chapter 29 Jess Flashcards
(101 cards)
0
Q
Measurement of vital signs to determine a patients what?
A
Baseline
1
Q
Vital signs are used to:
A
Monitor patients condition
Identify problems
Evaluate response to intervention
2
Q
Assessment of vital signs provide data for what?
A
- to identify nursing diagnosis
- implement planned interventions
- evaluate outcomes of care
3
Q
Guidelines for measuring vital signs
6
A
- equipment is functional and right size
- know when ok and not ok to delegate
- understand and interpret values
- know patients usual range of vital signs
- get medical history, medication history , current meds
- control or minimize environmental factors that affect vital signs
4
Q
Who is responsible for vitals?
A
The nurse is
5
Q
Temp sights (8)
A
Oral, tympanic, temporal, esophageal, pulmonary artery, bladder
6
Q
Normal adult temp
A
98.6-100.4f
36-38 c
7
Q
Most common, or preferred temp sights in regular practice
A
Oral, axillary, temporal, tympanic
8
Q
Define tachycardia
A
Elevated heart rate above 100 bpm
9
Q
Define bradycardia
A
Slow heart rate below 60 bpm
10
Q
What is a full assessment of the radial pulse
A
Measuring the rate rhythm strength and equality
11
Q
What is a full assessment of an apical pulse
A
Rate and rhythm only
12
Q
What are the two types of dysrhythmia?
A
Regularly irregular and irregularly irregular
13
Q
What is Pulse strength and what is considered normal pulse strength?
A
0, 1+, 2 +, 3+, 4+,
2+ normal
14
Q
When a person changes from a lying to sitting or standing position what can happen to the heart rate?
A
It can temporarily increase
15
Q
What should you do if you detect abnormal heart rate when taking a radial pulse?
A
Assess the
apical pulse
16
Q
What do the sounds lub and dub consist of?
A
Lub is S1 and is low pitched and dull
Dub is s2, is higher pitched and shorter
17
Q
How do you calculate a pulse deficit?
A
Find the rate difference between the apical and the radial pulse
18
Q
How do you assess a pulse deficit
A
Simultaneously one person taking radial pulse is another person takes apical pulse
19
Q
What is the common order to document a dysrhythmia?
A
Electrocardiogram a Holter monitor or telemetry monitor
20
Q
What is a common dysrhythmia of children?
A
A sinus dysrhythmia the heart rate speeds up with inspiration and slows down with expiration
21
Q
What happens if a child with a sinus dysrhythmia holds her breath?
A
The heart rate becomes regular
22
Q
What does the strength of a pulse measure?
A
The volume of blood ejected against the artery wall with each heart contraction
23
Q
How is pulse strength chart defined?
A
4+ is bounding 3+ it’s full or strong 2+ is normal and expected 1+ is diminished or barely palpable 0 is absent
24
What pulses should you never assess simultaneously?
The carotid pulses because it will occlude blood supply to the brain
25
What three processes are included in respiration?
Ventilation, diffusion, and perfusion
26
Breathing is what kind of process
Passive
27
What does the body measure to regulate ventilation?
CO2 and O2 Ion concentrations in arterial blood
28
What happens o2 falls below acceptable parameters?
Respiratory rate and depth of ventilation will increase
29
What is hypoxia
Low blood level of oxygen
30
Define ventilation
Movement of gases into and out of the lung
31
Define diffusion
Movement of oxygen and carbon monoxide between alveoli and red blood cells
32
Define perfusion
Distribution of red blood cells to and from the pulmonary capillaries
33
Define Eupnea
Ventilation of normal rate and depth
34
What are the three things to assess when taking respiration?
Great depth and rhythm
35
Respirations are tied to what functions of body systems
All functions of bodies
36
What can influence respiratory rate?
Age illness injury or disease
37
What are the three movements of ventilation
Deep normal or shallow
38
How do you evaluate diffusion and perfusion
By measuring O2 saturation of blood the percentage of hemoglobin is down with auction in the arteries is percent of saturation of hemoglobin or SA O2 they should be between 95 and hundred percent
39
What is SaO2
This is a laboratory value it is the percentage of hemoglobin that is bound with oxygen in the arteries it is the percent saturation of hemoglobin it should be between 95 and 100%
40
What factors influence the characteristic of respiration
Exercise, anxiety, smoking neurologic injury, hemoglobin function , body position medication and acute pain
41
How does exercise affect respiration rate
Increases the rate and depth of respiration to meet bodies need for additional auction into rid the body of CO2
42
How does pain alter respiration
Makes respiration shallow
43
How does anxiety affect respiration rate
Increases respiration rate and depth as a result of sympathetic stimulation
44
How does smoking change respiration rate
Smoking changes pulmonary airways which results in increased rate of respiration at rest when not smokeing
45
What posture promotes full chest expansion and what posture impairs ventilation movement
A straight posture promotes full chest expansion. A stooped or slumped posture impairs ventilation movement
lying flat prevents full chest expansion
46
What medication classes depress rate and depth of respiration
Opioid, analgesic, general anesthetic, and sedative hypnotic
47
What types of drugs increase rate and depth of respiration
Amphetamine and cocaine
48
How do bronchodilators affect respiration
Slows rate by causing airway dilation
49
How could a brainstem injury affect respiration
Impairs respiratory center and inhibits respiratory rate and rhythm
50
How does anemia affect respiratory rate
Decreased hemoglobin levels equals anemia , reduces oxygen-carrying capacity of the blood which increases respiratory rate
51
How does increased altitude affect respiration.
