Chapter 29 - Vital Signs
Transcript of Chapter 29 - Vital Signs
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Basal metabolic rate
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The heat produced by the body at absol
rest
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Blood pressure is reflected by the follow
Briefly explain each.
Blood volume
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The volume of blood circulating within
vascular system affects blood pressure
which normally remains constant
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Blood pressure is reflected by the follow
Briefly explain each.
Cardiac output
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Cardiac output increases as a result of an
increase in heart rate, greater heart musc
contractility, or an increase in blood volu
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Blood pressure is reflected by the follow
Briefly explain each.
Elasticity
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With reduced elasticity, there is greate
resistance to blood flow, and the system
pressure rises (systolic pressure)
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Blood pressure is reflected by the follow
Briefly explain each.
Peripheral resistance
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Peripheral resistance is the resistance to
blood flow determined by the tone of
vascular musculature and diameter of blo
vessels
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Blood pressure is reflected by the follow
Briefly explain each.
Viscosity
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Viscosity is the thickness that affects the
ease with which blood flows through bloo
vessels, determined by the hematocrit
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Briefly explain the following alterations
breathing patterns.
Apnea
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Respirations cease for several second
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Briefly explain the following alterations
breathing patterns.
Biot
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Biot respirations are abnormally shallow
two to three breaths followed by irregu
period of apnea
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Briefly explain the following alterations
breathing patterns.
Bradypnea
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Rate of breathing is regular but slow; 20 breaths/mi
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Briefly explain the following alterations
breathing patterns.
Hyperventilation
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Rate and depth of respirations increas
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Briefly explain the following alterations
breathing patterns.
Hypoventilation
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Respiratory rate is abnormally low, an
depth of ventilation is depressed
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Briefly explain the following alterations
breathing patterns.
Kussmaul
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Kussmaul respirations are abnormally d
regular and increased in rate
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Briefly explain the following alterations
breathing patterns.
SaO2
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Sa02 is the percentage of hemoglobin th
bound with oxygen in the arteries is the
percent of saturation of hemoglobin; nor
range is usually between 95% and 100%
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Briefly explain the following alterations
breathing patterns.
Tachypnea
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Rate of breathing is regular but rapid; >
breaths/min
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Category: Normal
Systolic: ?
Diastolic: ?
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Systolic:
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Category: Prehypertension
Systolic: ?
Diastolic: ?
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Systolic: 120-139
Diastolic: 80-89
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Category: Stage 1 hypertension
Systolic: ?
Diastolic: ?
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Systolic: 140-159
Diastolic: 90-99
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Category: Stage 2 hypertension
Systolic: ?
Diastolic: ?
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Systolic: >_160
Diastolic: >_100
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Conduction
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Transfer of heat from one object to anot
with direct contact
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Convection
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Transfer of heat away by air movemen
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Core temperature
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Temperature of the deep tissues
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Define auscultatory gap
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In some patients with hypertension, the
sounds usually heard over the brachialartery when the cuff pressure is high
disappear as pressure is reduced and the
reappear at a lower level. This temporarydisappearance of sound is the auscultato
gap,
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Define the following term.
Bradycardia
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Bradycardia is a slow rate (
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Define the following term.
Dysrhythmia
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A dysrhythmia is an abnormal rhythm
including early, late or missed beats
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Define the following term.
Pulse deficit
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Pulse deficit is an inefficient contraction
the heart that fails to transmit a pulse wa
to the peripheral site; it is the difference
between the apical and he radial pulse ra
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Define the following term.
Tachycardia
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Tachycardia is an abnormal elevated he
rate (>100 beats/min in adults)
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Define the following terms related to
respirations.
Diffusion
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Diffusion is the movement of oxygen a
carbon dioxide between the alveoli and
red blood cells
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Define the following terms related to
respirations.
Hypoxemia
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Hypoxemia is low levels of arterial 02
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Define the following terms related to
respirations.
Perfusion
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Perfusion is the distribution of red bloo
cells to and from the pulmonary capillar
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Define the following terms related to
respirations.
Ventilation
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Ventilation is the movement of gases in
out of the lungs
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Define the following terms.
Blood pressure
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Blood pressure is the force exerted on t
walls of an artery by the pulsing blood un
pressure from the heart
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Define the following terms.
