Basta BHC ni Flashcards
(135 cards)
1
Q
- measures of various physiological status, in order to assess the most basic body function
- indicates that the person is alive
- can be observed, measured and monitored
- changes with age and medical condition
- useful in detecting or monitoring medical problems
A
Vital Signs
2
Q
Measurements for the body’s basic function
A
a.Body temperature (Temp)
b.Pulse/heart Rate (PR/HR)
c.Respiration Rate (RR)
d.Blood Pressure (BP)
3
Q
- the balance between the heat production due to chemical activities by the body and heat lost from the body through radiation, conduction, convection and vaporization
A
Body Temperature
4
Q
When to assess Vital Signs?
A
Upon admission to any healthcare agency
Based on agency institutional policy and procedures
Any time there is changes in the patient’s condition
Before and after surgical or invasive diagnostic procedure
Before and after activity that may increase risk
Before and after administering medications that affect cardiovascular ore respiratory functioning
5
Q
-the temperature of deep tissues of the body (ex: cranium, thorax, abdominal cavity)
true core temperature can only be measured by invasive means
A
CORE TEMPERATURE
6
Q
What is the normal body temperature?
A
normal body temp : 36.2 to 37.2c
7
Q
the temperature of the skin, the subcutaneous tissue and fat
rises and falls in response to environmental changes
average oral temp: 36.7 – 37c
A
Surface Temperature
8
Q
Factors affecting Body’s Heat Production
A
Basal Metabolic Rate (BMR)
Muscle Activity
Epinephrine and symphathetic stimulation
Age
Gender
Diurnal variation
Exercise
9
Q
A body temperature above the usual range
A
Gender Alterations in Body temperature: PYREXIA
10
Q
usually referred as fever
A
Hyperthermia
11
Q
A very high temperature, e.g. 41c (105 f) is called
A
Hyperpyrexia
12
Q
temperature alternates at regular intervals between periods of fever and periods of normal temperatures.
A
Intermittent Fever
13
Q
a wide range of temperature fluctuations occurs over the 2 hour period, all of which are above normal
A
Remittent Fever
14
Q
short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.
A
Relapsing Fever
15
Q
body temperature fluctuates minimally but always remains elevated.
A
Constant Fever
16
Q
increased heart rate and respiratory rate and depth.
Shivering due to increased skeletal muscle tension and contraction.
Cold skin due to vasoconstriction.
Cyanotic nail beds due to vasoconstriction.
Complain of feeling cold.
Gooseflesh appearance of the skin.
Rise in body temperature.
A
Clinical Signs of Fever: ONSET (Cold or Chill Stage)
17
Q
Skin feels warm
increased pulse and respiratory rate.
increased thirst
mild to severe dehydration.
Cyanotic nail beds due to vasoconstriction.
Complain of feeling cold.
Gooseflesh appearance of the skin.
Rise in body temperature.
A
Clinical Signs of Fever: COURSE
18
Q
Flushed and warm skin
Sweating
Decreased shivering
Possible dehydration
A
Clinical Signs of Fever: ABATEMENT
19
Q
Treatment of Increasing Body temperature
A
Antypyretics (Paracetamol)
Cold sponge bath
Cold compress
20
Q
Core body temperature below the lower limit of normal
The ability of hypothalamus to regulate temperature is greatly impaired when the body temperature falls below 34.5c ( 94 F), and death usually occurs when the temperature falls below 34c (93.2 F)
A
Alterations in Body temperature: HYPOTHERMIA
21
Q
Physiologic Process of Hypothermia
A
excessive cold environment
inadequate heat production to counteract the heat loss
22
Q
Clinical signs of Hypothermia
A
Decreased body temperature
Pale, cool, waxy skin
Hypotension
Lack of muscle coordination
Disorientation
Drowsiness may progress to coma
23
Q
- considered reliable when thermometer is place posteriorly into the sublingual pocket
- tracks changes of core temp
- the most common way in checking temp.
A
Orally (common way) n: 37c – taken 3- 5mins
24
Q
- measure by placing thermometer in the central position and adducting the arm close to the chest wall
- considered unreliable for estimating body temperature because there are no main blood vessels around this area
- most safest way in getting a patients body temp.
A
Axillary (safe way) n:36c +0.5c (10mins)
25
- most accurate method for measuring the core temperature
- should reduce 0,5c to actual reading
- the most accurate way in getting the body temp.
