Chapter 20

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Measuring Vital Signs
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1

Vital signs:

suggests assessment of vital or critical physiological functions

2

Variations in temperature are indicators of:

a person's state of health and function of the body system

3

Mean adult temperature oral:

98 F or 36.7 c

4

Mean adult temperature rectal:

98.6 F or 37 C

5

Pulse Normal range:

60-100 beats/min

6

Average pulse:

80 beats/min

7

Respirations Normal Range:

12-20 breaths/min

8

Blood pressure Normal range:

100-119 systolic; 60-80 diastolic

9

Blood pressure prehypertensive:

120-139 systolic; 80-89 diastolic

10

Blood pressure Average:

110/70

11

Body temperature:

is the degree of heat maintained by the body

12

Core temperature is:

97-100.8 F or 36.1 C to 38.2 C

13

Thermoregulation:

the process of maintaining a stable temperature

14

Vasodilation:

increase in the diameter of the blood vessels

15

Vasoconstriction:

Narrowing of the blood vessels

16

Piloerection:

Hairs standing on end

17

Metabolism:

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

18

Basal metabolic rate:

the amount of energy required to maintain the body at rest.

19

Hyperthyroidism:

an increase in the thyroid hormone thyroxine

20

Catabolism:

the breakdown of fats and carbs in muscle produces energy and heat

21

Nonshivering thermogenesis:

the metabolism of brown fat to produce heat

22

Radiation:

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

23

Convection:

the transfer of heat through currents of air or water

24

Evaportation:

occurs when water is converted to vapor and lost from the skin or the mucous membranes

25

Conduction:

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

26

What factors influence body temperature?

Developmental level, environment, gender, exercise, emotions and stress, circadian rhythm.

27

Circadian rhythm:

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

28

Fever:

also known as pyrexia; is a temperature above the person's usual range of normal. Usually higher than 100F (oral) or 101 (rectal)

29

Febrile

A person with a temperature

30

Afebrile:

a person without a temperature

31

A moderate fever is:

up to 103F or 39.5 C

32

Hyperpyrexia is a fever:

above 105.8F

33

Fever occurs in 3 phases:

initial phase, second phase, and third phase

34

Initial phase of fever:

the period during which body temp is rising but have not yet reached the new set point

35

Second phase of fever:

When body temperature reaches its maximum set point and remains fairly constant at the new higher level

36

Third phase:

the period during which the temperature returns to normal

37

Intermittent fever:

temperature alternates regularly between periods of fever and periods of normal or below-normal temperature without pharmacological intervention; the temperature returns to normal at least once every 24 hours

38

Remittent fever:

fluctuations in temperature (greater than 3.6F or 2 C), all above normal, during a 24 hour period

39

Constant (sustained) fever:

temperature may flucturate slightly but is always above normal

40

Relapsing or recurrent fever:

short periods of fever alternating with periods of normal temperatures, each lasting 1 to 2 days

41

Hyperthermia:

is a body temperature above normal; however it is higher than the set point

42

Heat stroke and heat exhaustion are examples of:

hyperthermia

43

Heat exhaustion are temperatures:

of 98.6 - 103 F or 37-39.4C

44

Heat Stroke:

Occurs when the body's temperature regulation fails.

45

Heat stroke temperatures are:

temps higher than 106F or 41.1C

46

Hypothermia:

Less than 95F or 35C

47

Early signs of hypothermia are:

shivering, cyanosis of lips and fingers, and poor coordination.

48

Severe hypothermia occurs:

when the body temperature drops below 82.4F or 28C

49

Perfusion:

the continuous supply of oxygenated blood through the blood vessels to the vital organs

50

Pulse:

the rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by contraction of the heart

51

Systole:

peak of the wave; contraction of the heart

52

Diastole:

resting phase of the heart

53

Stroke volume:

