pedis (top of foot)

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12
Q

Factors that affect PULSE

A

1) Age (babies/rapid, adults/slower)
2) Sex (M/F because of body build)
3) Pain (will cause tachycardia)
4) Emotions (tachycardia)

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13
Q

*** Apical Pulse

A
  • @ 5th intersticial space
  • ** couple “s under left nipple
  • mid clavicle
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14
Q

*** Pulse Deficit

A
  • Difference between Apical and Radial pulse
  • ** 2 nurses and the same time perform. coordinate count
  • Apical can NEVER be less than Radial
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15
Q

Heart Rate affected by

A
  • Drugs, Caffeine, EPI (checmials)

- Emotions

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16
Q

*** if doing a radial pulse and it feels irregular what should you do?

A

do an Apical pulse for 1 FUL MINUTE to ensure you detect any irregularities

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17
Q

Breathing controlled in what part of brain?

A

Medula Oblongata

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18
Q

What meds slow BREATHIMG rates?

A

Opiates
Coma
Severe brain damage

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19
Q

Subjective

A

Cant see it. I’m nauseous, It hurts, It itches

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20
Q

Objective

A

Can see it, measurable. Rash, Vomit, Blood

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21
Q

To make pain more objective, assign number ranking to it and obtain frequently to see pattern

A

more measurable

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22
Q

Vital Signs

A
  • Body Temp
  • Pulse
  • Respiratory Rate
  • Blood Pressure
  • Pain (subjective) (5th Vital sign)
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23
Q

2 Body Temp Types

A

Shell: warmth of skin
Core: deep within body

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24
Q

Never take oral temp w/in 15-30 min of…

A

eating/drinking

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25
Q

Factors affecting Body Temp

A
  • Food intake
  • Climate (excercise/activity)
  • Circadian rhythm (temp up/down during day)
  • Emotions
  • Illness/Injury
  • Meds (Febrifuge; Aspirin, Ibuprofen, Acetaminophen)
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26
Q

Freezing

A

32*F

0*C

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27
Q

Boiling

A

212*F

100*C

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28
Q

Neuroleptic, Malignant Syndrom

A

severe fever. reaction to Haldol or other antiphychotic drugs. Anestesia can cause similar reactions

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29
Q

Danger zone for body temp (measured in F)

A

lower than 84F (28.8C), higher than 110F (43.3C)

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30
Q

Poikilothermic

A

body temp fluctuates depending on environmental temp (animals, snakes, lizards)

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31
Q

Homeothermic

A

structural/physiologic adaptations keep body temp stable (humans)

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32
Q

Body Temp Assessment sites

A

-Ear, Tympanic (closest to brain)
-Temporal Artery
-Sublingual
-Rectal (most accurate)(not on cardiac patients though)
-

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33
Q

Antipyretic

A

Reduce Fever,

Tylenol, Iburprofen

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34
Q

Temp Assessment probe colors

A

RED - Rectal

BLUE - Oral

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35
Q

Do no take ORAL temps on …

A
  • the unconscious
  • kids w colds
  • trauma to face
  • eating/drinking
  • mouth breathing
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36
Q

How to position Infrared Tympanic Thermometer.

A

Adult: pinna up and back. device on face like phone
Child: tug earlobe down

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37
Q

Temp a Dots used for

A

Sublingual Temp

Isolation Rooms

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38
Q

Pulse Oximetry

A

device on fingertip measuring reading how red and oxygenated your blood is

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39
Q

Normal O level in blood

A

96 - 100*

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40
Q

Pyrexia

A
  • Fever (exceeds 99.3*F)
  • bring temp down slowly to avoid shivering causing muscles to increase heat again.
  • increases metabollic demand, increasing glucose required, WBC require glucose
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41
Q

Hyperthermia

A

Inflammatory response. NOT FEVER. exceed 105.8*

sit in sauna too long, heat stroke etc

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42
Q

Cortizone

A

released during body during anti-inflammatory response

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43
Q

Diabetics taking cortisone causes….

