-
classification of BP
- category systolic diastolic
- normal 90-<120 <80
- prehypertension 120-139 80-89
- stage 1 hypertension 140-159 90-99
- stage 2 hypertension >=160 >=100
-
conditions not appropriate for electronic BP
- irregular heart rate
- peripheral vascular obstruction
- shivering
- seizures
- excessive tremors
- inability to cooperate
- BP less than 90mmHg systolic
-
BP on lower extremity
- systolic: usually 10-40 mmHg higher than brachial artery (avg 30 mmHg)
- diastolic: same as brachial artery
-
ausculatory gap
silence between 1st thump and regular thumping
-
Korotkoff phases
- 1 a sharp thump
- 2 a blowing or whooshing sound
- 3 a crisp intense tapping
- 4 a softer blowing sound that fades
- 5 silence
-
factors effecting BP
- age
- stress
- ethnicity
- gender
- daily variation
- medications
- activity, weight
- smoking
-
pulse oximeter
- permits indirect measurment of O2 saturation for a client's VS database
- SpO2
-
SaO2
- the amount of hgb that is bound with O2 in the arteries
- measured as a % of saturation of hgb
- S arterial O2
- blood gas
-
Biot's respiration
respirations are abnormally shallow (very short) for 2-3 breaths followed by irregular period of apnea
-
Kussmaul's respiration
- respirations are abnormally deep, regular and increased in rate
- (ketoacidosis)
-
Cheyne-Stokes respiration
- respiratory cycle begins with slow shallow breths that gradually increase to abnormal rate and depth
- the pattern reverses breathing slows and becomes shallow climaxing in apnea before respiration resumes
-
hypoventilation
- respiratory rate is abnormally low and depth of ventilation is depressed
- hypercarbia sometimes occurs
-
hyperventilation
- rate and depth of respirations increase
- hypocarbia sometimes occurs
-
apnea
- respirations cease for several seconds
- persistant cessation results in respiratory arrest
-
hyperpnea
- respirations are labored, increased in depth and increased in rate
- occurs normally during exercise
-
tachypnea
rate of breathing is regular but abnormally rapid
-
bradypnea
rate of breathing is regular but abnormally slow
-
factors influencing the character of respirations
- exercise
- acute pain
- anxiety
- smoking
- body position
- medications
- neurological injury
- hgb function
-
perfusion
- the circulation of blood through tissues
- distribution of RBC's to and from the pulmonary capillaries
-
diffusion
movement of O2 and CO2
-
Ventilation
- external- exchange of O2 and CO2 at the alveolar level
- internal- exchange of O2 and CO2 at the cellular level
-
equality
- assessment of the character of the pulses on both sides of the peripheral vascular system
- except for the carotid pulses, each side can be assessed simultaneously
-
strength (amplitude)
- absent
- strong or normal- can be felt with moderate pressure of the fingers and can be obliterated with greater pressure
- weak or thready- can be easily obliterated with minimal pressure
- bounding or full- can be obliterated only with difficulty and great pressure
-
rythym
- regular
- irregular- (dysrhythmia) an interruption in successive beats
-
pulse deficit
- difference between apical and radial rate
- need two nurses
-
-
character of the pulse
- rate
- rhythm
- strength
- equality
-
first and second heart sounds
- S1: "lub" =closure of the nitral and tricuspid valves, end of distole
- S2: "dub" =closure of the aortic and pulmonic valves, end of systole (contraction)
- each set of "lub-dub" is counted as one heartbeat
-
using a stethoscope to assess apical pulse (PMI)
- diaphram: transmit high pitched sounds ("lub" "dub"), heart, bowel and lung
- bell: low pitched sounds, heart and vascular
-
factors influencing pulse rate
- exercise
- temperature
- emotions
- drugs
- hemorrhage
- postural changes
- pulmonary conditions
- age
- rest and sleep
- dehydration
- vomiting
- head injury
- electrolyte imbalance
-
pulse sites
- temporal
- carotid
- apical
- brachial
- radial
- ulnar
- femoral
- popliteal
- posterior tibial
- dorsalis pedis
-
stroke volume
volume of blood ejected from the left ventricle and entering the aorta
-
cardiac output
- volume of blood pumped by the heart in one minute
- the product of the heart rate and the stroke volume
-
pulse
- palpable bounding of blood flow in the peripheral arteries
- an indicator of circulatory status
- pulse rate: # of pulsing sensations occurring in one minute
-
frostbite
body exposed to subnormal temps and ice crystals form inside the cell with permanent circulatory and tissue damage
-
heat exhaustion
- profuse diaphoresis results in excess water and electrolyte loss
- normal pulse
- decreased BP
-
heatstroke
- hot dry skin due to severe electrolyte loss and hypothalamic dysfuntion
- temp as high as 113*F
- increased HR
- decreased BP
- higher mortality rate
-
relapsing fever
periods of febrile episodes and periods with acceptable temp. values, febrile episodes and periods of normothermia are often longer than 24hrs
-
remittent fever
fever spikes and falls without a return to normal temp levels
-
intermittent fever
fever spikes interpersed with usual temp levels, temp returns to acceptable value at least once in 24hrs
-
sustained fever
constant body temp continuously above 38*C (100.4*F) that has little fluctuation
-
pyrogen
triggers the immune system to produce and conserve heat
-
-
-
core temperature
- rectum: insert in direction of umbilicus 2.5-3.5 cm (1-1.5 in.)
- tympanic: depends on radiation of body heat to an infrared sensor, and shares same blood flow as hypothalamus
- temporal artery
- esophagus
- pulmonary artery
- urinary bladder
-
temperature in older adult
- Average: 35*C (96.8)
- factors effecting temp: deteriorating control mechanisms, poor vasomotor control, reduced metabolism, teduced sub-q tissue and sweat glands
-
average temperatures
- oral & tympanic: 37* C (98.6*F)
- rectal: 37.5*C (99.5*F)
- axillary: 36.5*C (97.7*F)
-
when to take vital signs
- upon admission
- in accordance with the physicians order
- before and after surgery
- before and after an invasive procedure
- before, during and after administration of medications that affect cardiovascular, respiratory or temperature control functions
- before and after nursing interventions that affect VS
- when the client reports non specific symptoms of physical distress
-
vital signs
- temperature
- pulse
- respirations
- oxygen saturation
- blood pressure
- (pain)
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