front 1 Wha are the 6 Vital Signs | back 1 TemperATURE (T)PULSE (P)RESPIRATIONS(R)BLOODPRESSURE(BP)OXYGEN SATURATION(O2 SAT, PULSE OX, OR SPO2, PAIN |
front 2 WHATS THE 5 OBJECTIVES OF VITAL SIGNS | back 2 To provide data regarding patients overrall condition. It reveals how certain systems are functioning.Its a base line against which changes can be measured. |
front 3 If a patient is in pain what can it affect? | back 3 Pulse, Respirations, BloodPressure Its a warning sign that tissues are injured or about to be injured |
front 4 When should you asses Vital signs ? | back 4 According to facility policy according to provider orders admission when a patient is complain of feeling unusual when their is a change in condition |
front 5 Whats the significance of vital signs | back 5 It monitors physiological condition identify new problems determine if an intervention needs to be performed determine if intervention was effective |
front 6 When should you asses vital signs | back 6 before, during and after administering certain medications , before during or after blood transfusion before during or after invasive surgery at least every four hours or more when the vital signs are abmormal |
front 7 When should you asses vital signs | back 7 A recheck when a vital sign is significantly different from the last assessment every 5 to 15 minutes if the patient is unstable |
front 8 Body Temp | back 8 Difference between the amount of heat the body produces and the amount of heat that is gained or lost to the external environment |
front 9 Systemic Approach to vitals signs | back 9 Temp, pules, Respirations, Bp,Obtain pulse oximeter reading ( oxygen Saturation o2 sat) dont forget to ask about pain |
front 10 Core Temp | back 10 Temp of the deeper structures and tissues NOrmally slightly warmer then superficial body tissue |
front 11 how do you asses the body surface or skin temp? | back 11 You have to place your hand on patients skin the dorsal part of hand determine if skin is warm ,hot , cool or cold |
front 12 What does the core temp do | back 12 Most important to maintain determines the temp of the brain, heart, and internal organs sterile thermometer probe inserted into the pulmonary artery, heart or urinary bladder |
front 13 What is thermogenesis | back 13 production of heat |
front 14 HOw is heat produced | back 14 digestion, absorption, breakdown synthesis of proteins intake in food will metabolism which then heat production in the body |
front 15 Any physical activity that increases metabolism will increase heat production | back 15 Muscle Contraction normally produce 25% of body heat in resting state, Shivering-involuntary skeletal muscle response increase heat production exercise can increase heat production |
front 16 What does the liver do with heat | back 16 Produces 15 to 20% of body heat in the resting state, As well as the secretion of hormones |
front 17 When you have elevated temp how does the body respond? | back 17 Blood vessels dilate-blood brought to skin surface-radiation |
front 18 ortho static usual in older adults | back 18 you must perform bp in supine position lying on back sitting standin |
front 19 The greater the cardiac output | back 19 The higher the blood pressure |
front 20 A pulse pressure less than 30 or greater then 50 | back 20 is consider abnormal |
front 21 Hypoxemia | back 21 decreased oxygen level in the blood |
front 22 hypoxia | back 22 decreased delivery of oxygen to the tissues and cells |
front 23 When do you see Cheyne stoke respirations | back 23 coma heart failure head injury drug overdose impending death |
front 24 characteristics to asses for respiration | back 24 rate per. min depth rhythm pattern respiratory effort |
front 25 When you are sleep what does the parasympathetic system do ? | back 25 Lowers the bloood pressure. |
front 26 When you are below normal temp how does the body respond? | back 26 Constrict blood vessels-redirect blood flow to vital organs |
front 27 femoral pulse site determines what | back 27 leg circulation |
front 28 you use the carotid pulse site during what | back 28 When person is in cardiac arrrest |
front 29 intracranial pressure | back 29 typically lowers the pulse rate any cause irregularity |
front 30 Cardiovascular disease can do what to pulse rate | back 30 it varies on disorder or disease it can increase or decrease and cause irregularity |
front 31 factor that can effect pulse rate | back 31 Increased fluid -fluid overload pulses full and bounding sometimes faster hypoxia pulse rate |