Diastolic pressure
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Diastolic pressure occurs when the ventr
relax; the blood remaining in the arteri
exerts a minimum pressure
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Define the following terms.
Pulse pressure
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Pulse pressure is the difference betwee
systolic and diastolic pressure
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Define the following terms.
Systolic pressure
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Systolic pressure is the peak of maximu
pressure when ejection occurs
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Evaporation
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Transfer of heat energy when a liquid
changed to a gas
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Explain the differences related to febri
states in each of the following.
Children
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Children have immature temperature-control mechanisms, so their temperatur
can rise rapidly, and they are at risk for
fluid-volume deficit
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Explain the differences related to febri
states in each of the following.
Hypersensitive response to drugs
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Drug fevers are often accompanied by ot
allergy symptoms such as rash or prurit
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First aid treatment for heatstroke is:
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Move the patient to a cooler environmen
remove excess body clothing; place cool,
towels over the skin; and use fans
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Frostbite
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Occurs when the body is exposed to
subnormal temperatures
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Give an example of each type of fever
therapy.
Nonpharmacologic
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Nonpharmacologic therapy includes tepisponge baths, bathing with alcohol water
solutions, applying ice packs to the axilla
and groin sites, and cooling fans
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Give an example of each type of fever
therapy.
Pharmacologic
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Pharmacologic therapy includes non
steroidal drugs and corticosteroids
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Heat exhaustion
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Profuse diaphoreses with excess water a
electrolyte loss
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Heatstroke
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A dangerous heat emergency
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Hyperthermia
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The body's inability to promote heat los
reduce heat production
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Hypothalamus
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Controls body temperature
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Hypothermia
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Cold that overwhelms the body's ability
produce heat
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Identify at least one teaching consideratithat emphasizes health promotion for the
following vital signs.
Blood pressure
Instruct patients on normal blood pressure value
risk factors for hypertension usual lack of
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risk factors for hypertension, usual lack of
hypertension symptoms, ability of therapy to con
but not cure, and benefits of a consistently followhypertension treatment plan.
Demonstrate how to obtain blood pressure to the
patient's family caregiver using an appropriate-s
blood pressure cuff for home use at the same tim
each day, after patient has had a brief rest, and t
same position and arm each time pressure is tak
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Identify at least one teaching consideratthat emphasizes health promotion for t
following vital signs.
Pulse
Instruct patients on risk factors for hypother
frostbite and heat stroke Demonstrate self-
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frostbite, and heat stroke. Demonstrate self
assessment of heart rate using the carotid pu
Patients taking certain prescribed cardiac
medications need to learn to assess their own
pulse rate to detect side effects of medication
Patients undergoing cardiac rehabilitation neto learn to assess their own pulse rate to
determine their response to exercise.
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Identify at least one teaching consideratithat emphasizes health promotion for the
following vital signs.
Respirations
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Instruct patient on signs and symptoms hypoxemia.
Instruct patient on the effect of cigarette
smoking on oxygen saturation.
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Identify at least one teaching consideratthat emphasizes health promotion for t
following vital signs.
Temperature
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Explain measures to prevent body
temperature alterations
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Identify at least two variations that ar
unique to older adults.
Blood pressure
a. Older adults often have decreased upper arm m
which requires special attention to selection of b
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q p
pressure cuff size.
b. Older adults sometimes have an increase in sypressure related to decreased vessel elasticity wh
the diastolic pressure remains the same, resultin
a wider pulse pressure.
c. Instruct older adults to change position slowly
wait after each change to avoid postural hypoten
and prevent injuries.
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Identify at least two variations that ar
unique to older adults.
Pulse
a. If it is difficult to palpate the pulse of an obese older ad
Doppler device provides a more accurate reading.
b The older adult has a decreased heart rate at rest
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b. The older adult has a decreased heart rate at rest.
c. It takes longer for the heart rate to rise in the older adu
meet sudden increased demands that result from stress, il
or excitement. Once elevated, the pulse rate of an older ad
takes longer to return to normal resting rate.
d. When assessing the apical rate of an older woman, the b
tissue is gently lifted, and the stethoscope placed at the fifintercostal space (ICS) or the lower edge of the breast.
e. Heart sounds are sometimes muffled or difficult to hear
older adults because of an increase in air space in the lung
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Identify at least two variations that ar
unique to older adults.
Respirations
a. Aging causes ossification of costal cartilage and downward slant of ri
resulting in a more rigid rib cage, which reduces chest wall expansion.
