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Flashcards in Chapter 6 Deck (128):
1

What is another name for Vital Signs

Cardinal Signs

2

Objective noninvasive evaluation
Temperature, pulse, respiration & blood pressure

Vital signs

3

Heat produced and heat loss
Degree of heat of the deep tissues
Hypothalamus/Respiratory system

Body Temperature

4

Body temperature is controlled by a small structure in the basal region of the diencephalon of the brain called

Hypothalamus
or Body's thermostat

5

What happened when the body's metabolism increases?

More heat is produced

6

When a whose body temperature is elevated above normal limits is said

Fever
or Pyrexia

7

As body temperature increases

the body's demand for oxygen increases

8

What range of body temperature w/t normal limits?

0.5-1 degree

9

What is an Average oral temperature?

98.6 F

10

Average temperature in children 3 months-3 years

99 F (37.2 C)-99.7 F (37.7 C)

11

Average temperature in children 5 yrs-13 yrs

97.8 F-98.6 F

12

Symptoms of fever

Increased pulse & respiratory rate
Discomfort
Aching
Flushed dry skin
Chill
Loss of appetite

13

Average temperature in children 5 yrs-13 yrs

97.8 F-98.6 F

14

A person with a body temperature below normal limits

Hypothermia

15

It is rare for a person to survive with a body temperature b/t

105.8 F (41 C) & 111.2 F (44 C)
or below 93.2 F (34 C)

16

What are 4 areas of body in which temperature is usually measured?

Oral
Tympanic
Rectal
Axillary

17

Hyperthermia

Fever
Febrile

18

Temporal artery (TA) thermometers

Most popular today on kids

19

Most common route
Taken by mouth under the tongue
98.6 F

Oral

20

Equivalent to rectal & tympanic

Tympanic membrane thermometer

21

Most accurate area to measure is?
99.6 F

Rectal

22

Most safest are to measure is?
97.6 F

Axillary

23

Most safest are to measure is?

Axillary

24

Area is measuring temperature with a tympanic thermometer
Is placed inside the external auditory canal
97.6

Tympanic

25

As the heart beats, blood is pumped in a pulsating fashion into arteries
Results in a throb ot pulsation of the arteries

Pulse

26

Which location requires the use of a stethoscope?

Apical pulse

27

Which location provides the most accurate pulse rate?
Over the apex of the heart

Apical pulse

28

Which pulse can be done over the carotid artery @ the front of the neck?
Most common

Carotid pulse

29

Which pulse can be done over the carotid artery @ the front of the neck?

Carotid pulse

30

Which pulse can be done over the femoral artery in the groin?

Femoral pulse

31

Which pulse can be done over the carotid artery @ the front of the neck?

Carotid pulse

32

Which pulse can be done over the femoral artery in the groin?

Femoral pulse

33

Which pulse can be done @ the posterior surface of the knee?

Popliteal pulse

34

Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?

Brachial pulse

35

Which pulse can be done @ the top of the feet in line with the groove b/t the extensor tendons of the great & 2nd toe
(May be congenitally absent)

Dorsalis pedis pulse (pedal)

36

Which pulse can be done on the inner side of the ankles?

Posterior tibial pulse

37

Which pulse can be done in the groove b/t the biceps & triceps muscles above the elbow @ the antecubital fossa?

Brachial pulse

38

What is child 4-10 years pulse rate?

90-100 BPM

39

What does BPM stand for?

# of beats per minute

40

What is an adult pulse rate?

60-90 BPM

41

Tarchycardia

Rapid heart rate over 100 BPM

42

Bradycardia

Slow heart rate below 60 BPM

43

What is an athlete pulse rate?

45-60 BPM

44

Abnormally rapid heart rate over 100 BPM called?

Tarchycardia

45

Abnormally slow heart rate below 60 BPM called?

Bradycardia

46

Can you use your thumb to assess the pulse?

NO
B/c Thumb has its own pulse

47

How to count pulse rate?

Count for one (1) full minute or
Count for 15 seconds then multiple by 4
Count for 30 seconds X 2

48

If pulse count is irregular?

Take for one full minute
Take apical pulse

49

Can you use your thumb to assess the pulse?

NO

50

What happens if you press too hard on the artery?

ARTERY IS COMPRESSED or DISAPPEARRED

51

What does an odd # mean when assessing the pulse rate?

