NOTES_1 Ch 30: Vital Signs - Temperature and Heart Flashcards
(76 cards)
1
Q
What is the acceptable temperature range for adults?
A
96.8-100.4
2
Q
What is the acceptable respiration range for adults?
A
12-20 breaths/min
3
Q
What is the acceptable pulse rate range for adults?
A
60-100 bp/min
4
Q
What an acceptable blood pressure for adults?
A
<120/<80
5
Q
Average oral/tympanic temp in adults is…
A
98.6
6
Q
Average rectal temp in adults is…
A
99.5
7
Q
Average axillary temp in adults is…
A
97.7
8
Q
What are the four main vital signs?
A
- Temperature
- Pulse
- Blood Pressure
- Respiratory Rate / Oxygen Saturation
9
Q
What is the occasional fifth vital sign?
A
Pain
10
Q
How do we take a temperature?
A
With a thermometer
11
Q
How do we take a pulse?
A
Palpate and count for 60 seconds
12
Q
How do we take a respiration rate?
A
Count the number of breaths for 1 minute
13
Q
With what do we take a blood pressure reading?
A
Sphygmomonometer
14
Q
Temperature control is regulated by…
A
the hypothalamus
15
Q
The anterior hypothalamus controls heat _____.
A
loss
16
Q
The posterior hypothalamus controls heat _____.
A
production
17
Q
Radiation is the transfer of…
A
heat from one surface to another
18
Q
Convention is the transfer of heat by…
A
air.
19
Q
A fan blowing on a surface promotes…
A
heat loss.
20
Q
Conduction is the transfer of heat from…
A
one molecule to another of lower temperature
21
Q
Dispursion of heat through air current is known as…
A
convection.
22
Q
The continuous evaporation of moisture from the respiratory tract, oral mucosa and skin is known as…
A
insensible heat/water loss
23
Q
What is Pyrexia?
A
A fever
24
Q
Acetametaphin is a(n)…
A
antipyretic
25
An antipyretic works against...
fever
26
Name 5 methods of assessing temperature and the cautions of each.
1. Orally; wait 20-30 mins after eating/drinking
2. Temporal; Forehead, not reliable due to variables
3. Tympanic Membrane; Watch for cerumen, eardrum and redness (indicating possible infection)
4. Axillary; Surface reading, caution of seat, add 1 degree to reading
5. Rectal; Contraindictions (should be used with those who have diarareah, rectal surgery, etc. Could effect cranial nerve 10
27
A.B.C. is an acronym for
Airway
Breathing
Circulation
28
A pt presenting a temp of 104°F with no diaphorisis may be symptomatic of
heatstroke
29
A pt presenting with high temp and profuse diaphoresis may be symptomatic of
heat exhaustion
30
Name ten heatstroke symptoms:
1. giddiness
2. confusion
3. delerium
4. excessive thirst
5. nausea
6. muscle cramps
7. visual disturbances
8. elevated temperature
9. elevated heart rate
10. low blood pressure
31
Someone with low blood volume is...
hypovolemic
32
Someone who is hypovolemic needs...
water & electrolytes
| (Sugar/salt water)
33
What is cardiac output and how is it calculated?
* Total amount of blood pumped in 1 minute
* HR x SV (Heart Rate x Stroke Volume)
34
If someone is Tachycardic, that means
they have a HR of 120 or more
35
What is arythmia?
This is when the heart beats too quickly, too slowly, or with an irregular pattern
36
What is dysrhythmia?
An abnormal heartbeat
37
Where are all the places you can take a pulse?
1. Temporal (temples of head)
2. Carotid (at neck)
3. Apical (on chest surface)
4. Brachial (at bend of elbow)
5. Radial (wrist at thumb)
6. Femoral (where leg meets torso, toward groin)
7. Popliteal (behind knee)
8. Posterior tibial (inside of ankle bone)
9. Dorsalis pedis (top of foot)
38
When listening to the "lub, dub" of the heartbeat, the "lub" is known as __ and represents the closure of the ___ valves known as the _____ and the \_\_\_\_\_.
S1, AV, Tricuspid, Mitral/bicuspid
39
When listening to the "lub, dub" of the heartbeat, the "dub" is known as __ and represents the closure of the ___ valves known as the _____ and the \_\_\_\_\_.
S2, Semilunar valves, pulmonic, aortic
40
The five points at which to listen to the heart are represented by what acronym?
