Ch 24 Ex 2 Lec A

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1

4 Classic Vital signs in order

Temp, Pulse, Resp, B/P

2

Temp

98.6

3

Pulse

60-100

4

Resp

12 - 20

5

B/P

120/80

6

what else could be used to take VS (vital signs)?

pulse ox or a pain reading (but not really VS

7

Hypertension

140/90

8

What is the silent killer

hypretension

9

Normal B/P

< 120/80

10

Prehypertension

120-139 over 80-89

11

high b/p stage 1

140-159 over 90-99

12

high b/p stage 2

>/= 160 over 100

13

After you take VS what is the 1st thing you need to do? What is the 2nd thing?

Compare them with the normal and then compare with pt. normal

14

If pt VS are off what 2 things should you ask yourself?

Why are the pt VS off? What is the cause?

15

The standard for taking VS

every shift

16

Also take VS when you are concerned about

pt is sweaty, confused, dizzy, unconscious, traumatic injury, fall

17

take VS per policy and procedures. Post-Op & Pre-op Ex. used was post-op. Most concern was___ b/c of ___

heart rate b/c of bleeding

18

If pt is bleeding w/happens to pulse rate? B/P? Blood volume? The beat? Respiratory rate?

Faster. Down. Down. Faster and Faster. UP. (why-body is trying to get ox

19

If a person were in pain what VS would be altered

B/P, Pulse Respiratory

20

VS of T-101.2, P-110, R-24, B/P-120/81. What might this indicate?

Infection

21

VS of T-101.2, P-110, R-24, B/P-124/84. Which one of those should be of the most concern?

Temp. (the others are not that far off)

22

When to assess VS

Admission, per policy and procedure, Before and after invasive procedures, Before and after activity. Before and after Meds

23

Central Line (central IV), Needle into chest to pull off fluid, endoscopy or colonoscopy are what type of procedure? If one of these are being done when would VS be taken

invasive. Before and after, maybe during

24

VS are to be taken before and after meds. Give 3 ex of why?

Receiving med 1st time. 1st time getting out of bed after surgery. Getting up after having a baby. CNS depressants

25

b/p meds

Diuretic-Diuril, Lasix, Lozol. K sparing-Aldactone, Dyrenium. Loop diuretic-bumetanide. Beta Blockers- atenolol. Ace Inhibitors- catopril. Angiotensin II receptor blockers-irbesarten, valsartan. ETC.

26

Meds that we are concerned with and VS need to be taken? Which one did she make a huge point about?

B/P, Beta Blockers, *any Cardiac. CNS depressants (she said any CNS med can alter VS and 1st time giving VS have to be checked)

27

1st VS to be taken?
According to text what is the normal range

Temp.
97 F- 99.5 F

28

Core temps that can be taken? People don't like them b/c they are considered? What is the preferred way to take a core temp?

Rectal and Tympanic. Invasive. Tympanic

29

Temp time of day Lowest__? Highest__? Females it will change due to __

Morning. Evening. Hormones

30

Thermoregulation in Older are not able to maintain heat as well B/C

Not as active. They don't have as much fat.

31

Men have a higher temp than women up till

menopause

32

Stress causes a ___ response of ___ &___.

Sympathetic. epinephrine and norepinephrine

33

Caused by exposure to heat or cold and both can lead to death? Body functions at its maximal capacity at?

hyperthermia or hypothermia. 97 F -99.5 F

34

Body compensates with __ when we are invaded by microorganisms. The ___ controls body heat.

fever. Hypothalmus

35

Involuntary way to produce heat? Voluntary?

Shiver. Activity

36

Who are we must concerned with loss of heat

Infants

37

When baby is born and covered with mucous the nurse wipes it off to prevent? Once it is wrapped it is put into a ___

Evaporation. Radiant warmer (Incubator)

38

Fan running on a person, they will loss heat by__. People sitting by a closed window loss heat by ___. Man leans on a cold wall he will loss heat by___. Your husband puts his cold, nasty toes on your hot leg, you give him heat by__

Convection. Radiation. Conduction. Conduction

39

Person is touching you__. When they sit next to you sucking up your warmth__

conduction. Radiation

40

Man is in ICU and has a temp of 103.6 F (___) & Doc want to ↓↓ temp. The doc would order an___ and ___ if it is infection. But you can't let fevers get tha high b/c it will cause___

Hyperthermia. Antipyretic & Antibiotics. Seizures

41

If you put ice packs under arm pits or in the groin man will loss heat by? If that man is given a tepid sponge bath he will loss heat by __ & __

Conduction. Evaporation and conduction. Loss of heat due to being wet & cold object touching them

42

Normal temp

97 F - 98.6 F

43

Pyrexia

100.4 - 104

44

Hyperpyrexia

105.8 - 111.2

45

Death would occur hyperpyrexia

111.2 F.

46

Death would occur hypothermia

93.2

47

Hypothermia

95 F - 93.2

48

With temp you need to know pt ___ b/c many people naturally run low temp. Grandma's temp might run__

baseline. 97.1

49

Doc's make judgement if it is __degrees higher or lower than normal & that would be a fever for that pt

2

50

Fevers that go away on their own-called____. Redness and swelling is a sign of ___. What would be another sign ____

Self-Limiting. Inflammation. Temp

51

The body temp alternates regularly b/w a period of fever and a period of normal or subnormal temp

Intermittent

52

The body temp fluctuates several degrees more than 2 C (3.6 F) above normal but does not reach normal fluctuations

Remittent

53

The body temp remains consistently elevated and fluctuates less than 2 C. (3.6 F)

Constant

54

The body temp returns to norm for at least a day, but then the fever recurs

Relapsing

55

The fever returns to normal suddenly

Crisis

56

The fever returns to normal gradually

Lysis

57

Oral fluids are given to maintain __and __ __, & prevent___

cellular and intravascular status and prevent dehydration

58

__ __ are included in the diet to prevent tissue breakdown form the hypermetabolic state

Simple Carbohydrates

59

Thediffusion or dissemination of heat by electromanetic waves

Radiation

60

The dissemination of heat by motion b/w areas of unequal density

Convection

61

The conversion of a liquid to a vapor

Evaporation

62

The transfer of heat to another object during direct contact

Conduction

63

The body gives off waves of heat from uncovered surfaces

Radiation

64

An oscillating fan blows currents of cool air across teh surface of a warm body

Convection

65

Body fluid in the form of perspiration and insensible loss is vaporized from the skin

Evaporation

66

The body transfers heat to an ice pack, causing the ice to melt

Conduction

67

__ fever is the result of damage to the hypothalamus from pathologies such as intracranial trauma, intracranial bleeding, or ↑↑ incranial pressure. Do antipyretic Meds work (Yes or NO). A fever of 38.3 C/101 F or higher for 3weeks or longer w/out known cause is called___

Neurogenic. NO. Fever of unknown origin (FUO)

68

Happens nearly every 24 hours

Circandian Rhythms

69

May remain open on the surface of the skin during exercise or a hot day to allow heat to dissipate. ___ nervous system controls this. It would allow heat to __ on a hot day

arterioveonous shunts. Sympathetic. Evaporate