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during initial screening pt should be observed for the following
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patient intake should include
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clinical 2 ch 11
vital signs
| Question | Answer |
|---|---|
| during initial screening pt should be observed for the following | appearance, odor, gait, level of awareness,emotional state |
| patient intake should include | chief complaint(CC); patient hx; height and weight; VS |
| values that are obtained through measuring | mensuration |
| mensuration values include | height, weight, circumference, vital signs |
| BMI | body mass index |
| BMI less than 18.5 is | underweight |
| BMI greater than 30 is | obese |
| standard VS are considered | temperature, pulse, respiration and blood pressure (TPR and BP) |
| what is considered to be the 5th VS? | pain |
| VS provide an overall picture of the patients | general state of health |
| temperature regulator of the body | hypothalmus |
| structures that help regulate body temperature | blood vessels, skin, neuromuscular system |
| to be without a fever | afebrile |
| with fever | febrile |
| temperature in early morning has a tendency to be | lower |
| temperature in evening has a tendency to be | higher |
| normal value 98.6 and most common method for temp | oral |
| normal value 97.6 least accurate | axillary |
| normal value 99.6, most reliable and core temp | rectal |
| normal value 99.6 | temporal artery |
| factors that affect accuracy of the oral temp | eating, drinking, smoking, dental issues, sinus congestion, unconsciousness, lack of understanding |
| temporary elevation of body temperature | fever |
| low grade fever starts at | 100.4 |
| causes of fever include | infection, injury, neoplasm,connective tissue disease |
| pulse points | temporal; carotid; apical; brachial;radial; femoral; popliteal; posterior tibial; dorsalis pedis |
| pulse on side of head | temporal artery |
| pulse on side of neck | carotid artery |
| pulse found in antecubital space used for blood pressure | brachial artery |
| pulse on inner side of wrist, most common used | radial artery |
| pulse found in groin | femoral artery |
| pulse found behind the knee | popliteal artery |
| pulse found behind the ankle | posterior tibial artery |
| pulse found on top of foot | dorsalis pedis |
| factors affecting pulse rate | gender, level of fitness; emotional state, pregnancy, fever, medications, increase activity |
| rapid heart rate over 100bpm | tachycardia |
| slow heart rate under 60bpm | bradycardia |
| refers to amount of blood being discharged from the heart | strength or volume |
| refers to the interval timing between measured beats | rhythm |
| a regular pulse is counted for how long and then multiplied times 2? | 30 seconds |
| and irregular pulse should be counted for | 1 minute |
| if you cannot palpate a radial pulse you should do a | apical pulse |
| the apical pulse can be heard at | the 5th intercostal space, mid-clavicular line over the apex of the heart |
| process of inspiration and expiration | respiration |
| respiration is controlled by the | medulla oblongata |
| factors that affect respiration | physical activity, emotional state, medications, age, infectious states |
| difficult or labored breathing | dyspnea |
| rapid shallow breathing | tachypnea |
| rapid deep breathing | hyperpnea |
| hyperpnea is also known as | hyperventilation |
| measurement of the amount of force exerted on arterial walls as the hearts ventricles contract and relax | blood pressure |
| phase where ventricles contract creating the greatest force against arterial walls | systole |
| phase where ventricles relax and have the least amount of pressure against arterial walls | diastole |
| always recorded as the top number of blood pressure | systolic |
| always recorded as the bottom number of blood pressure | diastolic |
| the difference between the systolic and diastolic pressure | pulse pressure |
| sounds heard during blood pressure measurement | Korotkoff sounds |
| Korotkoff sounds include | tapping, swishing, knocking, muffling, silence |
| normal BP for adults | <120/80 |
| elevated or controlled HTN | 130/90 |
| stage 1 hypertension | 130-139/ 80-89 |
| stage 2 hypertension | >140/90 |
| measurement of amount of arterial oxygen saturation in the blood | pulse oximetery |
| oxygen saturation that requires intervention | less than 95%(94% and below) |
| normal resp rate for newborns | 30-60/min |
| normal resp rate for adults | 12-16/min |
| normal pulse for athletes | less than 60bpm |
| normal pulse for adults(>10yrs) | 60-100bpm |
| period of silence between phase one and phase two of korotkoff sounds | ausculatory gap |
| numeric difference between the apical pulse and radial pulse | pulse deficit; may indicate an arrhythmia |
| easier breathing while sitting or standing | orthopnea |
| blood pressure that drops with a change in position, usually from lying to standing | orthostatic hypotension |
| elevated blood pressure | hypertension |
| low blood pressure | hypotension |
| normal HR for newborns | 140-160bpm |
| normal BP for newborns | 60-70/30-40 |
| normal HR for children 3-10yrs | 60-120bpm |
| normal RR for children age 3-10yrs | 18-30/min |
| normal BP for children 3-10yrs | 80-120/40-80 |
| deep breathing followed by periods of apnea; usually preceeds death | Cheyne-Stokes breathing |
| irregural and unpredictable breathing pattern indicating brain damage | Ataxic breathing |
| wet sounding breath sounds usually heard with CHF or pneumonia | rales |
| course or snore like breath sounds usually heard with bronchitis or an URI | rhonchi |
| high pitched whistle like breath sound usually heard with asthma and COPD | wheezing |
| barky seal like sound associated with croup | stridor |
| creaking crackle sounds usually indicating inflammation of the pleural mambreanes | pleural rub |
| piece of equipment that actually measures the BP | sphygmomanometer |
| T 100.4-101 | low grade fever |
| T101-103 | moderate fever |
| T 103-105 | high grade fever |
| T >105 | hyperpyrexia |
| antipyretics | ibuprofen and acetaminophen |
| hypertensive crisis | >180/120 |
Created by:
clarevoyant1019
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