| Term | Definition |
|---|
| Vitals in General | Nursing intervention on medical. Tells us cardiovascular system functions as well as respiratory system and temperature. |
| When Do You Take Them? | Establish baseline upon admission, home care visit, pre/post op, administration of blood products, administration of meds that afeect heart, lungs, temp., change in condition |
| Temperature | Body temp is the difference between heat produced and heat loss (norm = 36-38 C) |
| Febrile | fever, increase in body temp |
| Afebrile | no temp |
| Factors That Affect Body Temp | Age, exercize, hormone levels, circadian rhythm (higher @ night), environment |
| Releiving/Reducing Fever | Antipyretics (tylenol, motrin), minimize heat production, O2 if needed, Fluids! (w/ sweating you need to replace fluids lost), promote comfort |
| Procedure for Temp | Oral (98.6), rectal (99.5), Tympanic (98.6), axillary (97.7), temporal |
| Hypothermia | Temp below 96.8 |
| Hyperthermia | Temp as high as 113 |
| Pyrexia | Temp not harmful if below 102.2 |
| Pulse | Taken over a peripheral artery (carotid-neck, radial-wrist, posterior tibial-inside ankle, dorsalis pedis, femoral-inside thigh, brachial). Regulated by the ANS through the SA node of heart. |
| Pulse Ranges | Diminishes from childbirth to adulthood. Infant/child 120-160bpm and adult 60-100bpm |
| Length of Measurement - Pulse | 30 sec (x2) and a full 60 sec if abnormal |
| Characteristics of a Pulse | rate, rhythm, strength, equality |
| Tachycardia | High heart rate (>100) |
| Bradycardia | Low heart rate (<60) |
| Dysrhythmia | Abnormalities in an otherwise normal pulse |
| Apical-Radial Pulse | Taking the apical and radial pulse at the same time, need two people |
| Pulse Deficit | The different between the apical pulse and the radial pulse when there is an incongruity. |
| Respriations | Assessment of ventilation and the movement of gasses in and out of the lungs. In COPD, low O2 becomes the stimulus to breat! |
| Process for Assessing Respirations | Client is unaware, rate, depth (shallow, deep, normal), rhythm |
| Factors Influencing Respiration | Exercize, acute pain, anxiety, smoking, body position, meds, neurological injury, hemoglobin |
| Kussmauls | Deep, regular breathing |
| Hyperpnea | Deep and fast breathing |
| Eupnea | Normal breathing |
| Tachypnea | Fast breathing |
| Apnea | No respirations at all |
| Dyspnea | Difficulty breathing |
| Orthopnea | Easier to breath sitting up |
| Cheyne-Stokes | Alternating periods of apnea and hyperventilation (usually end of life) |
| Blood Pressure | The force of the heart against an artery |
| Influences of B/P | Lower when young increase with age, stress, ethnicity (african american have higher b/p), gener, medications, weight/excersize, smoking, white coat syndrome |
| Sphygmomanometer | Cuff |
| Karotkoff Sounds | The sounds heard during a B/P reading, not the lubdub |
| Systolic | When the heart is contracting. The maximum arterial pressure during contraction of the left ventricle of the heart. |
| Diastolic | The minimum arterial pressure during relaxation and dilatation of the ventricles of the heart when the ventricles fill with blood. |
| Pulse Oximetry | Measures the level of hemoglobin or concentration of oxygen in the blood. |
| Measuring Pain (PQRSTU) | Palliative (what makes it better) vs. provocative (what makes it worse), Quality, Region/radiation, Scale, Timing, How does it affect yoU! |
| Pain Rating Scales | Numeric, visual analog, McGill pain questionnaire |
| Shift Assessment | ABC'S (Airway, Breathing, Circulation, Safety), vital signs, pain assessment, mental status, pt priorities, assessment of tubes, dressings, equipment, monitors, and a plan for the day. |
Combine with other sets
Share on Facebook
Share on MySpace