Nursing 105 Test 1

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Anonymous
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100815
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Nursing 105 Test 1
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2011-09-10 02:30:44
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Nursing 105 test Vital signs
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Nursing 105 test 1 Vital signs
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  1. When should you measure vital signs?
    • On admission to hospital
    • At begining of shift
    • Visit to healthcare provider office
    • B4, during & after surgery
    • To monitor effects of meds and txs
    • When pt condition changes
  2. Older adults tend to have _________ body temperatures
    Lower
  3. Pregnant women tend to have_________ baseline body temperatures.
    Higher
  4. Adult core body temp ranges from
    97 to 100.8 degrees
  5. oral and axillary measurements reflect __________ temperatures
    surface
  6. Rectal and tympanic membrane measurements reflect ______________ temperatures
    core.
  7. Process of temp regulation is
    thermoregulation
  8. Factors influencing Body temp
    • Developmental level - infant older adult
    • Environment
    • Sex - women hormones increase
    • Exercise- can raise to 100 to 104 degrees
    • Emotions & stress
    • Circadian Rhythm- lowest early am
  9. Pyrexia
    • fever- temp above person's normal range.
    • Need severa readings at different times
  10. afebrile
    without fever
  11. Hyperpyrexia
    • fever above 105.8
    • dangerous damages body cells causes delerium.
  12. Fevers occur in response to
    pyrogens
  13. Pyrogens induce secretions of ___________ (substances that reset the hypothalamic thermostat at a higher temperature)
    prostaglandins
  14. 4 types of fevers
    • Intermittent - temp fluctuates between normal to high without intervention
    • Remittent- Fluctuations of temp all above normal 24 hr period
    • Constant- fluctuates but always above normal
    • Relapsing - short periods of fever alternating with normal temps over 1 to 2 days
  15. Death results if temp becomes higher than
    109 to 112
  16. Hyperthermia
    body temp is higher than set point. Hypothalamic set point is not reset
  17. Hyperthermia examples
    Heat exhaustion and heat stroke
  18. heat exhaustion occurs when core body temp reaches
    • 98.6 to 103
    • weakness, nausea, vomiting, syncope, tachycardia, muscle aches, headache, diaphoresis, flushed skin
  19. Heat stroke occures if hyperthermia progresses to temp above
    • 103
    • rapid strong pulse, throbbing headache, delirium, confusion, impaired judgement, red, hot, dry skin, dizziness, seizures, & coma
  20. Hypothermia
    • abnormal low core temp less than 95 degrees
    • mental impairment, confusion, disoriention, slowing of heart rate & respirations
  21. severe hypothermia
    • below 82.4 degrees
    • pt unconscious, pulse and resp difficult to detect
  22. Although survival has occurred at core temp of 60.8 death results when body temp falls below
    70 to 75 degrees
  23. Formula to change temp from Fahrenheit to Centigrade
    (temp F- 32) x 5/9
  24. Formula to change temp from Centigrade to Fahrenheit
    (Temp C x 9/5) + 32
  25. least accurate site for temp
    axillary
  26. most accurate site for temp
    • Temporal artery
    • requires special scanning thermometer
  27. Rank temp sites from lowest to highest
    axillary, oral, tympanic, rectal, temporal
  28. factors that influence pulse rate
    • development level
    • sex - women more rapid
    • exercise
    • Food- ingestion raises
    • Stress
    • Fever- rate up 10 beats for each degree
    • Disease
    • Blood loss - temporary increase in pulse
    • Position changes- standing sitting
    • Medications - stimulants up, sedatives down
  29. Arteries where you palpate pulse
    • temporal
    • carotid
    • brachial
    • ulnar
    • radial
    • femoral
    • popliteal
    • posterior tibial
    • dorsalis pedis
  30. when to auscultate apical pulse?
    • radial pulse weak or irregular
    • rate less than 60 or greater than 100
    • pt on cardiac meds
    • assessin children & infants 3 and below (their pulses may be difficult to palpate.
