Term
| What is the fifth vital sign? |
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Definition
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Term
| When and how often to assess a specific client's vital signs are nursing judgments! |
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Definition
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Term
| VS should be taken based on a client's health status. |
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Definition
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Term
| Physician ordered assessments should be considered a minimum. Take VS more often if the client's status requires it. |
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Definition
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Term
| When can you delegate VS to a UAP? |
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Definition
| Only when the pt is medically stable, in a chronic condition, not fragile and the VS measurement is considered routine. |
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Term
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Definition
| Temperature of deep tissues of the body (ie: abdominal cavity) |
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Term
| T/F. Core temperature is relatively constant. |
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Definition
| True. Core temperature remains relatively constant. |
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Term
| Define: Surface temperature |
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Definition
| Temperature of the skin, SQ tissue and fat. |
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Term
| T/F. Surface temperature is relatively constant. |
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Definition
| False. Surface temperature rises and falls in response to the environment. |
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Term
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Definition
| When heat production equals heat loss. When the body is in heat balance the temperature remains relatively constant. |
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Term
| The younger the person the higher the BMR. |
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Definition
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Term
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Definition
| Rate of energy utilization in the body required to maintain essential activities such as breathing. |
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Term
| What factors affect the body's heat production? |
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Definition
1. BMR
2. Muscle activity
3. Thyroxine output
4. Epi/norepi, stress response.
5. Fever |
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Term
| What are the ways the body loses heat? |
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Definition
| Conduction, convection, vaporization, radiation. |
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Term
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Definition
| Transfer of heat from surface of one object to surface of another object WITHOUT contact between the two objects. |
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Term
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Definition
| Dispersion of heat by air currents. |
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Term
| What regulates temperature? |
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Definition
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Term
| When the skin become chilled, what physiologic processes increase the body temperature? |
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Definition
1. Shivering increases heat production
2. Sweating is inhibited
3. Vasoconstriction decreases heat loss |
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Term
| How does stress affect temperature? |
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Definition
| Stress stimulates sympathetic nervous system and increases production of epinepherine and norepinephrine. This increases metabolic activity and heat production |
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Term
| Nurses may anticipate that a highly stressed person have an elevated temperature (r/t stimulation of the sympathetic nervous system) |
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Definition
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Term
| What would you label a pt with out a fever? |
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Definition
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Term
| Why might a women experience fluctuations in her body temperature throughout the month? |
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Definition
| Women secrete progesterone at the time of ovulation and this can increases body temp by ~1F |
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Term
| The infant is greatly influenced by temperature of the environment. |
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Definition
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Term
| When would you expect a patient to have the highest body temperature? |
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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. |
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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? |
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Definition
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Term
| What is a intermittent fever? |
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Definition
| Body temp alternates at regular intervals between periods of normal(or subnormal)and periods of FEVER |
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Term
| What is the term used to decribe the pt with a temperature higher than 41 C (105.8 F)? |
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Definition
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Term
| What is a common cause of fever spike? |
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Definition
| Bacterial blood infection |
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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? |
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Definition
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Term
| What is a constant fever? |
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Definition
| When a pt has minimal temperature fluctuation but all temps are above normal. |
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Term
| What is a constant fever? |
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Definition
| When a pt has minimal temperature fluctuation but all temps are above normal. |
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Term
| Why should a nurse monitor a febrile patients' WBC count? |
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Definition
| To watch for indications of infection. |
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Term
| What are the signs of heat stroke? |
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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. |
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Term
| What is heat exhaustion? S/S? |
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Definition
Excessive heat and dehydration.
S/S: paleness, dizziness, nausea, vomiting, and fainting. |
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Term
| Why do elderly patients have a hard time regulating body temp? What are they at risk for? |
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Definition
| Thermoregulation system is not as good as when they were younger. These pts are at risk for hyper and hypothermia. |
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Term
| Why are elderly pts (esp over 75) are at risk for hyperthermia? |
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Definition
| Inadequate diet, loss of subQ fat, sensitivity to environment temperature and poor thermoregulatory systems. |
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Term
| T/F. Newborns body temperatures are extremely labile. |
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Definition
| True. Newborns temps fluctuates with te environment. |
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Term
How should you position the ear of a 1 year old to take a tympanic temperature?
That of a 3 year old? |
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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. |
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Term
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Definition
~5L/min.
CO = SV x HR
CO = 70ml/beat x 65 BPM |
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Term
| T/F. When a pt is of old age, their arteries may lose compliance thus causing elevated BP. |
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Definition
| True. When arteries lose distendability, greater pressure is required to pump blood to the arteries. |
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Term
| Where do you listen to the Apical pulse? |
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Definition
At the "Point of Maximal Impulse" (PMI).