Kyphosis and scoliosis that occur in older adults also restrict chest expan
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Kyphosis and scoliosis that occur in older adults also restrict chest expan
and decrease tidal volume.
b. Older adults depend more on accessory abdominal muscles duringrespiration than on weaker thoracic muscles.
c. The respiratory system matures by the time a person reaches 20 years o
and begins to decline in healthy people after the age of 25. Despite this d
older adults are able to breathe effortlessly as long as they are healthy.
However, sudden events that require an increased demand for oxygen (e
exercise, stress, illness) create shortness of breath in the older adult.d. Identifying an acceptable pulse oximeter probe site is difficult with old
adults because of the likelihood of peripheral vascular disease, decreased
cardiac output, cold-induced vasoconstriction, and anemia.
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Identify at least two variations that ar
unique to older adults.
Temperature
a. The temperature of older adults is at the lower end of the normal temperatu
range, 36 to 36.8 C (96.8 to 98.3 F) orally and 36.6 to 37.2 C (98 to 99
rectally. Therefore temperatures considered within normal range sometimes r
fever in an older adult In an older adult fever is present when a single oral
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fever in an older adult. In an older adult fever is present when a single oral
temperature is over 37.8 C (100 F); repeated oral temperatures are over 37.
(99 F); rectal temperatures are over 37.5 C (99.5 F); or temperature has inmore than 1 C (2 F) over baseline
b. Older adults are very sensitive to slight changes in environmental temperat
because their thermoregulatory systems are not as efficient.
c. A decrease in sweat gland reactivity in the older adult results in a higher thr
for sweating at high temperatures, which leads to hyperthermia and heatstrok
d. Be especially attentive to subtle temperature changes and other manifestatifever in this population such as tachypnea, anorexia, falls, delirium, and overa
functional decline.
e. With aging loss of subcutaneous fat reduces the insulating capacity of the sk
men are especially high risk for hypothermia.
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Identify evaluative measures for tempera
alterations
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Body temperature will return to anacceptable range, other vital signs will
stabilize, and the patient will report a se
of comfort
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Identify factors that influence the charac
of respirations and the mechanism of ea
factor (8)
a. Exercise - exercise increases rate and depth to meet the body's need for additional oxygen and to rid thCO2b Acute Pain - pain alters rate and rhythm of respirations; breathing becomes shallow ; Patient inhibits
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b. Acute Pain - pain alters rate and rhythm of respirations; breathing becomes shallow ; Patient inhibitschest wall movement when pain is in area of chest or abdomenc. Anxiety - anxiety increases respiration rate and depth as a result of sympathetic stimulationd. Smoking - chronic smoking changes pulmonary airways, resulting in increased rate of respirations atnot smokinge. Body Position - A straight, erect posture promotes full chest expansion; A stooped or slumped positionventilatory movement; Lying flat prevents full chest expansionf. Medications - opioid analgesics, general anesthetics, and sedative hypnotics depress rate and depth;amphetamines and cocaine sometimes increase rate and depth; bronchodilators slow rate by causing aidilationg. Neurological Injury - injury to brainstem impairs respirator center and inhibits respiratory rate and r
h. Hemoglobin Function - decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the which increases respiratory rate; increased altitude lowers amount of saturated hemoglobin, which incrrespiratory rate and depth; abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemcary oxygen, which increases respiratory rate and depth.
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Identify four nursing diagnoses related
thermoregulation. (4)
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a. Risk for Imbalanced Body Temperatub. Hyperthermia
c. Hypothermia
d. Ineffective Thermoregulation
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Identify seven factors that may increase
decrease the pulse rate. (7)
a. Exercise
b T t
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b. Temperature
c. Emotionsd. Drugs
e. Hemorrhage
f. Postural changesg. Pulmonary conditions
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Identify some of the risk factors for
orthostatic hypotension
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Dehydrated, anemic, experienced prolon
bed rest, recent blood loss, medication
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Identify the acceptable range for respirarates for the following age groups.
Adolescents
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16 to 20
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Identify the acceptable range for respirarates for the following age groups.
Adults
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12 to 20
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Identify the acceptable range for respirarates for the following age groups.
Children
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20 to 30
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Identify the acceptable range for respirarates for the following age groups.
