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nurs 220L > perfusion and vital signs > Flashcards

perfusion and vital signs Flashcards

1
Q

vitals signs

A

indicators of health status- effectiveness of circulatory, respiratory, neural and endocrine systems

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2
Q

name vital signs

A

temp, pulse, respiration, bp, oxygen saturation, (pain)

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3
Q

temp can be affected by

A

age, exercise, hormone level, circadian rythm, environment, temp alterations

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4
Q

radial pulse measurement includes

A

rate, rhythm, and quality; 30 sec if reg, 1 min if irregular

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5
Q

apical pulse

A

rate and rhythm, always 1 min

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6
Q

respiration affected by

A

exercise, smoking, pain, anxiety, meds, body position, neurological injury, hemoglobin fn

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7
Q

bp affected by

A

age, stress, ethnicity, gender, daily variations, meds, activity, weight, smoking

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8
Q

hypertension - physiological changes

A

thickening of walls, less elastic; family hx, risk factors

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9
Q

hypotension -physiology and effects

A

dilation of arteries, loss of blood volume, dec blood flow to organs; systolic < 90mm Hg

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10
Q

normal temp range

A

36-38 C (96.8-100.4 F)

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11
Q

average oral / tympanic temp for adult

A

37 C (98.6F)

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12
Q

average rectal temp

A

37.5 C (99.5F)

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13
Q

average axillary temp

A

36.5 C (97.7F)

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14
Q

average pulse - adult

A

60-100 beats/ min

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15
Q

average respirations adult

A

12-20 breaths/ min

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16
Q

average pulse pressure adult

A

30-50 mm Hg

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17
Q

pulse pressure

A

difference between systolic and diastolic pressure, normally 30-40 mm Hg

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18
Q

newborn body temp

A

35.5-37.5 C (95.9-99.5F)

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19
Q

progesterone levels effect on temp

A

decreased levels during menstrual fluctuations cause baseline temp to decrease few tenths of a degree

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20
Q

when body temps is too low, the hypothalamus initiates

A

vasoconstriction - blood flow to the skin is decreased to preserve heat

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21
Q

physical and emotional stress - effect on body temp

A

increased - via hormonal and neural stimulation

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22
Q

fever is usually not harmful if stays below

A

39 C (102.2F)

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23
Q

fever

A

alteration in the hypothalamic set point

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24
Q

pyrogens

A

bacteria and viruses that elevated body temp; act as antigens stimulating an immune response

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25
Q

patterns of fever

A

sustained, intermittent, remittent, relapsing

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26
Q

sustained fever

A

continued temp above 38C (100.4F), little fluctuation

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27
Q

intermittent fever

A

fever spikes interspersed with normal temp (temp normal at least once in 24 hr)

28
Q

remittent fever

A

fever spikes and falls without return to normal temp

29
Q

relapsing fever

A

periods of febrile and afebrile episodes; febrile and normothermia episodes often longer than 24 hr

30
Q

hypothermia classification

A

mild, moderate, severe

31
Q

mild hypothermia

A

34-36 C(93.2-96.8)

32
Q

moderate hypothermia

A

30-34 C (86- 93.2F)

33
Q

severe hypothermia

A

> 30 C (86F)

34
Q

body metabolism increases during fever by

A

10% for every degree C

35
Q

hyperthermia

A

body temp exceeds set point; inability of the body to promote heat loss or inhibit heat production

36
Q

malignant hyperthermia

A

due to certain anesthetic drugs; hereditary condition of uncontrolled heat production

37
Q

heat stroke

A

body temp of 40C or more (104F); heat depresses hypothalamic function; high mortality

38
Q

symptoms of heat stroke

A

delirium, thirst, muscle cramps, nausea, visual disturbance, incontinence, inc HR, low BP

39
Q

MOST important sign of heat stroke

A

hot, dry skin- no sweat due to electrolyte loss and hypothalamic malfunction

40
Q

progression of heat stroke

A

unconscious, fixed nonreactive pupils; permanent neurological damage

41
Q

heat exhaustion

A

diaphoresis results in electrolyte and water loss

42
Q

hypothermia

A

heat loss due to prolonged exposure to cold overwhelms ability to produce heat; can be intentionally induced during surgical procedures

43
Q

accidental hypothermia

A

develops gradually, can go unnoticed for hours; when temp drops below 35C / 95F uncontrollable shivers, memory loss, depression, poor judgment

44
Q

if body temp falls below 34.4 C (94F)

A

HR, resp, and BP fall; cyanotic skin, dysrhythmias, loss of consciousness, unresponsive to pain

45
Q

severe hypothermia symptoms

A

similar to death - lack of response to stimuli, extremely slow resp and pulse

46
Q

frostbite

A

ice crystals form inside the cell; permanent circulatory and tissue damage; area becomes white, waxy and firm to touch; sensation loss

47
Q

areas susceptible to frostbite

A

earlobes, tips of nose, fingers ad toes

48
Q

frostbite tx

A

gradual warming, analgesia, protect tissues

49
Q

compare oral, rectal and axillary temp

A

rectal usually .5C (.9F) higher than oral, axillary .5C lower than oral

50
Q

convert C to F

A 
F = 9/5C +32
C= (F-32) x 5/9
51
Q

advantage of oral temp

A

easily accessible,comfortable, shows rapid change in core temp; provides accurate surface temp reading; reliable for intubated patients

52
Q

oral temp limitations

A

delay if patients smoked, ate cold/ hot, or receiving oxygen by mask / cannula; not for patients with oral surgery, hx of epilepsy, shaking chills; risk of fluid exosure

53
Q

don’t use oral temp with

A

infants, small children, confused, unconscious or uncooperative

54
Q

tympanic temp benefits

A

if patient has tachypnea - does not disturb breathing; provides accurate core temp - close to hypothalamus; sensitive to core temp changes; rapid measurement (2-5s), unaffected by oral intake, smoking

55
Q

tympanic temp used with newborns why?

A

reduce infant handling and heat loss

56
Q

tympanic temp disadvantages

A

more variability than other core temp devices, requires removing hearing aid; disposable cover available in only 1 size; otis media and cerumen distorts reading; not accurate for core temp changes before / after exercise; affected by fans, incubators; incorrect handling of device = errors

57
Q

rectal temp benefit

A

more reliable if can’t get oral temp

58
Q

rectal temp disadvantages

A

lags behind during rapid core temp changes; requires lubrication, not usually for newborns

59
Q

axillary temp often used for

A

newborns and unconscious patients

60
Q

axillary temp limitations

A

underestimates core temp; time consuming, needs continuous positioning by nurse; requires exposure to thorax - heat loss (esp newborns); affected by environment including time to place thermometer

61
Q

axillary temp not recommended for fever detection in

A

infants and young children

62
Q

skin temp benefit

A

noninvasive, safe, continuous reading; used in neonates

63
Q

skin temp limitations

A

lags behind during core temp changes - esp hyperthermia; sweat affects adherence, affected by environmental temp; can have allergy

64
Q

temporal artery benefit

A

rapid, used in premature infants, newborns, children; reflects rapid change in core temp change; sensor cover not required

65
Q

temporal temp affected by

A

sweat, moisture, hair on forehead

nurs 220L (11 decks)

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