1
Q
What is the normal body temperature range?
A
36-38 degrees C
2
Q
Body Temperature =
A
Heat produced – heat lost
3
Q
What is the center for controlling body temperature?
A
Hypothalamus
4
Q
What are the core temperature sites?
A
Rectum Tympanic Membrane Esophagus Pulminary Artery Urinary Bladder
5
Q
Factors that affect body temperature.
A
PHYSIOLOGICAL & BEHAVIORAL MECHANISMS,
BASAL METABOLIC RATE, PERIPHERAL VASODILATION,
LACK OF SWEAT GLANDS, DIAPHORESIS (PROFUSE SWEATING), FEVER,
EXTERNAL ENVIRONMENT
6
Q
How do you convert celsius to farenheit?
A
1.8 * 37 (temp in C) +32 (number) you alwawys add
7
Q
How do you convert farenheit to celsius?
A
98.6(temp in F) - 32 (number) you always subtract/ 1.8
8
Q
Contraindications with rectal temperature.
A
Never use on someone with diarrhea, rectal surgery, rectal disorders, or bleeding tendencies.
Should not be used on newborns.
9
Q
What position would you put a patient in for rectal temp?
A
Position left side in sims.
10
Q
What things are to be considered when taking rectal temp?
A
•Requires special positioning, may be embarrassing (make sure the area is private)
•Impacted stool alters reading
•Risk of exposure to body fluids
•Lubrication is required
* Always wear gloves
* Explain rationale from a safety perspective
*Safety considerations
11
Q
What are Tympanic membrane- disadvantages
A
- More variable with this device than other core temp devices
- Hearing aids must be removed cannot be used if surgery of the ear or tympanic membrane
- Readings are altered by cerumen impaction and otitis media
- Probe cover comes only in one size
- Does not accurately measure temp changes during and after exercise
- Positioning the device correctly is difficult in newborns, infants and children younger than 3 years old
- Inaccuracies result from incorrect positioning
- Readings are affected by ambient temperature devices such as incubators, radiant warmers, and fans
12
Q
What are the Tympanic membrane- Advantages
A
- Easily accessible, minimal client repositioning required
- Obtained without disturbing or waking client
- Provides core reading, inasmuch as the eardrum is close to the hypothalamus
- Measurement is rapid (2 to 5 seconds)
- Unaffected by oral intake of foods fluids or smoking
- Can be used for tachypneic clients without affecting breathing
- Can be used for newborns to reduce handling of infants & heat los
13
Q
What are the surface temperature sites?
A
Skin, Oral cavity, Axilla
14
Q
What are the advantages in skin site tempature?
A
- Inexpensive
- provides continues reading
- safe
- noninvasive
15
Q
What are the disadvantages in skin site tempature?
A
- lags behind other sites during temp changes
- diaphoresis can impair adhesion
- can be affected by environmental temperature
16
Q
What is Pyrexia?
A
A TECHNICAL NAME FOR A FEVER
17
Q
What is Hypothermia
A
A REDUCTION OF BODY TEMPERTAURE TO SLOW METABOLIC PROCESS
18
Q
What is Hyperthermia
A
AN EXTERMLY HIGH FEVER
19
Q
What is Febrile
A
PERTAINING TO FEVER
20
Q
What is hyperpyrexia
A
WITH A TEMPERTURE OF 41 C or MORE
21
Q
What is Afebrile
A
WITHOUT FEVER
22
Q
What is pulse rate?
A
the number of pulsing sensations occuring in one minute
23
Q
What indirectly evaluates the heart’s cardiac output?
A
Pulse rate, rhythm, & strength. (regular VS irregular)
24
Q
What does peripheral pulse indicate?
A
The status of blood perfusion to the area.
25
What is the most commonly used site for pulse?
The radial artery
26
If the radial artery is weak or hard to find you?
Palpate the carotid artery.
27
What factors raise your pulse rate?
* emotional reasons
* caffine
* exercise
* alcohol
* certain medications
* shock (blood/volume loss)
* fever
28
What factors decrease your pulse?
* Valsalva Maneuver
* Certain medications
* beta blockers
* depressants
29
What is the purpose of measuring a pulse?
Measuring the pulse can give very important information about your health. Any change from normal heart rate can indicate a medical condition. Fast pulse may signal an infection or dehydration. In emergency situations, the pulse rate can help determine if the patient's heart is pumping.
30
What are the two (2) most commonly used sites when measuring heart rate in adults?
