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Vital Signs Ch. 29
Exam 1 (Foundations)
91
Nursing
Undergraduate 3
09/07/2010

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Term
What is the fifth vital sign?
Definition
Pain
Term
When and how often to assess a specific client's vital signs are nursing judgments!
Definition
Term
VS should be taken based on a client's health status.
Definition
Term
Physician ordered assessments should be considered a minimum. Take VS more often if the client's status requires it.
Definition
Term
When can you delegate VS to a UAP?
Definition
Only when the pt is medically stable, in a chronic condition, not fragile and the VS measurement is considered routine.
Term
Define core temperature:
Definition
Temperature of deep tissues of the body (ie: abdominal cavity)
Term
T/F. Core temperature is relatively constant.
Definition
True. Core temperature remains relatively constant.
Term
Define: Surface temperature
Definition
Temperature of the skin, SQ tissue and fat.
Term
T/F. Surface temperature is relatively constant.
Definition
False. Surface temperature rises and falls in response to the environment.
Term
What is heat balance?
Definition
When heat production equals heat loss. When the body is in heat balance the temperature remains relatively constant.
Term
The younger the person the higher the BMR.
Definition
Term
Define BMR:
Definition
Rate of energy utilization in the body required to maintain essential activities such as breathing.
Term
What factors affect the body's heat production?
Definition
1. BMR
2. Muscle activity
3. Thyroxine output
4. Epi/norepi, stress response.
5. Fever
Term
What are the ways the body loses heat?
Definition
Conduction, convection, vaporization, radiation.
Term
Radiation:
Definition
Transfer of heat from surface of one object to surface of another object WITHOUT contact between the two objects.
Term
Convection:
Definition
Dispersion of heat by air currents.
Term
What regulates temperature?
Definition
Hypothalmus
Term
When the skin become chilled, what physiologic processes increase the body temperature?
Definition
1. Shivering increases heat production
2. Sweating is inhibited
3. Vasoconstriction decreases heat loss
Term
How does stress affect temperature?
Definition
Stress stimulates sympathetic nervous system and increases production of epinepherine and norepinephrine. This increases metabolic activity and heat production
Term
Nurses may anticipate that a highly stressed person have an elevated temperature (r/t stimulation of the sympathetic nervous system)
Definition
Term
What would you label a pt with out a fever?
Definition
afebrile
Term
Why might a women experience fluctuations in her body temperature throughout the month?
Definition
Women secrete progesterone at the time of ovulation and this can increases body temp by ~1F
Term
The infant is greatly influenced by temperature of the environment.
Definition
Term
When would you expect a patient to have the highest body temperature?
Definition
Between 1600 and 1800. This is in the normal diurnal cycle of body temps. In the morning you could expect the temp to be lower and peak between 1600 and 1800.
Term
A patient has the flu. She has a wide range of temperature fluctuations and over 24 hours but all temperatures are above normal. What is this type of fever called?
Definition
Remittent fever.
Term
What is a intermittent fever?
Definition
Body temp alternates at regular intervals between periods of normal(or subnormal)and periods of FEVER
Term
What is the term used to decribe the pt with a temperature higher than 41 C (105.8 F)?
Definition
Hyperpyrexia
Term
What is a common cause of fever spike?
Definition
Bacterial blood infection
Term
Your pt has a fever of 100.5F on Monday. No fever on Tuesday but has another fever of 101.0F on Wed. What type of fever does this pt have?
Definition
Relapsing fever.
Term
What is a constant fever?
Definition
When a pt has minimal temperature fluctuation but all temps are above normal.
Term
What is a constant fever?
Definition
When a pt has minimal temperature fluctuation but all temps are above normal.
Term
Why should a nurse monitor a febrile patients' WBC count?
Definition
To watch for indications of infection.
Term
What are the signs of heat stroke?
Definition
(Generally occurs when pts. have been exercising in heat) S/S: warm flushed skin, often do not sweat, with temp above 106F.
Patient with heat stroke may be: delirious, unconscious, having seizures.
Term
What is heat exhaustion? S/S?
Definition
Excessive heat and dehydration.
S/S: paleness, dizziness, nausea, vomiting, and fainting.
Term
Why do elderly patients have a hard time regulating body temp? What are they at risk for?
Definition
Thermoregulation system is not as good as when they were younger. These pts are at risk for hyper and hypothermia.
Term
Why are elderly pts (esp over 75) are at risk for hyperthermia?
Definition
Inadequate diet, loss of subQ fat, sensitivity to environment temperature and poor thermoregulatory systems.
Term
T/F. Newborns body temperatures are extremely labile.
Definition
True. Newborns temps fluctuates with te environment.
Term
How should you position the ear of a 1 year old to take a tympanic temperature?