Rectal (accurate reading) 37c – 0.5c (2-3 mins)
26
Contraindications of Oral thermometer
the child is under 6 years old
unconscious patient
psychiatric patients
patient who cannot breath from his nose
mouth surgery or infection
patient on oxygen mask
27
Contraindications of Rectal thermometer
rectal surgery
rectal disorder (hemorrhoids, rectal fissure)
diarrhea
28
Types of Thermometer
Electronic /Digital
Glass/mercury
Tympanic
infrared
29
Alterations in thermoregulation
Heat exhaustion
Heat stroke
Hypothermia
Frostbite
30
- a wave of blood created by contraction of the left ventricle of the heart
- a measurement of a pressure pulsation created when the heart contracts and ejects blood into the aorta
Pulse
31
refers to the feel of the pulse, its rhythm and forcefulness
Pulse Quality
32
indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waved over a pulse point
Pulse Rate
33
regularity of the heartbeat
Pulse Rhythm
34
the beats are evenly spread
Regular
35
the beats are not evenly spread
Irregular
36
irregular rhythm caused by early or late or missed heartbeat
Dysrhythmia (arrhythmia)
37
measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction
Pulse Volume
38
less than normal rate
Bradycardia
39
more than normal rate
Tachycardia
40
Pulse Volume Scale
Scale Description
0 Absent Pulse
1 Weak and thread pulse
2 Normal Pulse
3 Bounding Pulse
41
Factors contributing to increase pulse rate
pain
fever
stress, exercise
bleeding
decrease in blood pressure
some medications (Adrenalin, aminophylline)
42
Factors contributing to slow pulse rate
rest
increasing age
people with thin body size
some medications
thyroid gland disturbances
43
- Accessible, used routinely and when radial is inaccessible
Temporal
44
Accessible, used routinely for infants and during shock or cardiac arrest when peripheral pulses are too weak to palpate,
- Used to assess cranial circulation
Carotid
45
used to auscultate heart sounds and assess apical field
Apical
46
- used in cardiac arrest for infants
- to assess lower arm circulation
- to auscultate the blood pressure
Brachial
47
- accessible, used routinely in adults to assess character of peripheral pulse
Radial
48
used to assess circulation to ulnar side of hand and to perform allen’s test
Ulnar
49
used to assess circulation to legs and during cardiac arrest
Femoral
50
used to assess circulation to the legs and blood pressure
Popliteal
51
Use to assess circulation of the feet
Posterior Tibial & Dorsalis
52
is indicator for clients whose peripheral pulse is irregular as well as for clients with known cardiovascular, pulmonary, and renal diseases.
It is commonly assessed prior to administering medications that effect heart rate.
The apical side is also used to assess the pulse for newborns, infants, and children up to 2-3 years old.
Apical Pulse Assessment
53
difference in the apical pulse and the radial pulse.
These should be taken at the same time, which will require that 2 people take the pulse.
One with a stethoscope and one at the wrist.
Count for 1 full minute. Then subtract the radial from the apical.
Pulse Deficit
54
movement of air in and out of the lungs
Pulmonary Ventilation (breathing)
55
Factors affecting Respiration
Pain, anxiety, exercise
Medications
Trauma
Infection
Respiratory and cardiovascular disease
Alteration in fluids, electrolytes, acid base balance
56
Assessing Respiration
inspection
listening with stethoscope
monitoring arterial blood gas result (ABG)
using pulse oximeter
57
located centrally in the medulla in peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentration of oxygen ( O2), carbon dioxide ( Co 2), and hydrogen ( H+) levels in the arterial blood.
Chemoreceptors
58
refers to easy respirations with normal rate of breaths per minute that is age specific
Eupnea
59
characterized by rate of 10 or fewer breaths per minute
Bradypnea (less than normal)
60
characterized at a rate of 10 or fewer breaths per minute
Bradypnea (less than normal)
61
characterized by shallow respiration
Hypoventilation
62
respiratory rate greater that 24 breaths per minute
Tachypnea (more that normal)
63
characterized by deep, rapid respiration
Hyperventilation
64
occurs when external intercostal muscles and the other accessory muscles are used to move the chest upward and outward.
Costal (thoracic) breathing
65
occurs when the diaphragm contracts and relaxes as observed by movement of the abdomen.
Diaphragmatic(abdominal) breathing
66
refers to difficulty in breathing as observed by labored or forced respirations through the use of accessory muscles in the chest and neck to breathe.
Dyspnea
67
respirations cease for several seconds. Persistent cessation is called respiratory arrest.
