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46 Cards in this Set
- Front
- Back
When do you measure vital signs?
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-Complete physical assessment (provides a baseline for further assessments)
- client's considtions determines when, where, how and by whom vital signs are measured |
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What are some guidelines for measuring vital signs?
(see p. 494 for full descriptions) |
-unregulated care providers may measure selected vital signs (and nurse responsible may interpret and act on these measurements)
- use appropriate and functional equipment -select equipment based on client's condition and characteristics -minimize environmental factors that may affect vital signs -use organized approach -use baseline measurements to compare -develop teaching plan to instruct client of caregiver on vital sign asssessment |
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Normal vital sign ranges
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Temperature Range: 36C-38C
Avg. oral/tympanic: 37C Avg. rectal: 37.5C Avg. axillary: 36.5C Pulse: 60-100 bpm Respiration: 12-20 breaths Blood pressure: Avg: 120/80 mmHg Pulse Pressure: 30 to 50 mmHg |
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core temperature?
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-temp. of deep tissues controlled by temp. controlled mechanisms
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What is the average temp. for healthy young adults?
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37
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Thermoregulation?
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Balance between heat lost and heat produced that is regulated by physiological and behavioural mechanisms.
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What does the hypothalamus do?
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The hypothalamus (located b/w the cerebral hemispheres) controls body temp. The anterior hypothalmus controls heat loss and the posterior hypothalmus controls heat production. (See p. 495 for more details of how it works).
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What produces heat production processes in the body?
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-Basal metabolic rate (BMR): accounts for heat produced at absolute rest and thyroid glands affect the BMR.
Shivering: involuntary body response to temperature differences in the body. Nonshivering thermogenesis: occurs primarily in newborns. |
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What produces heat loss processes?
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Radiation: transfer of heat from the surface of one object to the surface of another w/o direct contact b/w the two.
Conduction: transfer of heat from one object to the other. Convection: transfer of heat away by air movement. Evaporation: transfer of heat energy when liquid is changed to a gas Diaphoresis: visible perspiration, prim. on forehead and upper thorax. |
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How does skin regulate temperature?
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through insulation of body, vascoconstriction, and temperature sensation.
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Factors that affect body temperature
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-Age
-Excercise -Hormone Level -Circadian Rhythm -Stress -Environment -Temperature Alterations |
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What is pyrexia?
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Fever. Occurs when heat-loss mechanisms are unable to keep pace with excess heat production. Not harmful if stays below 39C.
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What is hyperthermia?
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body temp. that is elevated as a result if the body's inability to promote heat loss or reduce heat production. It's an overload of the body's thermoregulatory mechanisms
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What can lead to hyperthermia?
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-heatstroke (prolonged exposure to the sun or high environmental temp.).
-heat exhaustion (excess water and electrolyte loss from profuse disphoresis) |
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What is hypothermia?
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-heat loss from prolonged exposure to cold overwhelms the ability to produce heat
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What is the equation to convert Fahrenheit to Celsius?
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(F-32) x 5/9
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What is the equation to convert Celsius to Fahrenheit?
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(C x 9/5) + 32
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Describe an electronic thermometer.
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-battery powered with display unit
- separate unbreakable probes available for oral (and axillary) and rectal use -Also tympanic version -advantage is that they are easily readible and read within seconds 2 modes: 4 sec. predictive & 3 min. standard -signal sound when peak temp. reading has been measured. |
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See p. 499 to 503 for different ways to measure body temperature
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See p. 499 to 503 for different ways to measure body temperature
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See p. 504 for a detailed list of advantages and disadvantages of select temperature measurement sites.
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See p. 504 for a detailed list of advantages and disadvantages of select temperature measurement sites.
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What are antipyretics?
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drugs that reduce fever.
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What id cardiac output?
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the volume of blood pumped by the heart during 1 minute
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What is the most common artery for taking pulse rate and why?
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radial artery because it is easily palpated.
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when is the cartoid artery assessed?
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When condition of the client suddenly changes--the heart will continue delivering blood through the cartoid artery to the brain.
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When do you use a stethoscope?
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When assessing the apical pulse rate
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See p. 511 to 514 for detailed descriptions on assessing the radial and apical pulses.
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See p. 511 to 514 for detailed descriptions on assessing the radial and apical pulses.
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What is the acceptable ranges if heart rate for an infant?
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120-160
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What is the acceptable ranges if heart rate for a toddler?
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90-140
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What is the acceptable ranges if heart rate for a preschooler?
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80-110
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What is the acceptable ranges if heart rate for a school-age child?
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75-100
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What is the acceptable ranges if heart rate for an adolescent?
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60-90
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What is the acceptable ranges if heart rate for an adult?
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60-100
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When do you assess the temporal artery?
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to assess pulse in children
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When do you assess brachial artery?
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to assess status of circulation of lower arm, to ausculate blood pressure
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When do you assess radial pulse?
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assess character of pulse peripherally and assess status of circulation to hand
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When do you assess ulnar artery?
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assess circulation of hand and perform the allen test
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When do you assess femoral artery?
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assess pulse during physiological shock or cardiac arrest when other pulses are not palable; assess status of circulation to the leg
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When do you assess popliteal artery?
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assess circulation of lower leg
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When do you assess posertial tibial?
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assess status of circulation to foot
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When do you assess dorsalis pedis?
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assess circulation to foot
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What are the characteristics of the pulse?
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Rate
Rhythm (normally there is a regular interval between each pulse or heart rate) Strength Equality (pulses on both side of peripheral vascular system should be assessed to compare |
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Factors that influence character of respiration
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-Excerise
-Acute Pain -Anxiety -Smoking -Body Position -Medications -Neurological injury -Hemoglobin function |
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What is respiration?
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the mechanism that the body uses to exchange gases b/w atomosphere and the blooed and b/w the blood and the cells
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What does respiration involve?
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Ventilation (movement of gases in and out of the lungs)
Diffusion (movement of oxygen and carbon dioxide b/w the alveoli and the red blood cells) Perfusion (distribution of red blood cells to and from the pulmonary capillaries) |
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What is hypoxemia?
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low levels of arterial O2 (which chemoreceptors in the carotid artery and arota signal the brain to increase the rate and depth of ventilation.
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Should you let a client know you are assess their respiration?
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No b/c they may change how they breath. Best time is right after assessing the radial pulse.
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