Infants
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30 to 50
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Identify the acceptable range for respirarates for the following age groups.
Newborns
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35 to 40
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Identify the acceptable range for respirarates for the following age groups.
Toddlers
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25 to 32
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Identify the factors that affect body
temperature. (7)
a. Age
b. Exercise
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c. Hormone leveld. Circadian rhythm
e. Stress
f. Environment
g. Temperature alterations (fever, hypertherm
heat stroke, heat exhaustion, hypothermia)
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Identify the following Korotkoff sound
Fifth
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The disappearance of sound (diastoli
pressure in adolescents and adults)
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Identify the following Korotkoff sound
First
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Clear rhythmic tapping corresponding topulse rate that gradually increases in
intensity (systolic pressure)
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Identify the following Korotkoff sound
Fourth
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Muffled and low-pitched as the cuff furtdeflated (diastolic pressure in infants a
children)
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Identify the following Korotkoff sound
Second
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Blowing or swishing sound as the cuf
deflates
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Identify the following Korotkoff sound
Third
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A crisper and more intense tapping
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Identify the guidelines that assist the nuwith incorporating vital sign measurem
into practice. (12)
a. The nurse may delegate the measurement of vital signs but is responsible fo
analyzing and interpreting their significance and select appropriate interventi
b. Equipment needs to be appropriate and functional
c. Equipment needs to be based on the patient's condition and characteristics
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q p p
d. Know the patient's usual range of vital signse. Know the patient's medical history
f. Control or minimize environmental factors
g. Use a systematic approach
h. Collaborate with health care providers to decide on the frequency
i. Use measurements to determine the indications for medication administrat
j. Analyze the resultsk. Verify and communicate significant changes with the patient's health care p
l. Develop a teaching plan
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Identify the measurement criteria for tfollowing pulse sites.
Apical
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Fourth to fifth intercostal space at lef
midclavicular line
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Identify the measurement criteria for tfollowing pulse sites.
Brachial
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Groove between biceps and triceps mus
at antecubital fossa
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Identify the measurement criteria for tfollowing pulse sites.
Carotid
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Along medial edge of sternocleidomastmuscle in neck
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Identify the measurement criteria for tfollowing pulse sites.
Dorsalis pedis
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Along top of foot, between extensiontendons of great and first toe
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Identify the measurement criteria for tfollowing pulse sites.
Femoral
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Below inguinal ligament, midway betwesymphysis pubis and anterior superior i
spine
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Identify the measurement criteria for tfollowing pulse sites.
Popliteal
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Behind knee in popliteal fossa
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Identify the measurement criteria for tfollowing pulse sites.
Posterior tibial
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Inner side of ankle, below medial malleo
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Identify the measurement criteria for tfollowing pulse sites.
Radial
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Radial or thumb side of forearm at wri
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Identify the measurement criteria for tfollowing pulse sites.
Temporal
l l b f h d b
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Overal temporal bone of head, above alateral to eye
d if h i i f
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Identify the measurement criteria for tfollowing pulse sites.
Ulnar
Ul id f f i
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Ulnar side of forearm at wrist
Id if h i l bl d f
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Identify the optimal blood pressure for following ages.
1 month
8 / H
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85/54 mm Hg
Id tif th ti l bl d f
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Identify the optimal blood pressure for following ages.
1 year
/6 H
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95/65 mm Hg
Id tif th ti l bl d f
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Identify the optimal blood pressure for following ages.
6 years
/6 H
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105/65 mm Hg
Id tif th ti l bl d f
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Identify the optimal blood pressure for following ages.
10 to 13 years
110/65 H
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110/65 mm Hg
Identify the optimal blood pressure for
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Identify the optimal blood pressure for following ages.
14 to 17 years
119/75 mm Hg
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119/75 mm Hg
Identify the optimal blood pressure for
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Identify the optimal blood pressure for following ages.
Newborn
40 (mean) mm Hg
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40 (mean) mm Hg
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Identify the optimal blood pressure for following ages.
Older than 18 years
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Identify the patients who are at risk fohypothermia.
Those at risk include the very young and
very old; persons debilitated by trauma,
stroke, or diabetes; those who are
intoxicated by drugs or alcohol; patients
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intoxicated by drugs or alcohol; patientswith sepsis; and those who have inadequ
home heating and shelter. Fatigue, dark
color, malnutrition; and hypoxemia alsoincrease the risk
Identify the two common sites to assess
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Identify the two common sites to assess pulse rate, (2)
a Radial
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a. Radialb. Apical
Identify which phase of respirations is acd h h
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Identify which phase of respirations is acand which is passive.