Describe each point
All Patients Take Medicine
* A= Aortic; Right sternal border at 2nd intercostal space
* P= Pulmonic; Left sternal border at 2nd interncostal space
* T= Tricuspid; Left sternal border at 4th intercostal space
* M= Mitral; Left sternal border at 5th intercostal space at midclavicular line
41
PMI stands for...
Point of Maximal Impulse
42
Where do we take the apical pulse?
Left midclavicular line at the fifth intercostal space.
43
Orthostatic hypotension is defined as a decrease in systolic blood pressure of __ mm Hg or a decrease in diastolic blood pressure of __ mm Hg within __ minutes of standing when compared with blood pressure from the sitting or supine position
20, 10, 3
44
If a patient presents with orthostatic hypotension, the priorty is ____ and what should you do with the pt?
safety, lay them back down
45
What are the four characteristics of the pulse?
1. Rate
2. Rhythm
3. Strengh
4. Equality
46
How do we determine heart rhythm?
With an EKG
47
What is meant by pulse equality?
Is it the same on both sides of the body
48
How is a pulse documented?
* Bounding = 4+
* Strong = 3+
* Normal and expected = 2+
* Diminished or barely palpable = 1+
* Abscent = 0
49
When does exercise increase pulse rate?
during short-term exercise
50
When does exercise result in a decreased pulse rate?
When the heart is conditioned to long-term exercise and results in a lower resting pulse rate and quicker return post exercise.
51
How does internal temperature effect pulse rates?
fever and heat = increase
hypothermia = decrease
52
What effect do emotions have that increase pulse rate?
Acute pain or anxiety can stimulate the sympathetic nervous system resulting in increased pulse rate.
53
When would emotions decrease pulse rate?
Unrelieved severe pain can cause a parasympathetic reaction slowing heart rate
54
Do positive chronotropic drugs increase or decrease pulse rate?
increase
55
Do negative chronotropic drugs increase or decrease pulse rate?
Decrease
56
A pulse deficit is when...
Apical pulse is greater than radial pulse
57
A pusle deficit can indicate...
* The thrust of blood from heart is too feeble for wave to be felt at peripheral site
* May indicate vascular disease is preventing impulses from being transmitted
* Can also result from disrythmia
58
What does A/O stand for?
Alert and Oriented
59
How is A/O assessed?
If the patient can name
* person (who they are)
* place (where they are)
* time (date)
You can also add
* Current event
60
What is meant by A/Ox3
Patient is fully alert and oriented
Answered:
Person, Place, Time
61
What is meant by A/Ox2
They got two of the A/O assessment questions correct
62
What are the two tupes of body temperature?
Core: deep tissue (constant)
Surface: varies pending blood flow to skin and heat lost to environment
63
A pulse rate \> than 100 bpm is known as...
tachycardia
64
A pulse rate \< than 60 bpm is known as...
Bradycardia
65
How do the following effect pulse rate?
1. Sort-term Exercise
2. Long-term Exercise
3. Fever and Heat
4. Hypothermia
1. Sort-term Exercise = increases hr
2. Long-term Exercise = Decreases hr
3. Fever and Heat = Increase hr
4. Hypothermia = Decreases hr
66
How do the following effect pulse rate?
1. Hemorrhage
2. Standing or sitting
3. Lying down
4. Acute pain and anxiety
5. Diseases causing poor oxygenation such as asthma, COPD
1. Hemorrhage = Increase
2. Standing or sitting = Increase
3. Lying down = Decrease
4. Acute pain and anxiety = Increase
5. Diseases causing poor oxygenation such as asthma, COPD = Increase
67
What is orthoscopic hyotension?
Sudden low blood pressure caused by elevation changes in Standing, sitting, or lying down
68
Orthostatic hypotension signs and symptoms include:
* Feeling lightheaded or dizzy after standing up
* Blurry vision
* Weakness
* Fainting (syncope)
* Confusion
* Nausea
69
A discrepancy between AP and Radial pulse is indicitive of...
a pulse deficit
70
What causes a pulse deficit?
The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral site.
71
Pulse deficit is indicative of
vascular disease that is preventing impulses from being transmitted
72
Pulse deficits can be associated with
abnormal rhythms
73
Describe how an Apical-Radial Pulse is performed
* 2 nurses
* Start and stop is called by radial nurse
* Counted for 60 seconds
* Document each pulse
74
True or False
Radial pulse can never be greater than apical pulse
True
75
An irregular pulse or heart rate should be doublechecked at what pulse site?
Apical
or
PMI (Point of Maximal Impulse)
76
If an auto BP is abnormal, you should...
double check it manually