Two most commonly used sites: wrist (radial) and chest (apical).
31
What is pulse deficit?
PULSE DEFICIT: the difference between the heart rate and the pulse rate in atrial fibrillation. It is checked by:
•One person measures apical pulse with stethoscope
•Second person measures pulse at radial site at same time
•Measure both pulses for 1 full minute
•Subtract radial pulse from apical pulse rate
•Difference is pulse deficit
32
State the rationale for assessing the following prior to taking a client’s pulse:
a) Emotional and activity level:
b) Colour and warmth if taking pedal pulse:
c) Facial pallor and cyanosis:
Xx
33
What is Tachycardia?
heart rate that exceeds normal range
34
What is Bradycardia?
heart rate that is below normal range
35
What is Pulse Amplitude?
is the transmission of data by varying the amplitudes (volyage or power levels) of the imdividual pulses in a regular timed sequence of electrical pluses
36
What is Pulse Contour?
The wave of a pulse
37
What is Dysrhythmia?
Abnormality in a physiological rhythm, esp. in the activity of the brain or heart.
38
What is Ventilatory pattern?
A specific combination of control variable and breath sequence.
39
What is Hyperventilation?
an increased depth and rate of breathing greater than demanded by the body needs; can cause dizziness and tingling of the fingers and toes and chest pain if continued
40
What is Hypoventilation?
Breathing at an abnormally slow rate, resulting in an increased amount of carbon dioxide in the blood.
41
What is Tachypnea?
Abnormally rapid breathing
42
What is Bradypnea?
Abnormally slow breathing
43
What is Eupnea?
Normal, relaxed breathing
44
What is Dyspnea?
Difficulty, or labored breathing.
45
What is Orthopnea?
Form of dyspnea in which the person can breathe comfortably only when standing or sitting erect; associated with asthma and emphysema and angina pectoris
46
What is Apnea?
Temporary cessation of breathing
47
What is the purpose in assessing a patient’s pulse oximetry/oxygen saturation levels?
Measurement of respiratory rate, pattern, depth along with SpO2 enables you to assess ventilation, diffusion, & perfusion.
48
What factors affect oxygen saturation?
Outside light sources
· Carbon monoxide from smoking or poisoning
· Movement
· Jaundice
· Intravascular dyes
· Polish or artificial nails
· Dark skin pigment
49
What is blood pressure?
Blood pressure is the force of blood against the walls of arteries. Blood pressure is recorded as two numbers—the systolic pressure (as the heart beats) over the diastolic pressure (as the heart relaxes between beats).
49
What is the purpose of assessing blood pressure?
We monitor the blood pressure frequently because small changes in the pressure readings over a period of time can give us clues about the cardiovascular and respiratory health of the patient.
50
What are the various factors can affect blood pressure? How do these factors affect BP?
age-pulse decreases from birth to adulthood then increases with advancing old age
gender -women have slightly faster pulse rate then men
race -hypertension is common with certain ethnic groups such as south asian, aboriginal, & black canadian
diurnal rhythm - ???
Weight - obesity is a factor in hypertension
exercise -the heart must beat faster to meet the increased demand for oxygen
emotion - fear, anger, anxiety, & excitement increase the pulse rate
51
What does the brain stem regulate?
the involuntary control of respirations
52
What are the three processes of respirations?
Ventilation, diffusion, and perfusion
53
What is ventilation?
It is regulated by levels of CO2, O2 & pH in the arterial blood, it is also the mechanical movement of gases into and out of the lungs
54
What is perfusion?
the distribution of RBCs to and from the pulmonary capillaries
55
What are normal respirations in adults?
12-20 times a minute
56
What are normal respirations in newborns?
30-60 times a minute
57
What are normal respirations in children?
20-30 times a minute
58
What are normal respirations in older adults?
16-25 times a minute
59
The assessment of ventilation (the movement of gasses in and out of the lungs) involves?
respiratory rate
respiratory depth
respiratory rhythm
60
Which device can assess diffusion and perfusion?
O2 Saturation monitor which is called an arterial O2 saturation monitor
61
What is systemic or arterial BP?
It is the force exerted on the walls of an artery pulsing blood under pressure from the heart.
62
What is systolic BP?
It is the peak of maximum pressure ejected.
63
What is diastolic BP?
It is the minimal pressure exerted on the arterial walls at all times.
64
What is pulse pressure?