Lowers the amount of saturated hemoglobin, which increases respiratory rate and depth
52
How can sickle-cell disease disease affect respiration?
Abnormal blood cell function reduces ability of hemoglobin to carry oxygen, which increases respiratory rate and depth
53
Cheyne- stokes respiration
Respiratory rate and depth or irregular, characterized by alternating periods of apnea and hyperventilation seen in dying patients
54
Kussmauls respiration
Respirations are abnormally deep regular , increased in rate this is seen in ketoacidosis
55
Biots respiration
Respirations are abnormally shallow for 2 to 3 breaths followed by an irregular Period of apnea
56
What is SV 02
The hemoglobin saturation of venous blood, this is lower than the SaO2
57
What is the normal value for SV 02
70%
58
What is used for simple measurement of oxygen saturation
A pulse oximeter
59
What does the pulse ox meter measure
The pulse saturation SPO2
60
What is SPO2 a reliable estimate of?
SaO2 arterial oxygen saturation
61
What can affect the accurate reading of a pulse oximeter
Any factor that affects late transmission
62
What does the systolic blood-pressure measure?
Maxim peak pressure during ventricular contraction
63
What is the diastolic blood pressure measure
Minimal pressure during ventricular relaxation
64
What is pulse pressure
The difference between systolic and diastolic pressures
65
Define blood pressure
What pressure is the force exerted on the arterial wall by pulsing blood under pressure from the heart
66
What is blood-pressure a good indicator of
Cardiovascular health
67
What is the standard unit for measuring blood pressure
Millimeters of mercury this measurement indicates the height to which the blood pressure races a column of mercury
68
What is the pulse pressure for a blood pressure of 120/80
40
69
What five factors affect arterial blood pressure
Cardiac output, peripheral resistance, blood volume, viscosity, elasticity
70
What does blood-pressure depend on
Cardiac output
71
What is cardiac out put
The volume of blood ejected by the ventricles of the heart multiplied by the heart rate, other words stroke volume multiplied by the heart rate
72
What is Peripheral resistance
As the blood flows through arteries arterials capillaries and veins the size changes to meet the needs of surrounding structures and tissues
73
What is the normal blood circulating volume amount
5000 ML's
74
How does the volume of circulating blood affect blood pressure
Rapid infusion of volume elevates blood pressure decreased volume such as hemorrhage or dehydration causes blood pressure to fall
75
How does blood viscosity affect blood pressure
The thickness or viscosity of blood affects the Ease of blood flow through small vessels
76
What laboratory test measures viscosity of blood
Hematocrit
77
As blood pressure increases what happens to the diameter of blood vessels
They increased to accommodate the pressure
78
What are four factors that influence blood pressure
Age, stress, Ethnicity, gender
79
Where the four classifications of blood pressure
Normal, prehypertensive, stage one hypertension, stage two hypertension
80
How does stress affect blood pressure
Increases heart rate increases cardiac output and vascular resistance
81
Do African-Americans have a higher or lower rate of hypertension then European Americans
Higher rate
82
At what lifestage do men tend to have a higher blood pressure than woman
Puberty
83
Out what lifestage do women tend to have a higher blood pressure than men
After Menopause
84
What are four more influences of blood pressure
Daily variation, medication, activity, wait, smoking
85
What does daily variation of blood pressure mean
Blood-pressure will vary during the day around sleep intervals and activities blood-pressure is highest during waking hours and lowest during hours asleep
86
What medications can increase blood pressure
Vasoconstrictors
87
What medications can lower blood pressure
Antihypertensives, and opioid analgesics
88
How does weight affect blood pressure
Raises it
89
How does activity affect blood pressure
Immediately after will reduce it for several hours. Overtime will lower it
90
How does smoking affect blood
Smoking affects vessels, producing vasoconstriction. This causes blood pressure to rise
91
How do you reduce risk of skin breakdown for multiple blood pressure readings
Rotate measurement site
92
What is a normal pulse pressure range
60 - 70
93
What are alternative methods of measuring blood pressures
Lower extremity blood pressure cuff position above Popliteal
artery at mid thigh with knee flexed
94
When is it not appropriate to use electronic blood pressure machine
Irregular heart rate, peripheral vascular obstruction,( clots) shivering, seizures, excessive tremors, inability to cooperate, blood pressure less than 90 systolic
95
What are the advantages and disadvantages of patients measuring blood pressure at home
Advantages; detection of new problems. Patients can provide information about patterns of blood pressure. Self-monitoring helps adherence to therapy.
Disadvantages improper use and in accurate readings. Patients me inappropriately adjust medication
96
What is more, hypertension or hypotension
Hypertension
97
What are symptoms of hypotension
Pale skin, skin molting, clamminess, confusion, increased heart rate, decreased urine output
98
What are risk factors of hypertension
Obesity smoking alcohol consumption and High salt diet
family history diabetics African-American descent
99
What is postural hypotension
When he person develops symptoms and low blood pressure when raising to an upright position
100
How do you assess for postural orthostatic hypotension
Take vital signs and pulse while patient is supine sitting and standing