5th ICS and Left MCL (right under L nipple) |
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Term
| When would you need to assess the apical and peripheral pulse on an adult? |
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Definition
| When the peripheral pulse is difficult to locate or feel, pulse is weak in periphery, if there is irregular sounds/rhythm. |
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Term
| T/F. Temperature is not a good indicator of health in elderly adults. |
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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. |
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Term
| T/F. In a healthy adult the pulse reflects the heartbeat. |
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Definition
| True. However, in some CV disease heart-rate and pulses may differ. |
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Term
| Why would an athlete experience a less of a change in pulse with exercise? |
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Definition
| Because their heart is of greater cardiac size, strength and efficiency. |
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Term
| How would a fever cause a change in pulse? |
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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. |
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Term
| Which pulse location would give you the best information about how the heart is working? |
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Definition
| Dorsalis pedis. Because it is the FURTHEST away from the heart and would show haw effectively the heart is pumping. |
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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. |
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Definition
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Term
| Would you expect a patient with HYPOVOLEMIA to have an elevated or decreased pulse? |
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Definition
| Elevated. The body is attempting to increase the BP by increasing pulse. |
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Term
| How does stress affect the pulse? |
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Definition
| Stress increases heart rate and force of heart beat. This occurs due to stimulation of the sympathetic nervous system. |
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Term
| T/F You should always check BP before administering a "cardiotonic" such as Digitalis. |
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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 |
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Term
| The carotid artery is useful in assessing circulation to the brain! |
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Definition
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Term
| Which artery is used to measure BP? |
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Definition
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Term
| What should you do if you are having difficulty assessing the dorsalis pedis pulse? |
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Definition
| Use a doppler ultrasound stethoscope. |
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Term
| What part of your fingers are best for assessing pulse? |
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Definition
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Term
| What should you be careful of when assessing the radial pulse of a pt with a "weak thready" pulse? |
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Definition
| Not to press too hard and obliterate the pulse. |
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Term
| T/F. When someone has a dysrhythmia, you should assess the apical pulse. |
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Definition
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Term
| Pulse rate does not need to be counted when checking pulse for perfusion and equality. |
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Definition
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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? |
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Definition
| Dorsalis pedis pulse equal bilaterally. |
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Term
| When assessing pulses, start at the dorsalis pedis and work up. |
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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. |
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Term
| If you are taking a thigh BP, which artery would you listen to? |
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Definition
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Term
| Why should you NOT use the thumb to take pulses? |
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Definition
| BC the nurses pulse could be mistaken for the client's pulse. |
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Term
| Where would you take the pulse before giving digitalis? |
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Definition
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Term
| If you are having difficulty hearing a apical pulse, what should you have the pt do? |
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Definition
| Lay on their left side. Why? This positions the apex closer to the chest wall. |
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Term
| What are you hearing when you hear "S1" and "S2"? |
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Definition
S1: (lub) AV valves closing after ventricles have been filled.
S2: (dub) Semilunar valves closing after ventricles empty. |
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Term
| Distal pulses may be difficult to feel in infants |
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Definition
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Term
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Definition
| When the radial pulse is less than the apical pulse. (Apical pulse - radial pulse). |
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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? |
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Definition
| The radial pulse is never higher than the apical pulse. |
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Term
| You are assessing an elderly pt with tremors. What should you do? |
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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. |
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Term
| Factors that may increase respiration rate: |
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Definition
| Stress (Flight or fight), Exercise, lowered oxygen concentration (high altitudes) |
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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
| Ability to breathe in upright postions |
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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? |
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Definition
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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? |
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Definition
| Pt is experiencing "Dyspnea" |
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Term
| What three words describe respiratory volume? |
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Definition
| Shallow, normal and deep. |
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Term
| What is tidal volume? What is average tidal volume? |
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Definition
Tidal Volume is: 1 inspiration and 1 expiration.
Normal tidal volume is: 500mL or air |
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Term
| What words describe respiratory rhythm? |
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Definition
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Term
| Normal breathing is silent and effortless. |
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Definition
| Abnormal breathing may produce audible sounds and require effort. |
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Term
| Many sounds that occur in the lungs are due to fluid build up in lungs. |
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Definition
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Term
| What does a pulse oximeter measure? |
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Definition
| Amount of hemoglobin in arterial blood that is saturated with oxygen. |
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Term
| What does a pulse oximeter measure? |
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Definition
| Amount of hemoglobin in arterial blood that is saturated with oxygen. |
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Term
| Where are possible locations to attached a pulse ox sensor? |
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Definition
| Finger, forehead, earlobe, toe, nose (or foot of neonate) |
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Term
| What are clinical signs of hypoxemia? |
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Definition
| Dusky skin and color and nail beds. |
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Term
| What are normal SaO2 levels? |
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Definition
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Term
| What is life threatening SaO2 levels? |
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Definition
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Term
| How does a Pulse Ox work? |
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Definition
| The LED pulse ox detects the amount of red and infrared light absorbed by oxygenated and deoxygenated hemoglobin in peripheral arterial blood. |
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Term
| How does Hemoglobin affect Pulse Ox? |
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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. |
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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. |
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Definition
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Term
| When might a patient have a constantly elevated pulse pressure? |
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Definition
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Term
| What is a normal Pulse pressure? |
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Definition
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