Apnea (a- absence)
68
respiratory rhythm is irregular, characterized by alternating periods of apnea and hyperventilation.
Cheyne–Stockes respiration
69
respirations are abnormally deep but regular, similar to hyperventilation. Characteristic of clients with diabetic ketoacidosis.
Kussmaul respiration
70
respiratory condition in which a person must sit or stand in order to breathe deeply or comfortably.
Orthopnea (ortho- bones/movement)
71
RR: adults
16-20 cmp (cycles per minute)
72
Patterns of Respiration
Respiration Desperation
Tachycardia >24 cpm, shallow
Bradypnea <10cpm, regular
Hyperventilation Increase rate and depth
Hypoventilation Decrease rate and depth, irregular
73
is the force required by the heart to pump blood from the ventricles of the heart into the arteries. It is measured in systolic and diastolic pressure.
Blood pressure
74
NORMAL BP
(systolic)120/80mmHg (diastolic)
75
it is known as the force to pump blood out of the
Systolic pressure
76
it is known as relaxation period of the heart pump (ventricles ).
Diastolic pressure
77
The most common site for indirect blood pressure measurement
client’s arm over the brachial artery.
78
refers to a systolic blood pressure more than 120 mm Hg or 20 to 30 mm Hg more the client’s normal systolic pressure
Hypertension
79
a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110 mmHg in an adult whose normal pressure is higher than this
Hypotension
80
Factors Increasing Blood Pressure
Factor Effect
Age Increase
Exercise Increase
Stress Increase
Sex (Gender) Females- lower
Males- Higher
Medications either
81
Selected conditions affecting blood pressure
Condition Effect
Fever Increase
Stress Increase
Arteriosclerosis Increase
Obesity Increase
Hemorrhage decrease
Low hematocrit decrease
External heat decrease
Exposure to cold Increase
82
The period initiated by the first faint clear taping sound. These sound gradually become more intense.
Phase 1: Korotkoff's sounds
83
The period during which the sounds have a swishing quality.
Phase 2: Korotkoff's sounds
84
The period during which the sounds are crisper and more intense.
Phase 3: Korotkoff's sounds
85
The period , during which the sounds become muffled and have a soft, blowing quality.
Phase 4: Korotkoff's sounds
86
The period where the muffled, blowing sound disappear.
Phase 5: Korotkoff's sounds
87
Pulse Pressure
the numeric difference between the systolic and diastolic blood pressure
For example, if the resting blood pressure is 120/80 millimeters of mercury (mm Hg), the pulse pressure is 40.
A pulse pressure within 40 is the normal and healthy pulse pressure .
A pulse pressure greater than 40 mm Hg is abnormal.
A high pulse pressure may be a strong predictor of heart problems (valve regurgitation), especially for older adults.
A pulse pressure lower than 40 may mean a patient have poor heart function.
88
Equipment for assessing blood pressure
Stethoscope and sphygmomanometer.
Electronic or digital devices.
Alcohol cotton swap.
89
Pain assessments consist of two major components
(a) a pain history to obtain facts from the client
(b) direct observation of behaviors, physical signs of tissue damage, and secondary physiological responses of the client.
90
Pain History
Location
Duration: acute or chronic
Pain Intensity
91
Mild Pain
1 to 3
92
Moderate Pain
4 to 6
93
Severe Pain
7 to 10
94
elevated blood pressure with unknown cause.
