Term
Normal Vital Signs
Newborn |
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Definition
Temp - 36.8 Axillary
HR - 80-180
RR - 30 - 80
BP - 70/55 |
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Term
Normal Vital Signs
1 - 3 yr |
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Definition
Temp - 37.7 Rectal
HR - 80-140
RR - 20 -40
BP - 90/55 |
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Term
Normal Vital Signs
6 - 8 yr |
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Definition
Temp - 37 Oral
HR - 75 - 120
RR - 15 - 25
BP - 95/75 |
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Term
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Definition
Temp - 37 Oral
HR - 75 - 110
RR - 15 - 25
BP - 102/62 |
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Term
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Definition
Temp - 37 Oral
HR - 60 - 100
RR - 12 - 20
BP - 120/80 |
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Term
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Definition
Temp - 37 Oral
HR - 60 - 100
RR - 15 - 20
BP - 102/80 |
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Term
Normal Vital Signs
> 70 age |
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Definition
Temp 36 Oral
HR - 60 - 100
RR - 15 - 20
BP - 120/80 |
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Term
Fever
- Pyrexia Normal Range |
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Definition
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Term
Fever
- Nursing Interventions |
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Definition
- Monitor temp as Frequently as appropriate
- Monitor bp, pulse, and respirations as appropriate
- Monitor intake and output
- Monitor for Seizure Activities
- Administer Antipyretic medication as appropriate
- Administer IV fluid as appropriate
- Apply ice bag covered with towel to groin and axilla |
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Term
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Definition
- Vital Signs
- Hydration
- Thermoregulation
- Risk Control, Hyperthermia |
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Term
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Definition
- Hyperthermia
Related To Factors: Streptococcal Respiratory Infection, Exposure to environmental heat without adequate cooling, surgery with general anesthesia
- Hypothermia
Related To Factors: Exposure to freezing environmental temperature without adequate clothing
- Risk for imbalanced Body Temp
Related to Factors - Age of 92 years and head injury causing loss of consciousness
- Ineffective Thermoregulation
Related to FActors: Premature infant delivered at 30 weeks of gestation |
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Term
Pulse
- Factors contributing to Tachycardia |
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Definition
Tachycardia - increased HR
- decrease in bp such as occurs with blood loss when the hearts compensatory mechanisms attempt to meet the need for increased cardiac output
- elevated temperature which usually causes an increase of about 7 to 10 beats/min for each 0.6C of elevation above normal
- Any condition resulting in poor oxygenation of the blood, for example chronic pulmonary disease or anemia
- Exercise when the heart's compensatory ability attempts to meet the need for increased blood circulation
- Prolonged application of heat
- Pain
- Strong Emotions such as fear anger anxiety and surprise
- some medications such as epinephrine |
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Term
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Definition
0 - Absent Pulse - No pulse felt despite extreme pressure
1+ - Thready Pulse - pulsation not easily felt and slight pressure causes it to disappear
2+ - Weak Pulse - Stronger than a thready pulse, light pressure can cause it to disappear
3+ - Normal Pulse - Pulsation is felt easily, takes moderate pressure to cause it to disappear
4+ Bounding pulse - The pulsation is strong and does not disappear with moderate pressure |
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Term
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Definition
- Decreased Cardiac Output
Related to Factors: History of congestive heart failure and dysrhythmia, traumatic injury with extensive blood loss
- Ineffective Peripheral Tissue Perfusion
Related to Factors: History of Peripheral Vascular Disease with decreased popliteal pulses
- Deficient Fluid Volume
Related to FActors: Exposure to high environmental temperature, increased age, and tachycardia
- Acute Pain
Related to Factors: First postoperative day following major surgery, crying and tachycardia |
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Term
Respiratory Rate
- Factors contributing to respiratory rate, depth and movement |
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Definition
- Age: RR decreases with age
- Gender: Men are more diaphragmatic, women more intercostal
- Exercise: Exercise increases RR and depth
- Brain Lesions - hemorrhage or tumors can cause a change in both depth and rate of respirations (Cheyne-Stokes respirations)
- Acid Base Balance - Alterations in acid base blaance can cause increase in RR
- Increased Altitude - Cheyne SToke respirations, especially when asleep. Increase RR b/c of adaptation to increasing hemoglobin levels
- Respiratory disease - alterations in norm may result in changes in respiratory rate, depth, and patter.
