Term
| Temperature- common sites |
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Definition
| oral, rectal, axillary, tympanic, and temporal |
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Term
| Oral temperature (adv and d/a) |
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Definition
-accessible and convenient
-wait 30 minutes after eat or drink cold or hot food
-can break if bitten
-injure mouth after oral surgery |
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Term
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Definition
-reliable and accurate
-inconvenient and unpleasant for clients
-contraindicated rectal surgery, diarrhea, rectum disease, immunosuppressed, clotting disorder, or significant hemorrhoids |
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Term
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Definition
-safe and noninvasive
-may need to be in place for long time to get accurate measurement
-preferred site for newborns |
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Term
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Definition
-accessible and fast
-can be uncomfortable
-may damage membrane if placed too far
-right and left ear can vary
-cerumen presence can affect reading |
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Term
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Definition
-safe and noninvasive, very fast
-electronic equipment may be very expensive
-perspirationn on forehead may affect reading |
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Term
| Temperature: convert F to C |
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Definition
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Term
| Temperature: Convert C to F |
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Definition
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Term
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Definition
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Term
| body temperature above usual range (3) |
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Definition
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Term
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Definition
| very high fever 41°C (105.8°F) |
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Term
| Factors affecting body temperature |
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Definition
age
diurnal variations (circadian rhythms)
exercise
hormones
stress
environment |
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Term
| Factors affecting body temperature: Age |
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Definition
infant and elderly affected by extremes in environment
older people-risk of hypothermia, inadequate diet, loss of subcutaneous fat, lack of activity, reduced thermogregulatory efficiency |
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Term
| Factors affecting body temperature: Diurnal variations (circadian rhythms) |
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Definition
change throughout day may vary as much as 1°C (1.8°F)
highest usually 1600-1800
lowest 0400-0600 |
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Term
| Factors affecting body temperature: Exercise |
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Definition
| hard work or exercise can increase to as high as 38.3-40°C (101-104°F) measured rectally |
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Term
| Factors affecting body temperature: Hormones |
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Definition
| progesterone secretion at ovulation can raise body temp. by about 0.3 -0.6°C (0.5-1.0°F) above basal |
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Term
| Factors affecting body temperature: Stress |
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Definition
| stimulation of SNS increase epinepherine and noepinepherine which increases metabolic rate and heat production |
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Term
| Factors affecting body temperature: Environment |
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Definition
extremes in environmental temperatures can affect person's temperature regulatory system
-warm room with no air convection
-outside in cold without proper clothing
-altered mental state and cannot dress self |
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Term
| Factors affecting the Pulse |
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Definition
Age
Sex
Exercise
Fever
Medications
Hypovolemia/dehydration
Stress
Position
Pathology |
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Term
| Factors affecting the Pulse: Age |
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Definition
| as age ↑, pulse rate gradually ↓ |
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Term
| Factors affecting the Pulse: Sex |
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Definition
| after puberty, male's pules rate is slightly lower than the females |
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Term
| Factors affecting the Pulse: Exercise |
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Definition
pulse rate normally increases with activity
-rate of increase less with professional athlete because of greater cardiac size, strength and efficiency |
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Term
| Factors affecting the Pulse: Fever |
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Definition
| pulse rate ↑ in response to lowered blood pressure that results from peripheral vasodilation associated with elevated body temp and because of increased metabolic rate |
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Term
| Factors affecting the Pulse: Medications |
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Definition
| some meds ↓ the pulse rate and others ↑ |
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Term
| Factors affecting the Pulse: Hypovolemia/dehydration |
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Definition
loss of blood from vascular system ↑ pulse rate
in adults the loss of circulating volume results in and adjustment of the heart rate to increase blood pressure as the body compensates for lost blood volume |
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Term
| Factors affecting the Pulse: Stress |
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Definition
in response to stress, SNS stimulation ↑ overall activity of the heart. Increases rate as well as force of heartbeat
-fear, anxiety and severe pain stimulate the SNS |
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Term
| Factors affecting the Pulse: Position |
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Definition
| when sitting or standing, blood usually pools in dependent vessels of the venous system. Pooling results in ↓ in venous blood return to heart and reduction in blood pressure and increase in heart rate |
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Term
| Factors affecting the Pulse: Pathology |
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Definition
| diseases such as some heart conditions or those affecting oxygenation can alter resting pulse rate |
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
Newborn |
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Definition
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
1 Year |
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Definition
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
5-8 Years |
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Definition
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
10 Years |
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Definition
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
Teen |
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Definition
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
Adult |
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Definition
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Term
Variations in Pulse by Age
Pulse Average (and ranges)
Older Adult |
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Definition
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Term
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Definition
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Pedal (dorsalis pedis) |
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Term
Reasons for using specific pulse site
Radial |
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Definition
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Term
Reasons for using specific pulse site
Temporal |
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Definition
| used when radial pulse is not accessible |
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Term
Reasons for using specific pulse site
Carotid |
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Definition
-during cardiac arrest/shock in adults
-to determine circulation to the brain |
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Term
Reasons for using specific pulse site
Apical |
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Definition
-jused for infants and children up to 3 yrs
-determine discrepancies with radial pulse
-in conjunction with some meds |
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Term
Reasons for using specific pulse site
Brachial |
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Definition
-measure blood pressure
-during cardiac arrest for infants |
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Term
Reasons for using specific pulse site
Femoral |
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Definition
-in cases of cardiac arrest/shock
-determine circulation to leg |
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Term
Reasons for using specific pulse site
Popliteal |
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Definition
