Ch 17

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Ch 17
2011-04-13 20:11:10
Vital Signs Oxygenation

Ch 17 Vital Signs & Oxygenation
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  1. One of the most frequent assessments you will make as a nurse
    Vital Signs
  2. Typical timeframe to check vital signs in a hospital
    4-8 hours or as directed by the MD
  3. Typical timeframe to check vital signs in the ICU
    1-2 hours or as directed by the MD
  4. Typical timeframe to check vital signs in a SNF
    Weelky to monthly
  5. What are the 6 main vital signs to check, depending on what type of patient you are caring for?
    Temperature, pulse, respirations, BP, pain, and Pulse Oximetry (often included)
  6. Why can't we take a surface temperature, and rely on it's accuracy?
    The surface temperature will normally be lower than the core temperature
  7. Degree of heat maintained by the body / Heat produced minus heat lost
  8. Normal core temperature range in Farenheit and Celcius
    • 96.2o F to 100.4o F
    • (36.2o C to 38o C) with some variation
  9. In regards to temperature : Transfer of heat from a warm to a cool surface by direct contact
  10. In regards to temperature : Transfer of heat through currents of air or water
  11. In redards to temperature : Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air
  12. In regards to temperature : Water is converted to vapor and lost from the skin (perspiration) or the mucous membranes (through the skin)
  13. What is pyrexia?
    Fever >100.4F or 38C
  14. Pyrexia occurs in response to
  15. ___ induce secretion of substances (prostaglandins)that reset the hypothalamic thermostat at a higher temperature.
  16. Extreme fever
    Hyperpyrexia Fever >105.8o F (41.0o C)
  17. Core temperature below normal / associated with extended exposure to the cold
    Hypothermia (<96.8o F or 36o C)
  18. (TEMP) Initial- febrile episode: 3 characteristics
    • Body temperature is rising but has not yet reached the new set point
    • Can be sudden or gradual
    • Feels chilly and may shiver
  19. (TEMP) Second- course of fever: 2 characteristics
    • Temperature reaches its maximum or set point
    • Feels warm and dry
  20. (TEMP) Third- course - defervescence or crisis: 4 characteristics
    • Temperature returns to normal
    • Feels warm
    • Appears flushed- vasodilation
    • Diaphoresis occurs (Fever is “breaking")
  21. Temperature alternates between periods of fever, normal and below-normal
    Intermittent fever
  22. Wide fluctuations in temperature; All above normal
    Remittent fever
  23. Temp may fluctuate slightly; Always above normal
    Constant (sustained)
  24. Short periods of elevation alternating with normal temperature
    Relapsing fever
  25. Core temperature below normal (< 96.80 or 360 C); Associated with exposure to cold
  26. The nurse would monitor the body temperature most closely/frequently in the care of:
    A) The client with an infection
    B) The client who has experienced heat stroke
    C) The client with a head injury
    D) The client who is an infant
    C) The client with a head injury
    (this multiple choice question has been scrambled)
  27. Why would a patient with a head injury need closer monitoring for their temperature?
    They may have damage to the hypothalamus and therefore loss of global thermoregulation.
  28. The “wave” that begins when the left ventricle contracts and ends when the ventricle relaxes
  29. In regards to pulse, blood is forced into the already-filled aorta:
    Increased pressure within the atrial system occurs
  30. Peak of the wave or contraction of the heart
  31. Rough or resting phase of the heart
  32. Pulse rate is measured in ___ ___ ___
    beats per minute (BPM)