1 full minute

52

What is a function of the respiratory system?

Exchange of oxygen & carbon dioxide
Between environment & blood
Assess depth and pattern of ventilation

53

Diaphragm moves downward, chest expands

Inspiration

54

Relaxation of diaphragm, returns to normal position

Expiration

55

Adult Respiration Rates

15 to 20 breaths per minute (@ book 12-20)

56

Respiration rates for Child (under 10)

20 to 30 breaths per minute

57

Respiration for Infant (newborns)

30 to 60 breaths per minute

58

Inability to breathe

Apnea

59

Difficult to label breathing

Dyspnea

60

Cannot breathe when lying down

Orthopnea

61

More 20 Breath PM

Tachypnea

62

Below 12 Breath PM

Bradypnea

63

Dyspnea followed by apnea
Stroke or coma patients

Cheyne-Stokes

64

Fewer than 10 breaths per minute
Results in cyanosis, apprehension, restlessness, blue color, change in LOC

Head trauma

65

What is LOC?

level of consciousness

66

Head trauma patients

May or may not response

67

What makes one respiration?

Breathe in and out for 1 min)
Count for 30 seconds X 2
Even rise and fall of chest
Abdomen breather
Alter breathing pattern (not pattern b/c pt look @ you)

68

The rate of respiration to heartbeat is

1:4

69

What is Blood Pressure?

Measure of force exerted by blood on the arterial walls during contraction & relaxation of the heart
Flow times resistance

70

Sphygmomanometer includes

Blood pressure cuff (Mercury/Aneroid)
Inflatable bladder within cuff
Pressure manometer
Thumbscrew valve (Maintain or release pressure)
Pressure bulb (Inflates bladder)
Rubber tubing

71

Did you know….

Usually lower in am
Increases after large meal
Emotions/strenuous activity – systolic increases
Men higher than women/infants higher than adults/adolescents is lowest

72

What equipment used to measure blood pressure?

Sphygmomanometer

73

Sphygmomanometer includes

Blood pressure cuff
Mercury/Aneroid
Inflatable bladder within cuff
Pressure manometer
Thumbscrew valve
Maintain or release pressure
Pressure bulb
Inflates bladder
Rubber tubing

74

Which equipment is More accurate
Less convenient to use

Mercury manometer

75

Which equipment is Needle should point to zero prior to inflating?

Aneroid manometer

76

BP cuff should be

Selected according to patient size

77

Too large or small BP cuff can result in

Incorrect reading

78

What is 1st # is 120 mm Hg (highest #)
Peak pressure during contraction of the left ventricle as it pumps blood into the aorta

Systolic pressure

79

What is 2nd # is 80 mm Hg (lowest #)
Pressure inside the artery during relaxation of the ventricles – minimal pressure exerted against arterial wall

Diastolic pressure

80

Saints over Devils

Systolic over Diastolic

81

Normal ranges of systolic pressure

90 to 120 mm Hg
Less than 120 mm Hg

82

Normal ranges for diastolic pressure

50 to 70 mm Hg
Less than 80 mmHg

83

higher: BP 140 over 90

Hypertensive

84

lower: BP 90 over 65

Hypotensive

85

How to Measure Blood pressure

Taken @ the brachial artery
Cuff is positioned around the arm @ 1” above anticubital space
Steadily inflate cuff with dominate hand until pulsations can no longer be palpated @ radial artery (approximate systolic pressure)
Release cuff and place earpieces into ears
Tighten thumbscrew and reinflate until gauge reaches 30 mmHg above appropriate systolic pressure
Slowly loosen gauge to drop 2 to 4 mmHg/sec
Note systolic and diastolic pressure reading

86

Extraneous sounds
Tapping, knocking or swishing
Turbulent sound of blood flow through arteries

Korotkoff sounds

87

Brain cannot function for

Not longer than 4- 6 minutes without oxygen

88

What is an oxygen?

Toxic & supports combustion
oxygen is Drug

89

Oxygen Prescribed by

physician
Determines amount and type of delivery device

90

How to measure Oxygen?