| determine circulation to the lower leg |
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Term
Reasons for using specific pulse site
Posterior tibial |
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Definition
| determine circulation to the foot |
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Term
Reasons for using specific pulse site
Dorsalis pedis |
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Definition
| determine circulation to the foot |
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Term
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Definition
-any medication that could affect the heart rate
-whether client has been physically active (wait 10-15 minutes)
-baseline data about the normal heart rate of client |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| pattern of the beats and the intervals between the beats |
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Term
| pulse with an irregular rhythm (2) |
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Definition
dysrhythmia
arrhythmia
-may be random, irregular beats or a predictable pattern of irregular beats (regularly irregular)
-ECG necessary to define the dysrhythmia further |
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Term
| refers to the force of blood with each beat (3) |
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Definition
pulse volume
pulse strength
amplitude
-range from absent to bounding (0 to +4) +2 normal |
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Term
Respirations variations by Age
Average and ranges
Newborn |
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Definition
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Term
Respirations variations by Age
Average and ranges
1 Year |
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Definition
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Term
Respirations variations by Age
Average and ranges
5-8 Years |
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Definition
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Term
Respirations variations by Age
Average and ranges
10 Years |
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Definition
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Term
Respirations variations by Age
Average and ranges
Teen |
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Definition
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Term
Respirations variations by Age
Average and ranges
Adult |
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Definition
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Term
Respirations variations by Age
Average and ranges
Older Adult |
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Definition
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Term
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Definition
-should be assessed when client is relaxed (exercise and anxiety will affect rate and depth)
-may also need to assess after exercise to identify tolerance to activity
-clien'ts normal breathing patterns
-influence of health problems
-medications or therapies
-relationship with cardiovascular function |
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Term
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Definition
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Term
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Definition
| pressure of the blood as a result of contraction of the ventricles |
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Term
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Definition
pressure when the ventricle are at rest
-the lower pressure present at all times within the arteries. |
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Term
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Definition
difference between the diastolic and systolic pressures
-normal 40 mmHg but can be as high as 100mmHg during exercise
-consistent high occurs in ateriosclerosis
-low pulse pressure (less than 25mmHg) in severe heart failure |
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Term
Classifications of Blood Pressure
Normal |
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Definition
systolic <120 and
diastolic <80 |
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Term
Classifications of Blood Pressure
Prehypertension |
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Definition
systolic 120-139 or
diastolic 80-89 |
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Term
Classifications of Blood Pressure
Hypertension, stage 1 |
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Definition
systolic 140-159 or
diastolic 90-99 |
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Term
Classifications of Blood Pressure
Hypertension, stage 2 |
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Definition
systolic >160 or
diastolic >100 |
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Term
| Determinants of Blood Pressure (4) |
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Definition
Pumping action of the heart
Peripheral vascular resistance
Blood volume
Blood viscosity |
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Term
| Factors affecting Blood Pressure |
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Definition
Age-pressure rises with age until peaks at puberty, then tends to decline. In older adults decreased elasticity of arteries elevates systolic pressure, diastolic may also be high if arterial walls don't retract
Exercise -wait 20-30 minutes to assess
Stress-stimulation of SNS ↑ cardiac output and vasoconstriction of arterioles, thus ↑ BP: however sever pain can ↓BP by inhibiting vasomotor center and producing vasodilation
Race-African Americans over 35 tend to have higher BP
Sex- after puberty females usually lower BP than males until menopause, then women generally have higher BP than before
Medications
Obesity
Diurnal variations- usually lowest early in morning when metabolic rate is lowest, rises throughout day, and peaks in late afternoon or early evening
Medical conditions-any condition affecting cardiac output, blood volume, blood viscosity, artery compliance
Temperature- fever can ↑BP because of increased metabolic rate
-external heat causes vasodilation and ↓ BP
-cold causes vasoconstriction and ↑BP |
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Term
| Blood pressure not taken on a particular limb when: |
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Definition
-limb is injured or diseased
-cast or bulky bandage
-surgical removal of breast or axillary (or inguinal) lymph nodes on that side
-IV infusion
-presence of arteriovenous fistula |
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Term
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Definition
-phase 1- first faint, clear tapping or thumping sounds are heard (systolic BP)
-phase 2- sounds have a muffled, whooshing or swishing quality
-phase 3- blood flows freely through increasingly open artery and sounds become crisper, and more intense and again assume a thumping quality but softer than phase 1
-phase 4- sounds become muffled and have a soft, blowing quality
-phase 5- last sound is heard, (diastolic BP) |
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Term
| Determine if width of BP cuff is appropriate |
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Definition
width should be 40% of circumference, or 20% wider than the diameter of the midpoint, of the limb on which used.
-lay the cuff lengthwise at the midpoint of the upper arm, and hold the outermost side of the bladder edge laterally on the arm. with the other hand wrap the width of the cuff around the arm, and ensure that the width is 40% of the arm circumference
-the length of the bladder should cover at least 2/3 fo the limb's circumference |
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Term
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Definition
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Term
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Definition
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Term
| arm unsupported during BP assessment |
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Definition
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Term
| insufficient rest before BP assessment |
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Definition
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Term
| repeating BP assessment too quickly |
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Definition
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Term
| cuff wrapped too loosely or unevenly during BP assessment |
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Definition
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Term
| deflating cuff too quickly during BP assessment |
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Definition
| error low systolic, high diastolic |
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Term
| deflating cuff too slowly during BP assessment |
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Definition
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Term
| arm above level of heart during BP assessment |
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Definition
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Term
| BP assessment after meal, smoking or has pain |
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Definition
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Term
| BP assessment failure to identify auscultatory gap |
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Definition
| error low systolic and diastolic |
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Term
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Definition
| blood pressure that is persistently above normal 120/80 |
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