ch. 33

  1. 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
  2. conditions not appropriate for electronic BP
    • irregular heart rate
    • peripheral vascular obstruction
    • shivering
    • seizures
    • excessive tremors
    • inability to cooperate
    • BP less than 90mmHg systolic
  3. BP on lower extremity
    • systolic: usually 10-40 mmHg higher than brachial artery (avg 30 mmHg)
    • diastolic: same as brachial artery
  4. ausculatory gap
    silence between 1st thump and regular thumping
  5. 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
  6. factors effecting BP
    • age
    • stress
    • ethnicity
    • gender
    • daily variation
    • medications
    • activity, weight
    • smoking
  7. pulse oximeter
    • permits indirect measurment of O2 saturation for a client's VS database
    • SpO2
  8. 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
  9. Biot's respiration
    respirations are abnormally shallow (very short) for 2-3 breaths followed by irregular period of apnea
  10. Kussmaul's respiration
    • respirations are abnormally deep, regular and increased in rate
    • (ketoacidosis)
  11. 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
  12. hypoventilation
    • respiratory rate is abnormally low and depth of ventilation is depressed
    • hypercarbia sometimes occurs
  13. hyperventilation
    • rate and depth of respirations increase
    • hypocarbia sometimes occurs
  14. apnea
    • respirations cease for several seconds
    • persistant cessation results in respiratory arrest
  15. hyperpnea
    • respirations are labored, increased in depth and increased in rate
    • occurs normally during exercise
  16. tachypnea
    rate of breathing is regular but abnormally rapid
  17. bradypnea
    rate of breathing is regular but abnormally slow
  18. factors influencing the character of respirations
    • exercise
    • acute pain
    • anxiety
    • smoking
    • body position
    • medications
    • neurological injury
    • hgb function
  19. perfusion
    • the circulation of blood through tissues
    • distribution of RBC's to and from the pulmonary capillaries
  20. diffusion
    movement of O2 and CO2
  21. Ventilation
    • external- exchange of O2 and CO2 at the alveolar level
    • internal- exchange of O2 and CO2 at the cellular level
  22. 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
  23. 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
  24. rythym
    • regular
    • irregular- (dysrhythmia) an interruption in successive beats
  25. pulse deficit
    • difference between apical and radial rate
    • need two nurses
  26. rate
    how fast
  27. character of the pulse
    • rate
    • rhythm
    • strength
    • equality
  28. 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
  29. 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
  30. factors influencing pulse rate
    • exercise
    • temperature
    • emotions
    • drugs
    • hemorrhage
    • postural changes
    • pulmonary conditions
    • age
    • rest and sleep
    • dehydration
    • vomiting
    • head injury
    • electrolyte imbalance
  31. pulse sites
    • temporal
    • carotid
    • apical
    • brachial
    • radial
    • ulnar
    • femoral
    • popliteal
    • posterior tibial
    • dorsalis pedis
  32. stroke volume
    volume of blood ejected from the left ventricle and entering the aorta
  33. cardiac output
    • volume of blood pumped by the heart in one minute
    • the product of the heart rate and the stroke volume
  34. pulse
    • palpable bounding of blood flow in the peripheral arteries
    • an indicator of circulatory status
    • pulse rate: # of pulsing sensations occurring in one minute
  35. frostbite
    body exposed to subnormal temps and ice crystals form inside the cell with permanent circulatory and tissue damage
  36. heat exhaustion
    • profuse diaphoresis results in excess water and electrolyte loss
    • normal pulse
    • decreased BP
  37. 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
  38. relapsing fever
    periods of febrile episodes and periods with acceptable temp. values, febrile episodes and periods of normothermia are often longer than 24hrs
  39. remittent fever
    fever spikes and falls without a return to normal temp levels
  40. intermittent fever
    fever spikes interpersed with usual temp levels, temp returns to acceptable value at least once in 24hrs
  41. sustained fever
    constant body temp continuously above 38*C (100.4*F) that has little fluctuation
  42. pyrogen
    triggers the immune system to produce and conserve heat
  43. pyrexia
  44. surface temperature
    • skin
    • oral
    • axillae
  45. 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
  46. 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
  47. average temperatures
    • oral & tympanic: 37* C (98.6*F)
    • rectal: 37.5*C (99.5*F)
    • axillary: 36.5*C (97.7*F)
  48. 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
  49. vital signs
    • temperature
    • pulse
    • respirations
    • oxygen saturation
    • blood pressure
    • (pain)
Card Set
ch. 33
Vital Signs