ch. 33

• category systolic diastolic
• normal 90-<120 <80
• prehypertension 120-139 80-89
• stage 1 hypertension 140-159 90-99
• stage 2 hypertension >=160 >=100

• irregular heart rate
• peripheral vascular obstruction
• shivering
• seizures
• excessive tremors
• inability to cooperate
• BP less than 90mmHg systolic

• systolic: usually 10-40 mmHg higher than brachial artery (avg 30 mmHg)
• diastolic: same as brachial artery

silence between 1st thump and regular thumping

• 1 a sharp thump
• 2 a blowing or whooshing sound
• 3 a crisp intense tapping
• 4 a softer blowing sound that fades
• 5 silence

• age
• stress
• ethnicity
• gender
• daily variation
• medications
• activity, weight
• smoking

• permits indirect measurment of O2 saturation for a client's VS database
• SpO2

• the amount of hgb that is bound with O2 in the arteries
• measured as a % of saturation of hgb
• S arterial O2
• blood gas

respirations are abnormally shallow (very short) for 2-3 breaths followed by irregular period of apnea

• respirations are abnormally deep, regular and increased in rate
• (ketoacidosis)

• 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

• respiratory rate is abnormally low and depth of ventilation is depressed
• hypercarbia sometimes occurs

• rate and depth of respirations increase
• hypocarbia sometimes occurs

• respirations cease for several seconds
• persistant cessation results in respiratory arrest

• respirations are labored, increased in depth and increased in rate
• occurs normally during exercise

rate of breathing is regular but abnormally rapid

rate of breathing is regular but abnormally slow

• exercise
• acute pain
• anxiety
• smoking
• body position
• medications
• neurological injury
• hgb function

• the circulation of blood through tissues
• distribution of RBC's to and from the pulmonary capillaries

movement of O2 and CO2

• external- exchange of O2 and CO2 at the alveolar level
• internal- exchange of O2 and CO2 at the cellular level

• 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

• 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

• regular
• irregular- (dysrhythmia) an interruption in successive beats

• difference between apical and radial rate
• need two nurses

how fast

• rate
• rhythm
• strength
• equality

• 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

• diaphram: transmit high pitched sounds ("lub" "dub"), heart, bowel and lung
• bell: low pitched sounds, heart and vascular

• exercise
• temperature
• emotions
• drugs
• hemorrhage
• postural changes
• pulmonary conditions
• age
• rest and sleep
• dehydration
• vomiting
• head injury
• electrolyte imbalance

• temporal
• carotid
• apical
• brachial
• radial
• ulnar
• femoral
• popliteal
• posterior tibial
• dorsalis pedis

volume of blood ejected from the left ventricle and entering the aorta

• volume of blood pumped by the heart in one minute
• the product of the heart rate and the stroke volume

• palpable bounding of blood flow in the peripheral arteries
• an indicator of circulatory status
• pulse rate: # of pulsing sensations occurring in one minute

body exposed to subnormal temps and ice crystals form inside the cell with permanent circulatory and tissue damage

• profuse diaphoresis results in excess water and electrolyte loss
• normal pulse
• decreased BP

• hot dry skin due to severe electrolyte loss and hypothalamic dysfuntion
• temp as high as 113*F
• increased HR
• decreased BP
• higher mortality rate

periods of febrile episodes and periods with acceptable temp. values, febrile episodes and periods of normothermia are often longer than 24hrs

fever spikes and falls without a return to normal temp levels

fever spikes interpersed with usual temp levels, temp returns to acceptable value at least once in 24hrs

constant body temp continuously above 38*C (100.4*F) that has little fluctuation

triggers the immune system to produce and conserve heat

fever

• skin
• oral
• axillae

• 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

• Average: 35*C (96.8)
• factors effecting temp: deteriorating control mechanisms, poor vasomotor control, reduced metabolism, teduced sub-q tissue and sweat glands

• oral & tympanic: 37* C (98.6*F)
• rectal: 37.5*C (99.5*F)
• axillary: 36.5*C (97.7*F)

• 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

• temperature
• pulse
• respirations
• oxygen saturation
• blood pressure
• (pain)