Primary hypertension
95
elevated blood pressure with known cause
Secondary hypertension
96
located centrally in the medulla in peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the concentration of oxygen ( O2), carbon dioxide ( Co 2), and hydrogen ( H+) levels in the arterial blood
Chemoreceptors
97
-Process of moving gases into and out of the lungs, This requires the coordination of the muscular and elastic properties of the lung and thorax
-Major Muscle for inspiration: Diaphragm stimulated by phrenic nerve (3rd cervical vertebrae)
Ventilation
98
-The process that brings oxygen into the body and removes carbon dioxide waste
-The exchange occurs in the lungs
Respiration
99
the process by which oxygen is taken from the bloodstream into the cell and carbon dioxide is removed from cell to the bloodstream
Internal Respiration
100
refers to delivery of oxygen to the lungs so that it can be taken into the bloodstream
External Respiration
101
-The passage of fluid through the circulatory and lymphatic system to an organ or tissue
-Usually referred as delivery of blood to a capillary bed in tissue
Perfusion
102
1.Degree of Compliance
2.Airway Resistance
3.Presence of Active Respiration
4.Use of Accessory muscles of Inspiration
Factors Affecting respiration
103
-state of ventilation in excess of that required to eliminate the normal venous CO2 produced by cell metabolism
Anxiety, infection, drugs or acid-base imbalance can produce hyperventilation
HYPERVENTILATION
104
Signs and Symptoms of Hypoventilation
- Lightheadedness - Chest pain
- Disorientation - Shortness of Breath
- Dizziness - Blurred Vision
- Tachycardia - Extremity Numbness
105
Intervention of Hyperventilation
Breathe through pursed lips
Breath slowly into a paper bag or cupped hands
Attempt to breathe into your belly rather than chest
Hold breath for 10 to 15 seconds
Brown bag
106
-Alveolar ventilation is inadequate to meet body’s O2 demand
-PaCO2 elevates, PaO2 drops
-Severe atelectasis can cause hypoventilation
-COPD (Chronic Obstructive Pulmonary disease)
HYPOVENTILATION
107
Signs and Symptoms of Hypoventilation
Disorientation - convulsion
- lethargy - coma
- dizziness - dysrythmias
- headache - cardiac death
- decrease ability to follow instructions
108
Interventions of Hypoventilation
Oxygen therapy
Airway management: CPAP/BIPAP
Surgery
Weight loss
Inhaled medications
109
-Inadequate tissue oxygenation at the cellular level
-Deficiency of O2 delivery or O2 utilization at cell level
-Causes: Decreased Hgb, diminished concentration of inspired O2, decreased diffusion poor tissue perfusion, impaired ventilation
HYPOXIA
110
Other factors affecting Oxygenation
-Age
-Environment
-Lifestyle
-Medications
-Stress
-Infection
111
Nursing History
-Contains respiratory component
-Before starting the interview make sure patient is not in respiratory distress
-If distress, postpone the interview and help patient
If no emergency intervention are needed, obtain comprehensive history
112
Inspection
-Inspect chest contour and shape
-Observe respiratory rate and depth for 1 full minute
113
Palpation
-Palpate trachea (Should be midline) and assess skin temp
-Ensure thoracic excursion is symmetrical
-Assess tactile fremitus (the capacity to feel sound on the chest wall)
114
Auscultation
-Using diaphragm move from apex to base of lungs comparing one side other side
-Normal breath sounds includes vesicular, bronchial and broncho vesicular
If abnormal breath sounds is heard ask patient to cough then reassess
115
popping sound heard on inspiration
Crackles
116
continuous sound produced as air passes through constricted airways, narrowing, secretions and around obstruction
Wheezes
117
-Group of test that evaluate respiratory status to detect abnormalities
-Evaluate lung dysfunction and respiratory interventions
Pulmonary Function
118
measure the volume of air in liters exhaled or inhaled over time
Spirometry
119
refers to point of highest flow during expiration
Peak flow Expiratory flow rate
120
facilitate removal of respiratory tract secretion by reducing the viscosity of the secretion
Expectorant
121
drugs that suppress cough, recommended if patient is unable to sleep
Cough suppressants
122
use to relieve milk, nonproductive cough
Lozenges
123
If patient is unable to clear the coughing, aspirate secretions
* Nursing Interventions in Suctioning
Suctioning Airway
124
Appropriate size for suction catheter
Adult: Fr 12-18
Child :Fr 8-10
Infant: Fr 5-8
125
Length of Catheter
measure from tip of the clients nose to the earlobe or about 13cm (5in) for adult
126
Administered to dilate airways
Bronchodilators
127
loosen thick secretions
Mucolytics
128
reduce inflammation
Corticosteroid
129
disperse fine particles of medication into the airway
Nebulizers
130
CPAP
continuous positive airway pressure
131
BPAP
bi-level positive airway pressure
Applies mild airway pressure on continuous basis to keep airways continuously open in people who are not able to breath spontaneously
132
-Also called pleural tap
-Invasive procedure to remove fluid and air from the pleural space
-A cannula is introduced to the thorax
-Drains fluids from the lungs
-Used for patient with pleural effusion, hemothorax, pneumothorax
Thoracentesis
133
forceful striking of the skin with cupped hands. Can mechanically dislodge tenacious secretion from bronchial walls
Percussion (Clapping)
134
series of vigorrous quivering produced by hands that are place flat against the client’s chest wall. It is done to loosen mucous secretions
Vibration
135
expulsion of secretion form various lung segment by gravity
Postural Drainage