front 32 what are factors that decrease pulse rate | back 32 Decreased blood volume Hemorrhage or dehydration pulse rate increase Attempt to transport oxygen to tissues faster |
front 33 cafeine and nicotine does what ? | back 33 speed up the pulse rate |
front 34 adult pulserate | back 34 60 to 100 bpm |
front 35 What happens to older adults regarding body temperature | back 35 They have a difficult time maintaining normal body temp due to limited amount of fat that insulate the organs Any circulatory impairment will inhibit the vas-constriction and vasodilation aspect of controlling blood pressure |
front 36 What are factors that can affect body temp | back 36 Environment, Time of day , gender, physical activity and exercise ,medications, STRESS, food or drink and illness |
front 37 What happens if the environment is hot | back 37 The body temperature will tend to be higher. |
front 38 What happens when the environmental temp is cold what does it do to the body ? | back 38 Body temperature will tend to be lower |
front 39 Circadian Rythm | back 39 Body temp usually drops o.5 to f lower between midnight and dawn and rises 1 to 2 in the late afternoon and evening |
front 40 Factors affecting body temp Gender | back 40 Women tend to have a slight rise in body temperature during ovulation. |
front 41 factors affecting body Temp | back 41 Exercise raises the body temp |
front 42 Medications | back 42 Stimulants such as ephedrine increase the bodys metabolism -raise temperature |
front 43 What lowers Temperature Acetaminophen | back 43 Lowers elevated Temperature |
front 44 illness | back 44 Various diseases and injuries can directly affect the hypothalamus, resulting in changes i n body temp |
front 45 Food intake | back 45 type of food intake or lack of food intakes can directly affect body hot and cold fluids can have a mild effect on the oral temperature reading for 15 to 30 minutes after ingestion |
front 46 what are common conditions affecting body temp | back 46 Inflammatory processes, fluid loss, central nervous system tumors, head injuries, and heat stroke |
front 47 skin temp | back 47 Disposable topical stick on clean, dry skin affected by perspiration reflects surface temp special thermometer with skin probe tape to skin monitor temp read out |
front 48 When shouldn't you take tympanic Temp | back 48 should not have been lying on ear |
front 49 Tympanic temp how do you take it ? | back 49 Must face tympanic membrane adult pull pinna up and back in kids you pull down and back |
front 50 TYMPANIC TEMP | back 50 Unaffected by eating , drinking, smoking good for-people who have difficulty breathing its affected by environmental factors cannot use with ear infections or after ear surgery |
front 51 AXILLARY TEMP | back 51 IS THE LEAST ACCURATE FORM OF MEASUREMENT TEMP WILL BE 1 DEGREE LESS THEN CORE TEMP |
front 52 What are the routes for taking body temps | back 52 oral , Tympanic, TEMPORAL, RECTAL,AXILLARY, SKIN |
front 53 ORAL ROUTES CONTRAINDICATIONS | back 53 SUICIDAL, SEIZURE DISORDER, INFANT AND YOUNG CHILDREN , ORAL SURGERY OR INJURY TO NOSE AND MOUTH OR RECEIVING OXYGEN |
front 54 ORAL ROUTE CONTRAINDICATIONS | back 54 DO NOT USE IF ATE, DRANK OR SMOKED RECENTLY, WAIT 15 MIN GUM AND CHEWING TOBCCO AS WELL, UNCONSCIOUS PATIENT CONFUSED OR UNCOOPERATIVE |
front 55 IF YOU PUT A THERMOMETER THE ORAL ROUTE | back 55 LEAVE IN FOR 3 TO 5 MINS |
front 56 WHAT ARE YOU SUPPOSE TO DO OVER A GLASS THERMOMETER | back 56 SHAKE DOWN BEFORE COVERING APPLY A SHEATH OR PROBE COVER |
front 57 ORAL | back 57 BEST NON INVASIVE ROUTE FOR TEMP MAKE SURE TO CHECK IF PATIENT HAD ANYTHING TO EAT OR DRINK WITHIN THE LAST 15 TO 30 MINUTES WILL AFFECT TEMP READING |
front 58 what do you need for rectal route | back 58 thermometer probe cover lubricant tissue glove |
front 59 rectal route | back 59 Most accurate route -provides core temp Reflects temperature changes quickly Not a route of choice because of risk of intestinal perforation |
front 60 when shouldnt you use a rectal thermometer | back 60 Cannot be used for patients with diarrhea, severe hemorrhoids, rectal surgery Caution -immunocompromised high risk for bleeding |
front 61 whats the proper positioning of rectal route | back 61 left lateral ( on left side) it decreases risk of intestinal perforation |
front 62 Cicaddian Rythm | back 62 pulse rates are lower slowest from predawn hours to dawn and faster as the day progress towards the evening |
front 63 pulse deficit | back 63 Radial pulse is slower then the apical pulse rate ex88 apical radial 82 pulse deficit is 6 88-82 gives pulse defecit |