  33. An ___ ___ is the heartbeat at the apex of the heart and is heard with a stethoscope.
    Apical Pulse
  34. True or false: The apical pulse is the most accurate location to measure a patient's pulse.
  35. A heart beat is one series of the ___ and ___ sounds.
    LUB & DUB
  36. Pulse point at the apex of the heart
  37. Pulse point between midline and side of neck
  38. Pulse point located medially in the antecubital space
  39. Pulse point located laterally on the anterior wrist
  40. Pulse point located in the groin fold
  41. Pulse point located behind the knee
  42. Slow heart rate (<60 BPM)
  43. Fast heart rate (>100 BPM)
  44. What could a thready pulse indicate?
    The patient could be going into shock
  45. Quantity of blood pumped out by each contraction of the left ventricle
    Stroke volume
  46. Stroke volume X pulse (heart) rate
    Cardiac output
  47. If circulation is compromised, ___ or ___ may be present.
    pallor & cyanosis
  48. Paleness of skin when compared with another part of the body
  49. A bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood
  50. 80 year old patient with cool feet, and a weak, thready pulse in the dorsalis pedis pulse points. The nurses next would be to:
    A) Assess the popliteal and femoral pulses
    B) Assess a 1 minute apical pulse
    C) Notify the physician stat
    D) Apply a warm pack and reassess in 20 minutes
    A) Assess the popliteal and femoral pulses
    (this multiple choice question has been scrambled)
  51. The exchange of oxygen and carbon dioxide in the body
  52. What are the 2 processes to respiration?
    Mechanical & Chemical
  53. Type of respiration: breathing; active movement of air in and out of the respiratory system
    Mechanical respiration
  54. Type of respiration: Exchange and transport of oxygen and carbon dioxide throughout the body; Exchange of gases between the capillaries and tissues
    Chemical respiration
  55. What is the average respiration rate?
    12-20 breaths per minute
  56. Drawing air into the lungs; Involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs
  57. Relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs
  58. 3 RATE variations in respiration:
    Apnea, Bradypnea, Tachypnea
  59. Cessation of breathing
  60. Abnormally slow respiration
  61. Abnormaly fast respiration
  62. 2 DEPTH variations in respiration:
    Deep, Shallow
  63. Assessment of the pattern of respirations
  64. An abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea.
  65. An abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea
  66. Work of breathing
  67. Labored breathing
  68. Inability to breathe when horizontal
  69. High-pitched continuous musical sounds, usually heard on expiration
  70. Low-pitched continuous sounds caused by secretions in the large airways
  71. Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds
  72. A piercing, high-pitched sound heard primarily during inspiration
  73. How well the cells, tissues, and organs are supplied with oxygen
  74. Inadequate oxygen levels in the tissues and organs
  75. Low alveolar-capillary oxygenation
  76. The circulation of blood to all body regions
  77. 8 signs of decreased oxygenation:
    • 1. Pallor
    • 2. Cyanosis
    • 3. Restlessness
    • 4. Confusion
    • 5. Dizziness
    • 6. Tachycardia
    • 7. Tachypnea
    • 8. Decreased level of conciousness (LOC)
  78. Movement of air into and out of the lungs to maintain appropriate O₂ and CO₂ levels
  79. Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea); Client may complain of feeling light-headed and tingly
  80. The rate and depth of respirations are decreased and CO is retained; may lead to hypoxia
  81. 5 factors influencing oxygenation:
