Chapter 15 vital signs Flashcards
(99 cards)
1
Q
primary mechanism that adapt to response to maintain
A
homeostasis
2
Q
physiological process by which the internal systems are maintained
A
homeostasis
3
Q
mechanisms in homeostasis
A
body temp pulse rate respiratory rate blood pressure sensorium (mental alertness)
4
Q
measurement of degree of heat in deep tissue
A
body temperature
5
Q
term used to describe body’s maintenance of heat production and loss
A
Thermoregulation
6
Q
gland responsible for thermoregulation
A
hypothalamus
7
Q
regulation of heat loss
A
diaphoresis (sweating)
heat generation
8
Q
removes excess heat by ventilation
A
respiratory system
9
Q
five routes for body temperature measurement
A
Oral Axillary Tympanic Rectal Temporal
10
Q
Oral temp
A
under tongue 20 sec to 3 min
11
Q
Axillary temp
A
arm pit
inaccurate and time consuming 5-10 min
12
Q
Tympanic temp
A
electronic in ear
stable in 3 seconds
13
Q
rectal temp
A
ensure proper thermometer
2.5-5 min
14
Q
temporal temp
A
TA meter
most accurate and fastest
sweep divice along forehead
most popular
15
Q
normal body temps
A
- 7-99.5F
36. 5-37.5 C
16
Q
temperature abnormalities
A
when body temp increases, metabolic rate increases and demands on cardiopulmonary system increase
17
Q
temp above 99.5
A
hyperthermia
18
Q
febrile
A
fever
19
Q
temp below 97.7
A
hypothermic
20
Q
hypothermic causes
A
exposure to cold
trauma to hypothalamus
medically induced
21
Q
Respiratory system
A
delivery of O2 and elimination of CO2
22
Q
major muscle of ventilation
A
diaphragm
23
Q
inspiration
A
diaphragm moves downward expanding the chest cavity
24
Q
expiration
A
diaphragm relaxes and chest cavity compresses
25
respiratory phase
inspiration and expiration
26
measuring respiration rate
without patients knowledge
27
normal adult respiration rate
12-20
28
normal child respiration rate
20-30
29
normal newborn respiration rate
30-60
30
respiration rate descriptions
rate
depth
pattern
31
tachypnea
rate above 20
| child 30
32
bradypnea
rate below 12
| child 20
33
dsypnea
difficult breathing
34
apnea
absence of breathing
35
sites for pulse measurment
```
wrist
brachial artery
carotid artery
pedal artery
apical
pulse oximeter
```
36
Wrist measurement
base of thumb
| use index finger
37
brachial artery
```
antecubital fossa (inside of elbow)
upper arm of children
```
38
carotid artery
just below angle of the mandible
39
pedal artery
over instep of foot
| can be significant with concerns for peripheral circulation
40
Apical
stethoscope at apex of heart
count for full min
done if pulse is slow or irregular
41
assculation
listening to internal sounds of body with stethoscope
42
pulse oximeter
non invasive device
measures pulse and O2 saturation of arterial blood
usually located on finger, maybe earlobe, foot or nose
can be inaccurate. poor peripheral perfusion, nail polish/acrylic nails hinder readings
43
Normal resting pulse adult
60-100
44
normal resting pulse child
70-120
45
tachycardia
heart rate above 100
46
bradycardia
heart rate below 60
47
tachycardia causes
exercise, fever, anemia, shock , fear, pain and anger
48
bradycardia causes
unrelieved severe pain, physically fit atheletes, hypothermia
49
blood pressure
systolic over diastolic
50
diastolic
constant pressure on arteries when heart is relaxed
51
systolic
peak pressure during heart contraction
52
measure systolic
first sound you hear when cuff pressure released
53
measure diastolic
when blood flow sound is no long heard
54
normal systolic
95-140
55
normal diastolic
60-90
56
BP abnormalities
hypertension
| hypotension
57
hypertenstion
high BP above 140/90
58
hypotension
low BP
| 95/60
59
hypertension factors
increase workload on heart
heart, brain, kidney and lung damage
higher in men and African Americans
stress, medication, obesity and smoking
60
hypotension factors
dizziness, confusion, blurred vision
may have inadequate blood volume
shock
61
oxygen therapy
administration of additional O2
62
oxygen saturation
21% of atmospheric gas
63
absence of O2
brain damage in 6 min
64
hypoxia
low oxygen level to tissues
65
oxygen is defined as a
drug
must be prescribed by physician
as liters per min or concentration
66
oxygen tank identification
green tank labeled as oxygen
67
bad to give too much oxygen?
yes
dry out nasal mucosa
damage lungs
aveolar adema
68
oxygen therapy devices
low flow
| high flow
69
low flow
less than 6 lpm
| variable oxygen concentration
70
high flow
greater than 6 lpm
fixed or precise concentration
provides entire respiratory volume
71
oxygen therapy device types
nasal cannula
| oxygen mask
72
nasal cannula
```
most prequently used
never over 6 lpm
prongs point downward inserted into nares
rates of 1-4 lpm 24-36%
low flow device
```
73
Oxygen mask
```
not tolerated as well as cannula
simple mask
non-rebreathing mask
partial re breathing
aerosol
air entrainment
```
74
simple mask
low flow
75
non rebreathing mask
bags attached
| 1 way valve to prevent exhaled air from being re breathed
76
partial re breathing
does not have 1 way valve
77
aerosol
high flow
w/nebulizer
at least 8 LPM
watch for fluid in corrugated tubing
78
air entrainment
high flow
O2 forced through small tube in mask
constant O2 concentration regardless of changes to respiratory system
79
Pediatric Oxy patients
tent
| oxy hood
80
pediatric tent
covers entire bed
| difficult due to constant entering and exiting
81
pediatric hood
generally used on infants
| plastic or disposable box fits over infants head
82
ventilator
artificial airway inserted into trachea connected to ventilator
controls rate, volume and content
83
intubation
insertion of tube into canal or hollow organ, cavity
84
tracheal intubation
trans laryngeal via nose or mouth
oro-throat
endo nose
85
tracheostomy
surgical opening through naterior of trachea
86
proper placement of trach tube
distal tip 1-2 inches superior to tracheal bifurcation
87
malposition of tube
right stem due to lesser angle
| can cause atelectasis of left lung (collapsed lung)
88
chest tubes (thoracostomy)
used to drain intrapleural space and mediastinum
89
pleural effusion
fluid in the plerual cavity
90
pneumothorax
```
air/gas in pleural cavity
bleb
fractured rib
cv line insertion error
gas producing microorganisms (empyema)
```
91
bleb
rupture of lining of lung
92
CV lines
may be single double or triple lumen
93
types of cv lines
percutaneous
implanted
PICC lines
externally tunneled
94
percutaneous
subclavin
95
implanted
mediport
| infusa port
96
PICC line
peripheral insterted central cathether
basilic or cephalic vein
less infection
97
externally tunneled
through layers of skin
98
preferred junction for CV line
SVC
| 2-3 cm above right arterial junction
99
preferred CV line insertion site
RT subclavian vein