front 64 when should you take an apical heart rate ? | back 64 children less then 3 years old when radial pulse is weak prior to administering heart rate altering medication |
front 65 how should you asses apical pulse | back 65 if in bed elevated head 60 to 90 degree if out of bed sit up right in chair |
front 66 pmi point of maximum impulse | back 66 where the heart contraction is the strongest the apex of the heart |
front 67 what gives us a pulse | back 67 The pumping action of the heart produces a wave of blood that travels through the arteries as they expand and contract |
front 68 left atrium and left ventricles | back 68 oxygenated blood |
front 69 right atrium and right ventricle | back 69 deoxygenated blood |
front 70 Hypothermia | back 70 core temp below 95f (35C) slows body metabolism If hypothermia is prolonged or severe periods of hypothermia can result in death |
front 71 What is diaphoretic | back 71 Sweating alot |
front 72 Some patients find it difficult to breathe unless sitting up right position such as sitting or standing | back 72 orthopena |
front 73 dyspnea | back 73 A person who is having labored or difficulty breathing |
front 74 apnea | back 74 when respiration cease or are absent you only hav a brief window to restore respirations before brain damage and death occur |
front 75 tachypenea | back 75 respirations are above 20 |
front 76 Bradypena | back 76 your respirations are below 12 |
front 77 how do you get someone respirations | back 77 While pressing two fingers against radial pulse site, count the respiratory rate for 30 seconds then multiply it by2 for 30 seconds |
front 78 pules rate | back 78 3 + or bounding is good |
front 79 hypoxia | back 79 increases the pulse rate |
front 80 Blood volume decreased as in hemorrhage and dehydration | back 80 hemorrhage and dehydration will increase the pulse rate in an effort to more quickly transport the oxygen carried by red blood cells to the body tissues |
front 81 If your pulse rate is higher then 100 what is that called | back 81 tachycardia |
front 82 If your pulse is less then 60 what is it considerd | back 82 bradycardia |
front 83 what is a normal range for an adult pulse | back 83 60 to 100 bpm |
front 84 what are three Characteristics of the pulse | back 84 rate, Rhythm,and volume |
front 85 where are the peripheral pulse sites | back 85 temporal, carotid artery, brachial, femoral, ulnar and radial, posterior and tibal, dorsalis, pedis |
front 86 what regulates the heart beat | back 86 medulla oblongata |
front 87 whats an example of pulse defecit? | back 87 83bpm. 83-77=6 the radial pulse is 77bpm their is a pulse defcit of 6 which should be reported |
front 88 Where is the apex of the heart located? which is the primary site where the contraction is the strongest. | back 88 It located on the 5th intercostal space on the anterior wall. It is the central PRIMARY pulse site. |
front 89 when the radial pulse is slower then the apical pulse is known as what? | back 89 pulse defecit |
front 90 when heart sounds are normal what do you hear? | back 90 lub dub |
front 91 The amount of blood pumped from the heart in one minute is called ? | back 91 Cardiac output |
front 92 what kind of temp would you see if someone has hypothermia | back 92 elevations above 105 in temp |
front 93 WHAT ARE SIGN AND SYMPTOMS OF DEHYDRATION | back 93 DRY MUOUS MEMBRANES DECREASED SKIN TUGOR CHANGE IN COLOR URINE DECREASED AMOUNT OF URINARY OUTPUT |
front 94 NURSING CARE FOR PATIENTS WITH FEVER | back 94 ASSES VITALS EVERY TWO HOURS PROVIDE ALLOWED FLUIDS FREQUENT TO PREVENT DEHYDRATION MONITOR THE I AND O |
front 95 WHAT IS PHOTOPHOBIA | back 95 EYES HAVE INCREASED SENSITIVITY TO LIGHT |
front 96 SIGNS AND SYMPTOMS OF FEVER | back 96 HEADACHE,MYALGIA, LETHARGY OR DROWSINESS, DIAPHORIESIS, ANOREXIA,NAUSEA,CONFUSION SEIZURES IN KIDS AND INFANTS |
front 97 HOW MIGHT PATIENT FEEL WHEN THEY HAVE AN ELEVATED TEMP | back 97 FLUSHED, DRY,HOT SKIN THIRST DRY MUCOUS MEMBRANES , GLASSY OR DROOPY EYES, RESTLESSNESS PHOTOFOBIA |
front 98 ELEVATED TEMP | back 98 MOST PROVIDERS WILL NOT ATTEMPT TO REDUCE FEVER UNTILL IT ELEVATES ABOVE 102 ELEVATIONS ABOVE 105CAN RESULT TO DAMAGE OF BODY CELLS |
front 99 ELEVATED TEMP TERMINOLOGY | back 99 FEVER,PYREXIA, HYPERTHERMIA, FEBRILE |
front 100 WHAT ARE NORMAL RANGES FOR TEMP | back 100 97F TO 99.6 (36.1 C TO 37.5) THE AVERAGE 98.6 |
front 101 NCIT NONCONTACT INFRARED THERMOMETER | back 101 HOLD THERMOMETER 1 INCH AWAY FROM PATIENTS FOREHEAD |
front 102 temporal temp | back 102 its quick comfortable for patient not affected by food AND DRINNK PERSPIRATIION AFFECT IT IF HAIR IS TO THICK IT IS NOT ACCURATE |