- Smoking can result in increase in RR at rest
- Anemia - increase in RR due to decrease in o2 carrying hemoglobin
- Anxiety - increase in RR and depth
- Meds
- Acute Pain increase respiratory rate but decrease depthy |
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Term
Pulse
- Factors contributing to Bradycardia |
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Definition
- Age (decreases with age)
- Sleep
- Men and being thin cause slower rates
- Hypothermia
- medications (beta blockers)
- trained athletes
- vagal stimulation
- suctioning of respiratory secretions
- severe pain
- increased intracranial pressure
- myocardial infarction |
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Term
Respiratory Rate
- Patterns of Respiration
Tachypnea |
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Definition
>24 breaths/min
Shallow
Associated Features: Fever, Anxiety, Exercise, Resp Disorder |
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Term
Respiratory Rate
- Patterns of Respiration
Bradypnea |
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Definition
<10 breaths/min
Regular
Associated Features: Depression of the respiratory center by medications, brain damage |
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Term
Respiratory Rate
- Patterns of Respiration
Hyperventilation |
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Definition
Increased Rate and Depth
Associated Features - extreme exercise, fear, diabetic ketoacidosis (Kussmaul's respirations), overdose of aspirin |
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Term
Respiratory Rate
- Patterns of Respiration
Hypoventilation |
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Definition
Decreased Rate and Depth
Irregular
Associated Features: Overdose of narcotics or anesthetics |
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Term
Respiratory Rate
- Patterns of Respiration
Cheyne-Stokes Respirations |
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Definition
Alternating Periods of deep, rapid breathing followed by periods of apnea
Regular
Associated Features: drug overdose, heart failure, increased intracranial pressure, renal failure |
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Term
Respiratory Rate
- Patterns of Respiration
Biot's respirations |
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Definition
Varying depth and rate of breathing followed by periods of apnea
Irregular
Associated Features Meningitis, severe brain damage |
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Term
Respiratory Rate
- Nursing Dx |
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Definition
- Ineffective Breathing Pattern
Related to factors: Anxiety about diagnostic procedure for possible malignancy, increased intracranial pressure followed by head injury, infant delivered by cesarean delivery at 28 weeks gestation
- Impaired Gas Exchange
Related to factors: Presence of acute respiratory distress following smoke inhalation
- Risk for activity intolerance
As related to factors - history of smoking two packs of cigarettes a day for 10 years |
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Term
Blood Pressure
- Factors contributing to Blood pressure variations in healthy people |
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Definition
- Age - older adult has decreased elasticity of the arteries which increases peripheral resistance and therefore increases blood pressure
- Circadian rhythm - normal fluctiations occur during the day. Lowest in the am and highest in the late afternoon
Gender - women have lower bp then men in general until menopause
Food intake - blood pressure increases after eating food
Exercise - systolic bp rises du ring periods of exercise and strenous activity
Weight - blood pressure is higher in people who are obese then thin
Emotional state - emotions such as anger, fear, excitement and pain cause bp to rise but pressure falls to normal when situation passes
Body Position - blood pressure tends to be lower when prone or supine then sitting or standing
Race - hypertension is more prevalent in African American men and women
drugs/medication - oral contraceptives cause a slight increase in blood pressure in women |
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Term
Blood Pressure
- Prehypertension |
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Definition
Systolic 120 - 139
OR
Diastolic 80 - 89 |
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Term
Blood Pressure
- Hypertension |
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Definition
Stage 1
- Systolic 140 - 159
OR
- Diastolic 90-99
Stage 2
Systolic > (or equal to) 160
OR
Diastolic > (or equal to) 100 |
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Term
Blood Pressure
- Hypotension |
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Definition
systolic 90-115
Orthostatic hypotension - decrease in systolic bp to a number equal to or greater than 10mm HG within 3 mins of standing
Hypotension can be normal in some adults such as athletes
Pathologic hypotension could be from heart failure, loss of blood volume, or vasodilation of arterioles |
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Term
Blood Pressure
- Nursing Dx |
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Definition
- Decreased Cardiac Output
Related To Examples - serious blood loss with hypovolemia, myocardial infarction with damage to cardiac pacemaker,
- Ineffective Health Maintenance
Related to Factors: lack of financial resources to seek medical care for hypertension
Readiness for Enhanced Self-Health Managemetn
Related to Factors: Blood PRessure remains within normal limits for six months
- Risk for falls
Related to Factors: History of falls, age 86 year, and presence of orthostatic hypotension |
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Term
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Definition
| difference between the apical and radial pulse |
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Term
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Definition
| The measurement of force of blood against the arterial walls |
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Term
| Why does age cause an increase in blood pressure |
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Definition
| because of the decreased elasticity in the arterial walls |
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