It is the difference between the two i.e. 120/80
| the pluse pressure is 40
65
What is BP measured in?
milimeters of mercury.
66
What does assessing BP reflect?
The interrelationships of cardiac output, peripheral valcular resistance, blood volume, blood viscosity & artery elasticity.
67
What is Korotkoff's sounds?
The first Korotkoff sound is a clear rhythmical tapping that corresponds to the pulse rate and gradually increases in intensity. Onset of the sound corresponds to the pulse rate and gradually increases in intensity. A blowing or swishing sound occurs as the cuff continues to deflate; this is the second sound. The third sound is crisper and more intense tapping. The fourth sound is muffled & low pitched as the cuff is further deflated. The fifth sound is the disappearance of sound.
68
What is Hypotension?
Is considered present when the systolic blood pressure falls to 90mm Hg or lower.
69
What is Hypertension?
The most common alteration in blood pressure. hypertension is when diastolic reading is higher than 90mm Hg and the systolic readings higher than 140 mmHg
70
What is Orthostatic hypotension?
Occurs when a normotensize person ( a person with normal blood presssure) develops symptoms of low BP when rising to an upright position. also known asWhat is Postural hypotension
71
What factors can affect an improper read in BP?
* BP cuff is placed over shirt
* BP is taken while patient is talking or just had a cigarette
* Patient has anxiety (White Coat Hypertension)
* arm is not at heart level
72
What is the common noninvasive method used to measure BP?
sphygomomanometer & stethoscope
73
What is the normal pulse?
Between 60-100 BPM
74
What is normal O2 Saturation (Sat)
90-100%
75
What is normal Blood Pressure (BP)
120/80
76
What are the steps to taking BP?
* Put on BP cuff
* Find radial pulse
* Pump you don't feel pulse, mark number
& add 30
*release valve and let all air out
* straighten arm & find bracial pulse
*pump till you go past the number and the 30 mark
*then super slowly release the valve till you hear the first heartbeat-(systolic)mark number & then mark number at the last beat.Diastolic
77
State the rational for the following nursing actions:
a) place the client's arm at heart level, palm up.
b) palpate the brachial artery. Position cuff 2.5 cm above the brachial pulse. Center cuff above artery.
a) place client’s arm at heart level, palm up
** if the brachial artery is lower then the heart, blood pressure could increase by 10 mmHg. If higher then the heart then blood pressure will decrease as much as 10 mm Hg.
b) palpate the brachial artery. Position cuff 2.5 cm above the brachial pulse. Centre cuff above artery
**Inflating bladder directly over the artery ensures that proper pressure is applied during inflation.
c) after inflating the cuff to find point at which brachial pulse disappears, wait 30 seconds before re-inflating the cuff
**to allow the pressure to build up again.
78
What is Ausculatory gap?
In some hypertensive clients, the sounds usually heard over the brachial artery when the cuff pressure is high dissapear as pressure is reduced, then they reappear at a lower level. this temp disappearance is known as the ausculatory gap.
79
When would you take a client's blood pressure on his thigh? How do they vary from the arm?
Dressings, casts, intravenous catheters or arteriovenious fistulas or shunts can render the upper extremities inaccessible. In such cases blood pressure is taken from the thigh.
How do blood pressure readings taken on the thigh vary from those taken on the arm?
** Blood pressure reading can vary because systolic pressure is usually higher by 10-40mm Hg then in the brachial artery, but the diastolic pressure is the same.
80
What is white coat hypertension?
High blood pressure from being in a clinical setting.
81
What is the conversion factor to convert kilo's to pounds?
kg x 2.2 = pounds
83
What is the purpose for assessing height & weight?
Weight is the basis for determining drug dosage, limitations on caregiver lifting, or plan or care for position changes. Height is taken for growth and development
84
Discuss some common errors in blood pressure readings.
* Bladder or cuff is too wide – false low reading
* Bladder or cuff is too narrow or too short – false high reading
* Cuff wrapped to loosely or unevenly false high reading
* Deflating cuff to slowly- fast high diastolic reading
* Deflating cuff to quickly – false low or false high reading
* Arm below heart level – false high reading
* Arm above heart level – false low reading
* Arm not supported – false high reading
* Stethoscope applied to firmly – false low diastolic reading
* Cuff inflating too slowly – false high diastolic reading
* Repeating assessments too quickly – false high systolic
* Inadequate inflation – false low systolic
Nursing Practice 2
flashcards
Decks in class (4)
# Cards