Expirations
Passive
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Passive
Identify which phase of respirations is acd hi h i i
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Identify which phase of respirations is acand which is passive.
Inspiration
Active
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Active
List at least one advantage and one
disadvantage of each of the following
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disadvantage of each of the followingtemperature sites.
Axilla
A~
a. Safe and inexpensive
b. Used with newborns and unconscious patients
D~
a. Long measurement timeb Underestimates core temperature
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b. Underestimates core temperature
c. Requires continuous positioning by nurse
d. Measurement lags behind core temperature during rapid temperature c
e. Not recommended to detect fever in infants and young children
f. Requires exposure of thorax, which results in temperature loss, especia
newbornsg. Affected by exposure to environment, including time to place thermom
List at least one advantage and one
disadvantage of each of the following
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disadvantage of each of the followingtemperature sites.
Oral
A~a. Easily accessible - requires no position change
b. Comfortable for patient
c. Provides accurate surface temperature reading
d. Reflects rapid change in core temperature
e. Reliable route to measure temperature in patients who are intubated
D
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D~
a. Causes delay in measurement if patient recently ingested hot/cold fluid
foods, smoked, or is receiving oxygen by mask/cannula
b. Not for patients who had oral surgery, trauma, history of epilepsy, or s
chillsc. Not for infants, small children, or patients who are confused, unconsc
uncooperative
d. Risk of body fluid exposure
List at least one advantage and one
disadvantage of each of the following
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disadvantage of each of the followingtemperature sites.
Rectal
A~a. Sometimes considered to be more reliable when oral temper
cannot be obtained
D~
a. Lags behind core temperature during rapid temperature ch
b. Not for patients with diarrhea, rectal disorders, or bleedingtendencies or those ho had rectal s rger
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tendencies or those who had rectal surgery
c. Requires positioning and is often source of patient embarras
and anxiety
d. Risk of body fluid exposure
e. Requires lubricationf. Not for routine vital signs in newborns
g. Readings influenced by impacted stool
List at least one advantage and one
disadvantage of each of the following
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d s d ge o e c o e o o gtemperature sites.
Skin
A~
a. Inexpensive
b. Provides continuous reading
c. Safe and noninvasive
d. Used for neonatesD
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D~
a. Measurement lags behind other sites during temperatu
changes, especially during hyperthermia
b. Adhesion impaired by diaphoresis or sweat
c. Reading affected by environmental temperature
d. Cannot ne used for patients with allergy to adhesive
List at least one advantage and one
disadvantage of each of the following
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g gtemperature sites.
Temporal artery
A~a. Easy to access without position change
b. Very rapid measurement
c. No risk of injury to patient or nurse
d. Eliminates need to disrobe or be unbundled
e. Comfortable for patient
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f. Used in premature infants, newborns, and children
g. Reflects rapid change in core temperature
h. Sensor cover not required
D~a. Inaccurate with head covering or hair on forehead
b. Affected by skin moisture such as diaphoresis or sweati
List at least one advantage and one
disadvantage of each of the following
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g gtemperature sites.
Tympanic
A~a. Easily accessible siteb. Minimal patient repositioning requiredc. Obtained without disturbing, waking, or repositioning patientsd. Used for patients with tachypnea without affecting breathinge. Provides accurate core reading because eardrum close to hypothalamus; sensitive to core temperaturef. Very rapid measurement (2 to 5 seconds)g. Unaffected by oral intake of food or fluids or smoking
h. Used in newborns to reduce infant handling and heat lossD~a. More variability of measurement than with other core temperature devices
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a. More variability of measurement than with other core temperature devicesb. Requires removal of hearing aids before measurementc. Requires disposable sensor cover with only one size availabled. Otitis media and cerumen impaction distorts readingse. Not used in patients who have had surgery of the ear or tympanic membranef. Does not accurately measure core temperature changed during and after exerciseg. Does not obtain continuous measurementh. Affected by ambient temperature devices such as incubators, radiant warmers, and facial fansi. When used in neonates, infants, and children under 3 years old, use care to position device correctly becanatomy of ear canal makes it difficult to positionj. Inaccuracies reported caused by incorrect positioning of handheld unit
List eight factors that influence blood(8)
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gpressure. (8)
a. Ageb. Stress
c. Ethnicity
d. Gender
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e. Daily variations
f. Medications
g. Activity and weighth. Smoking
List some of the risk factors that are linkto h pertension
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to hypertension
Family history, obesity, cigarette smokin
heavy alcohol consumption, high sodium
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sedentary lifestyle, exposure to continuou
stress, diabetics, older African American
List the acceptable pulse ranges for thfollowing.
