Measuring Vital Signs (VS) Flashcards Preview

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Flashcards in Measuring Vital Signs (VS) Deck (150):
1

an assessment of vital or critical physiological functions

vital signs (VS)

2

the degree of heat maintained by the body

body temperature

3

an adult's normal internal temperature or (core temperature)

97-100 degrees F or
36.1-38.2 degrees C

4

the process of temperature regulation

thermoregulation

5

hairs standing on end

piloerection

6

the sum of all physical and chemical processes and changes that take place in the body

metabolism

7

the amount of energy required to maintain the body at rest

basal metabolic rate (BMR)

8

the metabolism of brown fat to product heat

nonshivering thermogenesis

9

is the loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air

radiation

10

the transfer of heat through currents of air or water

convection

11

when water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (breath)

evaporation

12

water loss by evaporation

insensible loss

13

moisture in the air

humidity

14

the process whereby heat is transferred from a warm to a cool surface by direct contact

conduction

15

a cyclical repetition of certain physiological processes that occurs every 24 hours

circadian rhythm

16

fever

pyrexia

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a person with a fever

febrile

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a person without a fever

afebrile

19

a fever above 105.8 F or 41.0 C

hyperpyrexia [hyper (above)-pyrexia (fever)]

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fever-producing substances

pyrogens

21

specialized white blood cells

phagocytes

22

substances that reset the hypothalamic thermostat at a higher temperature

prostaglandins

23

reset value

set point

24

the period when body temperature is rising but has not yet reached the new set point

in initial phase (febrile episode or onset)

25

the period when body temp reaches its maximum (set point) and remains fairly constant at eh new higher level

the second phase (course)

26

the period when the temp returns to normal

the third phase ( defervescence or crisis)

27

temp alternates regularly between periods of fever and periods of normal or below-normal temp w/o pharmacological intervention : or the temp returns to normal at least once every 24 hours

intermittent fever

27

Very thin wasted appearance

Cachectic

28

In a general system what are normal/abnormal findings?

Normal: alert,oriented x3, properly dressed, cooperative
Abnormal: lethargic ,confused, uncooperative , angry, sad, depressed

28

CRT

Capillary refill time

29

In skin what are norm/abnormal findings? Interventions?

Norm: warm dry intact no tenting no bruises or lesions
Abnormal : cold clammy wounds open areas bruises rashes tenting cyanosis jaundice
Intervention: turn q 2hrs skin softeners dressing changed / protect wounds use Braden scale to predict pressure ulcers

30

fluctuations in temp above normal during 24 hour period

remittent fever

30

The first step of the nursing process

Assessment

31

temp may fluctuate slightly but always above normal

constant (sustained) fever

31

The systematic gathering of information related to the physical, mental, spiritual, socioeconomic , and cultural status of an individual , group, or community

Assessment

32

short periods of fever alternating with periods of normal temp each lasting 1-2 days

relapsing (recurrent) fever

33

fever reducing

antipyretic

34

a body temp above normal but the elevated temp higher than the set point

hyperthermia

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a type of hyperthermia that is potentially life threatening; a state of weakness produced by exposure to heat, humidity and excessive loss of fluids and electrolytes; the body's thermoregulatory system is still functioning

heat exhaustion

36

a derangement of thermoregulation with altered mental status and high body tem; occurs if heat exhaustion is not treated; caused by high temp and high humidity

heat stroke

37

an abnormally low core temp less than 95 F or 35 C

hypothermia

38

the contraction of the heart

systole

39

the resting phase of the heart

diastole

40

the quantity of blood forced out by each contraction of the left ventrical

stroke volume

41

the total quantity of blood pumped per minute

cardiac output

42

feeling

palpation

43

listening with a stethoscope

auscultation

44

a sound-transmitting device (bell and diaphragm) that is attached to earpieces by rubber tubing and hollow metal tubes

stethoscope

45

pulse at the apex of the heart

apical pulse

46

a place where an artery can be pressed by the fingers against a bone

peripheral pulse

47

a difference between the two counts

pulse deficit

48

count the number of beats per minute while palpating or auscultating

rate

49

brady

slow

50

cardiac

heart

51

bradycardia

slow hart

52

tachy

rapid

53

the intervals between heartbeats establish a pulse pattern

rhythm

54

dys

irregular

55

when the intervals between beats vary enough to be noticeable

dysrhythmia

56

ECG

Electrocardiogram

57

a procedure that traces the electrical pattern of the heart

Electrocardiogram (ECG)