A

Diabetics have to worry about fever and increase in cortizone? increased glucose.

44
Q

Symptoms of Fever

A
  • increase pulse
  • disorientation/confusion
  • Febrile seizures (infants/kids NOT EPILEPSY)
  • fever blisters
  • flush skin
  • restlessness
  • irritability/poor appetite
  • glassy eyes, sensitive to light
  • increased perspiration
  • headache
45
Q

High Body temps damage

A

body cells

46
Q

??? P63

Intermittent Fever

A

normal up and down fever

47
Q

??? P63

Remitent Fever

A

temp changes up and down but never at NORMAL until patient is better.

48
Q

Defervescence

A

fever breaking

49
Q

Colder it gets, stronger Hemoglobin binds to O

A
  • shivering stops because muscles can no longer get oxygen

- patient dies of Hypoxia, no freezing

50
Q

Symptoms of Hypothermia

A
  • shivering until it stops
  • pale, cool, puffy skin (vessels constrict to save heat)
  • impaired muscle coord (O functionally low)
  • Listlessness/irreg heart beat
  • slow pulse and breathing
  • incoherent thinking and diminished pain sense
51
Q

Pulse

A

force exerted against wall of artery by L ventricular’s contraction

52
Q

Main Pulse Sites

A

Radial
Brachial
Apical (stethoscope)

53
Q

average adult heart contractions

A

60 - 100 bpm at rest

54
Q

RVR

A
  • Pulse rythm (reg/irreg)
  • Pulse volume (bounding, weak, thready
  • Pulse rate (#bpm)
55
Q

Pulse Volume Variations

A
  • Absent
  • Thready
  • Weak
  • Normal
  • Bounding
56
Q

Cardiac Output

A

volume of blood pumped by heart pm (mL blood/min). Cardiac output is a function of heart rate and stroke volume.

CO = Hear Rate x Stroke Volume

The heart rate is simply the number of heart beats per minute. The stroke volume is the volume of blood, in milliliters (mL), pumped out of the heart with each beat.

57
Q

Pulse Assessment Technique

A

Radial artery

58
Q

Alternate Assessment Techniques

A
  • counting apical heart rate (auscultating)
  • apical - radial rate (Pulse Defecit, 2 nurses)
  • Doppler ultrasound over peripheral artery (used if can’t palpate pulse)
59
Q

Peripheral Pulse sites

A
  • Apical
  • Temporal
  • Maxillary
  • Carotid (2)
  • Brachial (2)
  • Ulnar
  • Radial
  • Femoral (2)
  • Popliteal (2)
  • Posterior Tibial
  • Pedal (dorsalis pedis)
60
Q

Body Temp UP, Pulse ?

A

Pulse UP

61
Q

BP DOWN, Pulse ?

A

Pulse UP

Cause heart beating harder

62
Q

Dehydration, Pulse ?

A

Pulse UP

63
Q

what will affect pulse?

A

Drugs, Caffeine, Meds,

64
Q

Respiration

A

Exchange of Oxygen and CO2

65
Q

Respiratory Rate

A

number of ventilations per minute

66
Q

Cheyne-Stokes respiration

A

near death, severe brain damage (breath out, silence, gasp)

67
Q

Kussmaul Breathing

A

prolonged exhale, trying to rid body of excess CO2. (when in metabolic acidosis)

Diabetic Ketoacidosis

68
Q

Rapid respiratory rate

A

Tachypnea (elevated temp, dissease affecting cardiac and/or respiratory sys)

69
Q

Slow respiratory rate

A

Bradypnea

medication:opiates, neurological disorder, hypothermia

70
Q

Diabetic Ketoacidosis

A

TriGlyceride. Glycerin breaks off top and leave 3 ketones. Body turns glycerol to glucose.

71
Q

Narcan

A

anti opiate knocks out high immediately, increases HR

72
Q

Why no enemas or digital stimulation in cardiac patients?