Measured in LPM (liters per minute)
Ordered in LPM or concentration

91

Oxygen Precautions

Never completely remove oxygen device from patient while in your care
Transfer patient using a portable oxygen tank
Transfer to wall unit once in room
Turn off portable unit
Keep same amount of oxygen level – do not adjust

92

Decreased oxygen concentration in the blood

Hypoxemia

93

Reduction of oxygen supply to tissue

Hypoxia

94

Which Tissue is Most sensitive

Brain, heart, lungs & liver

95

Carbon dioxide is retained in the arterial blood

Hypercapnia

96

Brain cannot function for

Not longer than 4- 6 minutes without oxygen

97

What is an oxygen?

Toxic & supports combustion
oxygen is Drug

98

Oxygen Prescribed by

physician
Determines amount and type of delivery device

99

How to measure Oxygen?

Measured in LPM (liters per minute)
Ordered in LPM or concentration

100

Oxygen Precautions

Never completely remove oxygen device from patient while in your care
Transfer patient using a portable oxygen tank
Transfer to wall unit once in room
Turn off portable unit
Keep same amount of oxygen level – do not adjust

101

Decreased oxygen concentration in the blood

Hypoxemia

102

Reduction of oxygen supply to tissue

Hypoxia

103

Which Tissue is Most sensitive

Brain, heart, lungs & liver

104

Carbon dioxide is retained in the arterial blood

Hypercapnia

105

Storage tank

In an upright crate or lay tank down for storage & transport – never leave upright without securing

106

2 Regular valves

Pressure manometer & Flowmeter

107

pressure or volume of oxygen (how much oxygen or BP)

Pressure manometer

108

Rate of flow (LPM)
(green color)

Flowmeter

109

A device used to monitor the oxygen saturation of hemoglobin

Pulse Oximetry

110

Pulse Oximetry

Fast, noninvasive method of monitoring sudden changes
Sensor is attached to a fingertip or earlobe

111

Advantages of Non-rebreathing mask

Keeps exhaled air from bag & prevents rebreathing
Bag fills with oxygen to supply constant oxygen

112

8 Types of Oxygen Devices

1. Nasal cannula
2. Face Masks
3. Simple Mask
4. Non-rebreathing mask
5. Partial rebreathing mask
6. Venturi or air-entrainment mask
7. Aerosol mask
8. Oxygen Tent

113

Most common seen
Disposable plastic device with 2 hollow prongs that deliver oxygen into the nostrils
Receives oxygen & room air
1 – 4 LPM
Higher levels tend to dry the nasal mucosa
Oxygen flowing through tube prior to placing on patient

Nasal Cannula

114

Simple
Non-rebreathing (1 way valve)/Partial rebreathing (not have )
Aerosol
Venturi (aerosol mask)

Face masks

115

Covers nose & mouth
Low flow device

Simple masks

116

Simple mask is used for

Short term therapy

117

Disadvantages of Simple Face Mask

Uncomfortable
Unable to eat, drink or talk with it in place
(pt don’t like it/likeNasal cannula better)

118

Flow rates of Simple Masks

Flow rates greater than 5LPM to flush CO2 from mask
Concentration of 30 -50% (depends on pt/how much air they taking in)

119

May supply 100% concentration of Oxygen
Reservoir bag attach to it/(opening bag has valve)One-way valve (make sure bag stay and place it)

Non-rebreathing mask

120

Advantages of Non-rebreathing mask

Keeps exhaled air from bag & prevents rebreathing
Bag fills with oxygen to supply constant oxygen

121

No valve
Delivers 60 -90% oxygen

Partial rebreathing mask

122

Provides consistent concentration of oxygen regardless of patient’s respiratory pattern
Oxygen & entrained room air
Oxygen concentration at 24 – 50%

Venturi or air-entrainment mask

123

Mask attached to nebulizer (generates a mist) filled saline or sterile water

Aerosol mask

124

Functions of Aerosol mask

Provide medication (fine mist that is inhaled)
Provides precise oxygen concentration
60-80% oxygen mixed with water
Flow rate of a minimum of 6 – 8 LPM

125

Pediatric or NICU patients
Oxygen therapy & additional humidity
Fire hazard

Oxygen Tent

126

Artificial airway into trachea
Delivers a set respiratory rate, preset inspiratory volume & Fi02 (concentration)

Ventilators

127

Purpose of Ventilators

CXR – proper placement of tube
Observe rise & fall of chest

128

Inform nurse

Inform nurse before positioning patient
Use caution when moving patient & tubing
Alarms – do not silence or alter (in any way)