    • 1) Developmental stage
    • 2) Environment
    • 3) Lifestyle
    • 4) Medications
    • 5) Pathophysiological conditions
  82. Developmental stage (oxygenation) - risk for atelectasis, infection, and airway obstruction (choking)
  83. Developmental stage (oxygenation) - risk for infection and airway obstruction
  84. Developmental stage (oxygenation) - risk for respiratory disorders (cigarette smoking)
    School age & adolescents
  85. Developmental stage (oxygenation) - smoking & lack of exercise
    Young and middle adults
  86. Developmental stage (oxygenation) - risk for respiratory infections
    Older adults
  87. Developmental stage (oxygenation) - Reduced lung expansion and less alveolar inflation
    Older adults
  88. Developmental stage (oxygenation) - Difficulty expelling mucus or foreign material
    Older adults
  89. Developmental stage (oxygenation) - Diminished ability to increase ventilation
    Older adults
  90. Developmental stage (oxygenation) - Declining immune response
    Older adults
  91. Environmental factor (oxygenation) - increases risk for infection
  92. Environmental factor (oxygenation) - airway edema and spasms leading to difficulty breathing
    Allergic responses
  93. Environmental factor (oxygenation) - pollutants interfere with oxygenation
    Air quality
  94. Environmental factor (oxygenation) - increases oxygenation (requires more)
  95. Environmental factor (oxygenation) - reduces O₂demand
  96. What are the 3 "other factors" that can effect oxygenation:
    Lifestyle, medications, physiological conditions
  97. In regards to oxygenation, ABG = ?
    Arterial Blood Gas
  98. What are the 3 components to assessing a patient's oxygenation status?
    • 1. Health History
    • 2. Physical Exam (breathing, sputum, respiratory effort, pulse ox)
    • 3. Diagnostic testing (ABG, cardiac monitoring)
  99. A device used to deliver oxygen to a patient - consists of a plastic tube that fits behind both ears and two prongs that fit in the nostrils
    Nasal Cannula
  100. A device that delivesr a known oxygen concentration to patients on controlled oxygen therapy; high-flow oxygen therapy; aka Air Entrainment masks
    Venturi Masks
  101. Provides oxygen to the mouth without discomfort to the nose and mouth; open around the mouth & preferred by clostrophobic patients; used with traums and burn patients; open mask
    Face Tent
  102. Similar to a simple face mask, however, the side ports are covered with one-way discs to prevent room air from entering the mask; patient rebreaths some of exhaled air
    Partial Rebreather Mask
  103. Similar to a simple face mask but has multiple one-way valves in the side ports. These valves prevent room air from entering the mask but allow exhaled air to leave the mask; Only external device delivering 100% oxygen
    Nonrebreather Mask
  104. What are the 6 oxygen delivery devices for low oxygenation?
    Nasal Cannula, Simple Face Mask, Venturi Mask, Face Tent, Partial Rebreather Mask, & Nonrebreather Mask
  105. Artificial airways used in unconscious patients
  106. Artificial airways that could be used in semiconscious patients
  107. Artificial airways used in patients that are unable to breathe or who are at risk for obstructed airways
  108. Directly measures the partial pressures of oxygen, carbon dioxide, and blood pH
  109. Noninvasive method of monitoring respiratory status; Uses an external device that measures oxygen saturation
    Pulse Oximetry
  110. Pressure of the blood as it is forced against arterial walls during cardiac contraction
    Blood Pressure (BP)
  111. Peak pressure exerted against arterial walls as the ventricles contract and eject blood
    Systolic Pressure
  112. Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest
    Diastolic Pressure
  113. A widening pulse pressure is indicitative of a ___ problem.
  114. The difference between the systolic and diastolic pressures
    Pulse Pressure
  115. BP regulation is influenced by 3 factors:
    cardiac function, peripheral vascular disease, & blood volume
  116. The body constantly regulates and adjusts arterial pressure in order to supply blood to body tissues via:
    Perfusion of the capillary beds
  117. Consists of a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer (blood pressure cuff)
  118. Used to auscultate the systolic and diastolic pressure
  119. Most common method of measuring BP
    Indirect (noninvasive)
  120. Method of measuring BP that is very invasive, painful, and requires the assistance of a MD
    Direct - done only in inpatient settings, catheter is threaded into an artery under sterile conditions.
  121. The thump-thumps you hear when taking BP indirectly
    Korotfoffs Sounds
  122. Systolic blood pressure <100 mm Hg
    Hypotension (some people have normally low BP)
  123. A sudden drop in BP on moving from a lying to a sitting or standing position
    Orthostatic or postural hypotension
  124. BP reading of 120-130 systolic or 80-89 diastolic Obtained with two readings, taken 6 minutes apart, with the client sitting
  125. BP persistently higher than normal; Diagnosed when BP is >140 mm Hg systolic or >90 mm Hg diastolic on two or more separate occasions
  126. Increases the stress on the heart and blood vessels; left untreated it may lead to heart attack, heart failure, peripheral vascular disease, kidney damage, or stroke
  127. Diagnosed when there is no known cause for the increase; Accounts for at least 90% of all cases of hypertension
    Primary or Essential Hypertension
  128. As a result of a disease process; Example- renal hypertension
    Secondary hypertension