58

pulse volume and bilateral equality of pulses

pulse quality

59

the amount of force produced by the blood pulsing through the arteries

pulse volume

60

literally equal on both sides (peripheral pulses that are equal in rate and amplitude on both sides of the body)

bilateral equality

61

the paleness of skin in one area when compared to another part of the body

pallor

62

a bluish or grayish discoloration of the sin due to deficient oxygen in the blood

cyanosis

63

cyan

blue

64

breathing

pulmonary ventilation

65

the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply

external respiration

66

the transport of carbon dioxide and oxygen throughout the body

gas transport

67

the exchange of carbon dioxide and oxygen between the capillaries and body tissue

internal respiration

68

receptors located in the respiratory centers that is sensitive to CO2 and hydrogen ion (pH0 concentrations

central chemoreceptors

69

receptors (sense organ or sensory nerve ending) located in the carotid and aortic bodies that stimulate respirations when the partial pressures of oxygen in arterial blood (PaO2) falls below 100 mg Hg

peripheral chemoreceptors

70

drawing air into the lungs

inspiration

71

the expulsion of air from the lungs

expiration

72

the number of times a person breathes or completes a cycle of inhalation and exhalation

respiratory rate

73

the amount of air taken in on inspiration

tidal volume

74

the degree of work required to breathe

respiratory effort

75

labored breathing

dyspnea

76

difficulty or inability to breathe when in a horizontal position

orthopnea

77

high-pitched continuous musical sounds usually heard on expiration

wheezes

78

low-pitched continuous gurgling sounds caused by secretions in the large airways

rhonchi

79

discontinuous sounds usually heard on inspiration but they may be heard throughout the respiratory cycle

crackles

80

piercing, high-pitched sound that is heard w/o a stethoscope, primarily during inspiration, in infants who are experiencing respiratory distress or in someone with an obstructed airway

stridor

81

labored breathing that produces a snoring sound

stertor

82

the visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe

intercostal retraction

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when tissues are drawn in beneath the sternum (breastbone)

substernal retraction

84

when tissues are drawn in above the clavicle (shoulder girdle)

suprasternal retraction

85

inadequate cellular oxygenation

hypoxia

86

loss of the nail angle

clubbing

87

a forceful or violent expulsion of air during expiration

cough

88

measures the partial pressures of oxygen and carbon dioxide and blood pH

arterial blood gas sampling

89

ABG

Arterial blood gas

90

a noninvasive method of monitoring respiratory status with a device that measures oxygen saturation

Pulse oximetry

91

an indication of the oxygen being carried by hemoglobin in the arterial blood

oxygen saturation

92

when rapid and deep breathing result in excess loss of CO2

Hyperventilation (hypocapnia)

93

when the rate and depth of respirations are decreased and CO2 is retained or alveolar ventilations compromised

hypoventilation

94

the pressure of the blood as it is forced against arterial walls during cardia contraction

blood pressure (BP)

95

the peak pressure exerted against arterial walls as the ventricles contract and eject blood

systolic pressure

96

the minimum pressure exerted against arterial walls between the cardiac contractions when the heart is at rest

diastolic pressure

97

the difference between the systolic and diastolic pressure

pulse pressure

98

arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls

peripheral resistance

99

thickness

viscosity

100

elasticity

compliance

101

the percentage of red blood cells in plasma

hematocrit

102

hardening of the arteries

arteriosclerosis

103

a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer

sphygmomanometer

104

dials that register BP by pointers attached to a spring

aneroid manometer

105

using a calibrated upright tube containing mercury

mercury manometer

106

the sound you listen for when you assess BP that describe the sounds of blood pulsating through arteries