A

Because anal stimulation w stimulate Vegus nerve causing body to lower bp and pulse. If cardiac patient on mess already this would make it worse. Could pass out.

72
Q

Why no enemas or digital stimulation in cardiac patients?

A

Because anla stimulation w stimulate Vegus nerve causing body to lower bp and pulse. If cardiac patient on mess already this would make it worse. Could pass out.

73
Q

Orthostatic hypotension

A

When patient gets up too fast and bp drops they get weak

75
Q

Abnormal Breathing characteristics

A
  • Hyperventilation (rapid & deep)
  • Hypoventilation (slower/shallower)
  • Dyspnea (bad breathing, shortness)
  • Orthopnea (difficulty breathing laying down)
  • Apnea (no breathing)
  • Stertorous Breathing (noisy breathing)
  • Stridor (high pitch whistling noise) (indicate if wheezing is on inspiration or exhalation)
76
Q

Blood Pressure

A

force blood exerts within arteries.

77
Q

Normal Pulse rate

A

60 - 100

78
Q

Normal BP rate

A

120/80

79
Q

Vasodilation, ? pressure

A

Decrease

80
Q

Vasoconstriction, ? pressure

A

Increase

81
Q

?????? RAAS System

A

Review it

82
Q

Caridac output at rest ~

A

5-6L

83
Q

Arterial Pliancy

A

ability of arteries to stretch

84
Q

LT HTN causes

A

Left Ventricular Hypertrophy (enlarged heart)

85
Q

Factors affecting BP

A
  • Age (lower in children)
  • Circadian Rhythm (day/nigh rhythm)
  • Gender (higher in men because more circulating volume)
  • Exercise and Activity
  • Emotions and pain
86
Q

Orthostatic BP

A

BP sitting, standing and laying down

87
Q

Orthostatic Hypotension

A

(postural hypotension), form of low blood pressure that happens when you stand up from sitting or lying down.

88
Q

Blood Pressure increases when

A

-bladder full, legs crossed, person cold, drugs, caffeine

89
Q

Systolic pressure

A

BP on Contraction

90
Q

Diastolic pressure

A

BP at rest

91
Q

BP units?

A

mmHg (mm of mercury)

92
Q

BP

A

systolic/diastolic pressure

93
Q

*** Pulse Pressure

A

difference btwn Systolic and Diastolic

140/90 140-90 = 50

94
Q

*** Pulse Defecit

A

Difference btwn Apical and Radial pulse

95
Q

Don’t take pressure on arms that…..

A

masectomy, major surgery, IV, etc

95
Q

Essential Hypertension

A

(Aka primary hypertension or idiopathic hypertension) is the form of hypertension that by definition, has no identifiable cause. It is the most common type of hypertension, affecting 95% of hypertensive patients,[1][2][3][4] it tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors.

96
Q

Arterial sclerosis

A

Hardened, stiff arteries

97
Q

Arterial Sclerosis, ? BP

A

Increase

98
Q

5th Vital Sign

A

Pain

99
Q

Sphygmomanometer

A

BP Cuffs, dial face

100
Q

Aneroid Manometer

Electronic oscillometric manometer

A

Automatic BP machine

101
Q

Karatkoff Sounds

A

The first Korotkoff sound is the snapping sound first heard at the systolic pressure. Clear tapping, repetitive sounds for at least two consecutive beats is considered the systolic pressure. The second sounds are the murmurs heard for most of the area between the systolic and diastolic pressures.

102
Q

2 stage BP

A

1) inflate cuff while palpating radial pulse

2) when inflated high enough to obliterate pulse, record number and add 30 for starting point to inflate cuff.

103
Q

How many high BP before diagnosis of HTN?

A

At least 3 high within couple weeks

104
Q

What causes ED

A

Anti hypertensive drugs

105
Q

Gerontological

A
  • lower normal BP

- change in vasomotor (slower dilation and constriction)

Nursing, LPN, Year 1 (44 decks)

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