That of a 3 year old?
Definition
For a child < 2 y/o; pull the pinna straight back and slightly downward.

For a child > 2 y/o; Pull pinna straigh back and up.
Term
What is the average CO?
Definition
~5L/min.
CO = SV x HR

CO = 70ml/beat x 65 BPM
Term
T/F. When a pt is of old age, their arteries may lose compliance thus causing elevated BP.
Definition
True. When arteries lose distendability, greater pressure is required to pump blood to the arteries.
Term
Where do you listen to the Apical pulse?
Definition
At the "Point of Maximal Impulse" (PMI).
5th ICS and Left MCL (right under L nipple)
Term
When would you need to assess the apical and peripheral pulse on an adult?
Definition
When the peripheral pulse is difficult to locate or feel, pulse is weak in periphery, if there is irregular sounds/rhythm.
Term
T/F. Temperature is not a good indicator of health in elderly adults.
Definition
True. Elderly adults can often have an infection and only have a small temperature increase. And since elderly tend to have lower temps, this increase may fall into "normal" limits and go undetected.
Term
T/F. In a healthy adult the pulse reflects the heartbeat.
Definition
True. However, in some CV disease heart-rate and pulses may differ.
Term
Why would an athlete experience a less of a change in pulse with exercise?
Definition
Because their heart is of greater cardiac size, strength and efficiency.
Term
How would a fever cause a change in pulse?
Definition
When someone has a fever, there is vasodilation, causing a reduction in BP, and thus the pulse compensates in reduced BP by increasing. So the pulse would be higher in someone with a fever.
Term
Which pulse location would give you the best information about how the heart is working?
Definition
Dorsalis pedis. Because it is the FURTHEST away from the heart and would show haw effectively the heart is pumping.
Term
Never press both carotids at the same time!! This can cut off blood flow to the head and cause a reflex drop in BP or pulse.
Definition
Term
Would you expect a patient with HYPOVOLEMIA to have an elevated or decreased pulse?
Definition
Elevated. The body is attempting to increase the BP by increasing pulse.
Term
How does stress affect the pulse?
Definition
Stress increases heart rate and force of heart beat. This occurs due to stimulation of the sympathetic nervous system.
Term
T/F You should always check BP before administering a "cardiotonic" such as Digitalis.
Definition
T. These drugs slow the heart rate and you would want to be sure the pulse was at a specified rate before administering more of the med.
ALWAYS CHECK APICAL PULSE FOR THESE TYPES OF MEDS
Term
The carotid artery is useful in assessing circulation to the brain!
Definition
Term
Which artery is used to measure BP?
Definition
Brachial
Term
What should you do if you are having difficulty assessing the dorsalis pedis pulse?
Definition
Use a doppler ultrasound stethoscope.
Term
What part of your fingers are best for assessing pulse?
Definition
Your finger PADS
Term
What should you be careful of when assessing the radial pulse of a pt with a "weak thready" pulse?
Definition
Not to press too hard and obliterate the pulse.
Term
T/F. When someone has a dysrhythmia, you should assess the apical pulse.
Definition
Term
Pulse rate does not need to be counted when checking pulse for perfusion and equality.
Definition
Term
You are assessing a client's pulses. You feel the pulse on the right and left dorsalis pedis. They are the same. How would you chart this?
Definition
Dorsalis pedis pulse equal bilaterally.
Term
When assessing pulses, start at the dorsalis pedis and work up.
Definition
If you can not feel the dorsalis pedis you would move to the posterior tibial. If a pulse is felt here then you needn't go "up" any further bc there will be tissue perfusion more proximal to pulse felt.
Term
If you are taking a thigh BP, which artery would you listen to?
Definition
Popliteal
Term
Why should you NOT use the thumb to take pulses?
Definition
BC the nurses pulse could be mistaken for the client's pulse.
Term
Where would you take the pulse before giving digitalis?
Definition
Apical site.
Term
If you are having difficulty hearing a apical pulse, what should you have the pt do?
Definition
Lay on their left side. Why? This positions the apex closer to the chest wall.
Term
What are you hearing when you hear "S1" and "S2"?
Definition
S1: (lub) AV valves closing after ventricles have been filled.