Korotkoff sounds

107

the loss and later return of sound

auscultatory gap

108

when a person's BP drops suddenly on moving from a lying position to a sitting or standing position

orthostatic or postural hypotension

109

a BP reading of 120 to 139 mm Hg systolic or 80-89 mm Hg diastolic, obtained with two reading taken 6 minutes apart, with the patient sitting

Prehypertension

110

a persistently higher than normal BP

hypertension

111

diagnosed when there is no known cause for the BP elevation

primary or essential hypertension

112

when there is a clearly identified cause for the persistent rise in BP

secondary hypertension

113

ADLs

Activities of daily living

114

seeing the patient every hour

hourly rounding

115

preparing the patient for breakfast or other activities such as diagnostic tests

early morning care

116

hygiene care that occurs after breakfast

A.M. (morning) care

117

preparing patients to receive visitors or afternoon rest

P.M. (afternoon) care

118

skin, the subcutaneous layer directly under the skin, the hair, nails and the seat and sebaceous glands

integumentary

119

the thicker, outer layer of skin it consists of stratified squamous epithelia tissue composed of keratinized (dead) cells which are fused to make to the skin waterproof

epidermis

120

epidermis continually shed

desquamates

121

pigment that provides protection against the ultraviolet rays of the sun and that together with circulating blood, gives skin its color

melanin

122

the thinner, second layer of the skin it contains the blood and lymphatic vessels, nerves, bases of hair follicles, and sebaceous and sweat glands

dermis

123

secrete an oily substance called sebum which helps waterproof and lubricate the skin and decrease bacterial growth

sebaceous glands

124

concentrated in the axillae and external genitalia, excrete water in the form of perspiration; evaporation produces a cooling effect on the skin

sweat glands

125

softening of the skin due to prolonged moisture

maceration

126

paleness of skin

pallor

127

redness of the skin

erythema

128

yellow discoloration of the skin occurs in patients with impaired liver function best seen in the sclerae of the eyes

jaundice

129

a bluish coloring of the skin caused by decreased peripheral circulation or decreased oxygenation of the blood

cyanosis

130

itching

pruritus

131

loss of the superficial layers of the skin caused for example by scratching and by the digestive enzymes in feces

excoriation

132

rubbing away of the epidermal layer of the skin especially over bony areas or prominences is often caused by friction or shearing forces that occur when a patient moves or is moved in bed

abrasion

133

lesions caused by tissue compression and inadequate perfusion

pressure ulcers (decubitus ulcers)

134

an inflammation of the sebaceous glands

acne

135

at risk for skin being adversely altered

risk for impaired skin integrity

136

altered epidermis or dermis

impaired skin integrity

137

when a nurse helps the patient with areas that may be difficult to reach such as the back feet and legs

assist bath

138

nurse cleanses only the areas that may cause odor or discomfort such as the axillae and perineum

partial bath

139

bath for patients who must remain in bed but who are able to bathe themselves

bed bath

140

nurse will was the patient's entire body w/o assistance from the patient

complete bed bath

141

modification of the bed bath in which you place a large towel and a bath blanket in a plastic bag saturate the with a warmed commercially prepared mixture of moisturizer disinfectant, non-rinse cleaning agent and use them to bathe the patient

towel bath

142

a modification of the towel bath in which you use 8-10 washcloths instead of a towel and a bath blanket

bag bath

143

refers to a set of commercially prepared and packaged pre-moistened disposable washcloths

packaged bath

144

a prescribed bath with specific instructions for the type of bath and solution to be used or an area of the body to be treated an water temp

therapeutic baths

145

the area between the anus and vulva in the female or the anus and scrotum in a male

perineum

146

a cone-shaped thickening of the epidermis caused by continuous pressure

corn