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

54

Cardiac output:

the total quantity of blood pumped per minute

55

Palpation:

feeling

56

Auscultation:

listening with a stethoscope

57

Apical pulse is located at:

the apex of the heart

58

Radial artery is used for:

routine assessment of vital signs

59

Brachial artery is used when:

performing cardiopulmonary resuscitation of infants

60

Carotid artery is used when:

performing CPR of inpatient adults and for assessing circulation to the brain

61

Temporal artery is used when:

assessing circulation to the head or when other sites are not easily accessible

62

Dorsalis pedis is used for:

assessing peripheral circulation

63

Femoral artery is used for:

assessing circulation to the legs, in cases of cardia arret, and for children

64

Popliteal artery is used for:

assessing circulation to the lower leg

65

Bradycardia:

rates below 60 bpm

66

Tachycardia:

rates over 100 bpm

67

Dysrhythmia:

Abnormal beat rhythm

68

Pulse volume:

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

69

The quality of the pulse is assessed by:

determining the pulse volume and bilateral equality of pulses

70

Bilateral equality:

useful in determining whether the blood flow to a body part is adequate

71

Pallor refers to:

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

72

Cyanosis:

bluish or grayish discoloration of the skin resulting from deficient oxygen in the blood

73

If the peripheral pulse is absent or weak, it may be because:

the circulation is compromised in that extremity; if that is the case, then pallor or cyanosis may be present.

74

Respiration is:

the exchange of oxygen and carbon dioxide in the body.

75

Mechanical:

the mechanical aspects of respiration involve the active movement of air into and out of the respiratory system; also known as pulmonary ventilation

76

Chemical:

External respiration, gas transport, internal respiration.

77

External respiration:

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

78

Gas transport:

the transport of these gases throughout the body

79

Internal respiration:

the exchange of these gases between the capillaries and body tissue cells.

80

Inspiration:

drawing air into the lungs

81

Expiration:

expulsion of air from the lungs

82

Respiratory rate:

the number of times a person breathes within one full minute

83

Tidal volume:

the amount of air taken in on inspiration

84

Apnea:

absence of breathing

85

Eupnea:

normal respirations, with equal rate and depth; 12-20 breaths/min

86

Bradypnea:

Slow respirations less than 10 breaths/min

87

Tachypnea:

fast respirations, more than 24 breaths/min; usually shallow

88

Kussmaul's respirations:

respirations that are regular but abnormally deep and increased in rate

89

Biot's respirations:

irregular respirations of variable depth, alternating with periods of apnea

90

Cheyne-stokes respirations:

Gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea

91

Wheezes:

high-pitched, continuous musical sounds, usually heard on expiration

92

Rhonchi:

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

93

Crackles:

caused by fluid in the alveoli; discontinuous sounds

94

Stridor:

piercing, high=pitched sound that is heard without a stethoscope; primarily during inspiration

95

Stertor:

labored breathing that produces a snoring sound

96

Hypoxia:

inadequate cellular oxygenation

97

Clubbing:

loss of the nail angel

98

Chronic hypoxia causes:

clubbing

99

Cough:

forceful or violent expulsion of air during expiration

100

ABG sampling:

directly measures the partial pressures of oxygen and carbon dioxide and blood pH the gases in the arterial blood

101

Pulse oximetry:

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

102

Hyperventilation occurs when:

rapid and deep breathing result in excel loss of CO2

103

Hypoventilation occurs when:

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

104

Blood pressure:

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

105

Systolic pressure:

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

106

Diastolic pressure:

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

107

Pulse pressure

is systolic minus by diastolic

108

Normal bp:

systolic less than 120 and diastolic less than 80.

109

Prehypertension:

systolic: 120-139; or diastolic: 80-89

110

Stage I Hypertension:

systolic 140-159 or diastolic: 90-99

111

Stage II Hypertension:

systolic greater than 160 or diastolic greater than 100

112

Conditions that increase cardiac output by increasing stroke volume include:

increased blood volume, more forceful contraction of the ventricles

113

Conditions that decrease cardiac output by decreasing stroke volume include:

dehydration, active bleeding, and damage to the heart

114

Peripheral restistance:

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

115

Viscosity:

thickness

116

Compliance:

elasticity

117

Hematocrit:

the percentage of red blood cells in plasma

118

Arteriosclerosis:

hardening of the arteries

119

The normal volume of blood in the body is about:

5 liters or 5000 mL

120

Orthostatic hypotension:

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

121

Primary hypertension:

is diagnosed when there is no known cause for the BP elevation

122

Secondary hypertension:

there is clearly identified cause for the persistent rise in BP