  31. where is apex of heart located?
    adult - anterior chest 3 inches or less from sternum at 4th, 5th, or 6th intercostal space at midclavicular line
  32. pulse deficit
    difference between radial and apical pulse. Not all apex beats being transmitted to radial artery
  33. How to report pulse
    • Rate- also brady , tachy
    • Rhythm- regular/ irregular
    • Quality - Absent, weak , normal, bounding
    • Bilateral equality
  34. Pallor
    paleness of skin
  35. Cyanosis
    bluish or grayish discoloration of skin
  36. Respiration
    exchange of O2 and CO2 in the body
  37. mechanical aspect of respiration
    pulmonary respiration or breathing
  38. central chemoreceptors located in the respiratory centers are sensitive to
    CO2 and hydrogen ion (pH ) concentrations
  39. Factors that influence respiration
    • Developmental level- newborn higher
    • Exercise
    • Pain- acute pain up
    • Stress
    • Smoking- increases resting rate
    • Fever- increases
    • hemoglobin-(anemia down) rate & depth increase
    • Disease
    • Medications
    • Position- standing maximize lying flat reduces
  40. data to collect for respirations
    • rate- number of times person breathes complete in and out
    • Depth-Deep, normal, shallow
    • Rhythm- regular, irregular
    • Effort - labored or easy
  41. wheezes
    • high pitched continuous musical sound on expiration
    • caused by narrowing of airways
  42. rhonchi
    • low pitched contiuous gurgling
    • caused by secretions in airways clear with coughing
  43. crackles
    • caused by fluid in alveoli
    • discontinuous usually heard in inspiration
    • high pitched popping sounds
  44. stridor
    • piercing high pitched heard without stethoscope
    • obstructed airway
    • infants respiratory distress
  45. stertor
    labored breathing snoring sound
  46. intercotal Retraction
    visible sinking of tissues around and between ribs
  47. substernal retraction
    tissue drawn in beneath sternum
  48. suprasternal
    tissues are drawn in above clavicle
  49. hypoxia
    inadequate cell oxygenation
  50. ABS arterial blood gas
    measures partial pressures of O2 and CO2 and blood pH
  51. Hypoxia
    rapid and deep breathing, excess loss of CO2
  52. Hypoventilation
    rate and depth of respirations decreased and CO2 is retained
  53. Normal systolic
    Normal diastolic
    • below 120
    • below 80
  54. conditions that increase cardiac output/ blood pressure
    • Increased blood volume (pregnancy)
    • forceful contraction of ventricle (exercise)
  55. conditions that decrease cardiac output/ blood pressure
    • dehydration
    • active bleeding
    • damage to heart
    • very rapid heart rate
  56. Blood resistance
    refers to arterial capillary resistanceto blood flow as a result between blood and vessel walls
  57. blood viscosity
    ease in which blood flows through vessels. Determined by hemocrit (% red blood cells in plasma)
  58. arterial size
    smaller radius of a blood vessel the more resistance it offers to blood flow
  59. prehypertension
    • 120-139
    • 80-89
  60. stage 1 hypertension
    • 140-159
    • 90-99
  61. stage 2 hypertension
    • greater than 160
    • greater than 100
  62. arteriosclerosis
    hardening of arteries common in older adults
  63. normal volume of blood in the bodyis about _________ liters
    5
  64. factors influencing blood pressure
    • Developmental stage- increases with age
    • Sex- female increase after menopause men higher in general
    • Family HX
    • Lifestyle- sodium, smoking , ETOH more than 3
    • Exercise- wait 30 min after exercise to take
    • Body position- up standing, up unsupported, up feet dangling
    • Stress
    • Pain
    • Race
    • Obesity
    • Medications
    • diseases
    • Diurnal variations- daily schedule
  65. sphygmomanometer
    b/p cuff
  66. direct method B/P
    catheter inserted into artery attached to tubing connected to tubing
  67. what cuff size to use?
    • width of bladder 2/3 length upper arm (child all)
    • cuff width is 40% arm circumference
    • length of bladder encircles 80 % of arm
  68. cuff too narrow= ________ B/P
    too high
  69. cuff too wide= B/P _________
    too low
  70. Using B/P cuff or bladder of incorrect size can result in measurement error of ________.
    30mm HG
  71. Korotkoff sounds
    sounds you listen for when you assess BP
  72. loss and return of sound when taking B/P is called
    auscultatory gap
  73. Hypotension
    • systolic under 100
    • dizziness, fatigue, concentration problems, activity intolerance, SOB
  74. Orthostatic hypotension
    • when person's BP drops suddenly when moving from lying to sitting to standing
    • decrease 10mm Hg when standing assciatted with dizziness and fainting
  75. rectal thermometer how far to insert
    • 1 to 1.5 inch adult
    • .9 inch child
    • .5 inch infant
    • glass thermometer 3 to 5 min
  76. adult tympanic temp have to ____________________ ear.
    pull up & backward slightly away from head
  77. measure pulse for ____________ minutes
    • 15 or 30 sec if regular
    • 60 sec if irregular or when measuring apical
  78. where to auscultate apical pulse
    5th intercostal space at midclavicular line
  79. wait _______ minutes after pt smokes or ingests caffiene to take BP
    30

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