Ch 17

One of the most frequent assessments you will make as a nurse

Typical timeframe to check vital signs in a hospital

Typical timeframe to check vital signs in the ICU

Typical timeframe to check vital signs in a SNF

What are the 6 main vital signs to check, depending on what type of patient you are caring for?

Why can't we take a surface temperature, and rely on it's accuracy?

Degree of heat maintained by the body / Heat produced minus heat lost

Normal core temperature range in Farenheit and Celcius

In regards to temperature : Transfer of heat from a warm to a cool surface by direct contact

In regards to temperature : Transfer of heat through currents of air or water

In redards to temperature : Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air

In regards to temperature : Water is converted to vapor and lost from the skin (perspiration) or the mucous membranes (through the skin)

What is pyrexia?

Pyrexia occurs in response to

___ induce secretion of substances (prostaglandins)that reset the hypothalamic thermostat at a higher temperature.

Extreme fever

Core temperature below normal / associated with extended exposure to the cold

(TEMP) Initial- febrile episode: 3 characteristics

(TEMP) Second- course of fever: 2 characteristics

(TEMP) Third- course - defervescence or crisis: 4 characteristics

Temperature alternates between periods of fever, normal and below-normal

Wide fluctuations in temperature; All above normal

Temp may fluctuate slightly; Always above normal

Short periods of elevation alternating with normal temperature

Core temperature below normal (< 96.80 or 360 C); Associated with exposure to cold

The nurse would monitor the body temperature most closely/frequently in the care of:
A) The client with an infection
B) The client who has experienced heat stroke
C) The client who is an infant
D) The client with a head injury

Why would a patient with a head injury need closer monitoring for their temperature?

The “wave” that begins when the left ventricle contracts and ends when the ventricle relaxes

In regards to pulse, blood is forced into the already-filled aorta:

Peak of the wave or contraction of the heart

Rough or resting phase of the heart

Pulse rate is measured in ___ ___ ___

An ___ ___ is the heartbeat at the apex of the heart and is heard with a stethoscope.

True or false: The apical pulse is the most accurate location to measure a patient's pulse.
True False

A heart beat is one series of the ___ and ___ sounds.

Pulse point at the apex of the heart

Pulse point between midline and side of neck

Pulse point located medially in the antecubital space

Pulse point located laterally on the anterior wrist

Pulse point located in the groin fold

Pulse point located behind the knee

Slow heart rate (<60 BPM)

Fast heart rate (>100 BPM)

What could a thready pulse indicate?

Quantity of blood pumped out by each contraction of the left ventricle

Stroke volume X pulse (heart) rate

If circulation is compromised, ___ or ___ may be present.

Paleness of skin when compared with another part of the body

A bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood

80 year old patient with cool feet, and a weak, thready pulse in the dorsalis pedis pulse points. The nurses next would be to:
A) Apply a warm pack and reassess in 20 minutes
B) Assess a 1 minute apical pulse
C) Notify the physician stat
D) Assess the popliteal and femoral pulses

The exchange of oxygen and carbon dioxide in the body

What are the 2 processes to respiration?

Type of respiration: breathing; active movement of air in and out of the respiratory system

Type of respiration: Exchange and transport of oxygen and carbon dioxide throughout the body; Exchange of gases between the capillaries and tissues

What is the average respiration rate?

Drawing air into the lungs; Involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs

Relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs

3 RATE variations in respiration:

Cessation of breathing

Abnormally slow respiration

Abnormaly fast respiration

2 DEPTH variations in respiration:

Assessment of the pattern of respirations

An abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea.

An abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea

Work of breathing

Labored breathing

Inability to breathe when horizontal

High-pitched continuous musical sounds, usually heard on expiration

Low-pitched continuous sounds caused by secretions in the large airways

Discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds

A piercing, high-pitched sound heard primarily during inspiration

How well the cells, tissues, and organs are supplied with oxygen

Inadequate oxygen levels in the tissues and organs

Low alveolar-capillary oxygenation

The circulation of blood to all body regions

8 signs of decreased oxygenation:

Movement of air into and out of the lungs to maintain appropriate O₂ and CO₂ levels

Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea); Client may complain of feeling light-headed and tingly

The rate and depth of respirations are decreased and CO is retained; may lead to hypoxia

5 factors influencing oxygenation:

Developmental stage (oxygenation) - risk for atelectasis, infection, and airway obstruction (choking)

Developmental stage (oxygenation) - risk for infection and airway obstruction

Developmental stage (oxygenation) - risk for respiratory disorders (cigarette smoking)

Developmental stage (oxygenation) - smoking & lack of exercise

Developmental stage (oxygenation) - risk for respiratory infections

Developmental stage (oxygenation) - Reduced lung expansion and less alveolar inflation

Developmental stage (oxygenation) - Difficulty expelling mucus or foreign material

Developmental stage (oxygenation) - Diminished ability to increase ventilation

Developmental stage (oxygenation) - Declining immune response

Environmental factor (oxygenation) - increases risk for infection

Environmental factor (oxygenation) - airway edema and spasms leading to difficulty breathing

Environmental factor (oxygenation) - pollutants interfere with oxygenation

Environmental factor (oxygenation) - increases oxygenation (requires more)

Environmental factor (oxygenation) - reduces O₂demand

What are the 3 "other factors" that can effect oxygenation:

In regards to oxygenation, ABG = ?

What are the 3 components to assessing a patient's oxygenation status?

A device used to deliver oxygen to a patient - consists of a plastic tube that fits behind both ears and two prongs that fit in the nostrils

A device that delivesr a known oxygen concentration to patients on controlled oxygen therapy; high-flow oxygen therapy; aka Air Entrainment masks

Provides oxygen to the mouth without discomfort to the nose and mouth; open around the mouth & preferred by clostrophobic patients; used with traums and burn patients; open mask

Similar to a simple face mask, however, the side ports are covered with one-way discs to prevent room air from entering the mask; patient rebreaths some of exhaled air

Similar to a simple face mask but has multiple one-way valves in the side ports. These valves prevent room air from entering the mask but allow exhaled air to leave the mask; Only external device delivering 100% oxygen

What are the 6 oxygen delivery devices for low oxygenation?

Artificial airways used in unconscious patients

Artificial airways that could be used in semiconscious patients

Artificial airways used in patients that are unable to breathe or who are at risk for obstructed airways

Directly measures the partial pressures of oxygen, carbon dioxide, and blood pH

Noninvasive method of monitoring respiratory status; Uses an external device that measures oxygen saturation

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

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

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

A widening pulse pressure is indicitative of a ___ problem.

The difference between the systolic and diastolic pressures

BP regulation is influenced by 3 factors:

The body constantly regulates and adjusts arterial pressure in order to supply blood to body tissues via:

Consists of a vinyl or cloth cuff, a pressure bulb with a regulating valve, and a manometer (blood pressure cuff)

Used to auscultate the systolic and diastolic pressure

Most common method of measuring BP

Method of measuring BP that is very invasive, painful, and requires the assistance of a MD

The thump-thumps you hear when taking BP indirectly

Systolic blood pressure <100 mm Hg

A sudden drop in BP on moving from a lying to a sitting or standing position

BP reading of 120-130 systolic or 80-89 diastolic Obtained with two readings, taken 6 minutes apart, with the client sitting

BP persistently higher than normal; Diagnosed when BP is >140 mm Hg systolic or >90 mm Hg diastolic on two or more separate occasions

Increases the stress on the heart and blood vessels; left untreated it may lead to heart attack, heart failure, peripheral vascular disease, kidney damage, or stroke

Diagnosed when there is no known cause for the increase; Accounts for at least 90% of all cases of hypertension

As a result of a disease process; Example- renal hypertension