S2: (dub) Semilunar valves closing after ventricles empty.
Term
Distal pulses may be difficult to feel in infants
Definition
Term
Pulse deficit:
Definition
When the radial pulse is less than the apical pulse. (Apical pulse - radial pulse).
Term
A nurse is checking for pulse deficit. She notes the Apical pulse is 70 BPM and the radial pulse is 74 BPM. What is wrong with this?
Definition
The radial pulse is never higher than the apical pulse.
Term
You are assessing an elderly pt with tremors. What should you do?
Definition
Well, the radial pulse may be hard to count in a pt with tremors. Taking an Apical pulse would be the best and most accurate option.
Term
Factors that may increase respiration rate:
Definition
Stress (Flight or fight), Exercise, lowered oxygen concentration (high altitudes)
Term
Define: Hemoptysis
Definition
Blood in Sputum
Term
Non productive cough:
Definition
Dry harsh cough
Term
Orthopnea:
Definition
Ability to breathe in upright postions
Term
A pt is breathing very deep and then very shallow. Almost rhythmically. She is then experiencing periods of apnea. How would you describe this respiration pattern?
Definition
Cheyne-Stokes breathing
Term
The patient is having labored breathing. He feels as if he is not getting enough air. The pt is distressed. How would you chart his breathing?
Definition
Pt is experiencing "Dyspnea"
Term
What three words describe respiratory volume?
Definition
Shallow, normal and deep.
Term
What is tidal volume? What is average tidal volume?
Definition
Tidal Volume is: 1 inspiration and 1 expiration.
Normal tidal volume is: 500mL or air
Term
What words describe respiratory rhythm?
Definition
Regular or irregular
Term
Normal breathing is silent and effortless.
Definition
Abnormal breathing may produce audible sounds and require effort.
Term
Many sounds that occur in the lungs are due to fluid build up in lungs.
Definition
Term
What does a pulse oximeter measure?
Definition
Amount of hemoglobin in arterial blood that is saturated with oxygen.
Term
What does a pulse oximeter measure?
Definition
Amount of hemoglobin in arterial blood that is saturated with oxygen.
Term
Where are possible locations to attached a pulse ox sensor?
Definition
Finger, forehead, earlobe, toe, nose (or foot of neonate)
Term
What are clinical signs of hypoxemia?
Definition
Dusky skin and color and nail beds.
Term
What are normal SaO2 levels?
Definition
95%-100%
Term
What is life threatening SaO2 levels?
Definition
70% and below
Term
How does a Pulse Ox work?
Definition
The LED pulse ox detects the amount of red and infrared light absorbed by oxygenated and deoxygenated hemoglobin in peripheral arterial blood.
Term
How does Hemoglobin affect Pulse Ox?
Definition
A patient could be severely anemic but still have a normal pulse ox reading. Why? Total Hb may be low, but the "low level" of Hb may be fully saturated and return a normal pulse ox.
Term
A pulse ox can not distinguish between CO2 and O2. If a pt has CO poisoning, the Hb may appear to be "saturated" but with carbon monoxide and not oxygen.
Definition
Term
When might a patient have a constantly elevated pulse pressure?
Definition
Arteriosclerosis
Term
What is a normal Pulse pressure?
Definition
40 mmHg
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