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following.
Adolescents
60 to 90
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List the acceptable pulse ranges for thfollowing.
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following.
Adults
60 to 100
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List the acceptable pulse ranges for th
following.
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g
Infants
120 to 160
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List the acceptable pulse ranges for th
following.
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g
Preschoolers
80 to 110
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List the acceptable pulse ranges for th
following.
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g
School-age children
75 to 100
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List the acceptable pulse ranges for th
following.
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Toddlers
90 to 140
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List the characteristics to identify whe
assessing the following.
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Apical pulse
When assessing the apical pulse, considrate and rhythm only
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y y
List the characteristics to identify whe
assessing the following.
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Radial pulse
When assessing the radial pulse, considrate, rhythm, strength, and equality
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, y , g , q y
Malignant hyperthermia
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Hereditary condition of uncontrolled hproduction
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p
Nonshivering thermogenesis
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Vascular brown tissue is metabolized fheat production in the neonate
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Provide examples of goals for temperatu
alterations related to the environmen
L
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Long term
Obtain appropriate clothing to wear in cweather
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Provide examples of goals for temperatu
alterations related to the environmen
Sh t t
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Short term
Regain normal range of body temperatu
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Pyrexia
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Fever
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Pyrogens
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Bacteria and viruses that elevate bodytemperature
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Radiation
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Transfer of heat from the surface of on
object to the surface of another with ou
direct contact
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direct contact
Shivering
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Involuntary body response to temperatudifferences in the body
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State the formulas for the following
conversions.
Celsius to Fahrenheit
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Celsius to Fahrenheit
Multiply the Celsius reading by 9/5 and 32 to the product
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State the formulas for the following
conversions.
Fahrenheit to Celsius
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Fahrenheit to Celsius
Subtract 32 from the Fahrenheit readinand multiple the result by 5/9
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Summarize the treatment for hypotherm
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Remove wet clothes; wrap the patient blankets
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The ability to control body temperaturdepends on: (4)
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a. The degree of temperature extreme
b. The person's ability to sense feeling
comfortablec. Thought processes or emotions
d P ' bili bili
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d. Person's mobility or ability to remove
add clothes
The nurse bathes the patient who has a f
with cool water. The nurse does this to
increase heat loss by means of:
1. Radiation2. Convection
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3. Conduction
4. Condensation
3. The transfer of heat from one object to
other without direct contact (solids, liquand gases)
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g )
The nurse is assessing a patient who she susphas the nursing diagnosis hypothermia relate
vigorous exercise in hot weather. In reviewin
data, the nurse knows that the most importan
sign of heatstroke is:1. Confusion
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2. Excess thirst
3. Hot, dry skin4. Muscle cramps
3. Victims of heat stroke do not swea
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The nurse is auscultating Mrs. McKinnon's blood pressurenurse inflates the cuff to 180mm Hg. At 156mm HG, the n
hears the onset of a tapping sound. At 130mm Hg, the sou
changes to a murmur or swishing. At 100mm Hg, the soun
momentarily becomes sharper, and at 92mm Hg, it becom
muffled. At 88mm Hg, the sound disappears. Mrs. McKinn
blood pressure is:
1 130/88mm Hg
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1. 130/88mm Hg
2. 156/88mm Hg
3. 180/92mm Hg4. 180/130mm Hg
2. 156 is the onset of the first Korotkoff
sound (systolic pressure), and 88 is the fsound that corresponds with the diastoli
pressure
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pressure
The skin plays a role in temperature
regulation by:
1. Insulating the body2. Constricting blood vessels
3 Sensing external temperature variatio
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3. Sensing external temperature variatio
4. All of the above
4. The skin regulates temperature throu
insulation of the body, vasoconstriction, temperature sensations.
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Thermoregulation
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Mechanisms that regulate the balanc
between heat lost and heat produced
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