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the ___ and ___ systems work together to keep body temperature within normal range
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Core temperature measurement sites
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health assessment
fundamentals ati unit 2 ch 23
| Question | Answer |
|---|---|
| the ___ and ___ systems work together to keep body temperature within normal range | neurological and cardiovascular |
| Core temperature measurement sites | rectum and tympanic membranes |
| surface temperature measurement sites | skin, mouth and axillae |
| normal temperature range | 96.8 to 100.4 average is 98.6 |
| Difference between oral and rectal temperature | .5 degree higher than oral |
| difference between oral and axillary temperatures | .5 degrees lower than oral |
| heat production results from | inc in basal metabolic rate, muscle activity, thyroxine output and sympathetic stimulation |
| heat loss from body occurs through... | conduction, convection, evaporation, radiation. |
| conduction | transfer of heat from body to another surface. |
| convection | dispersion of heat by air currents |
| evaporation | dispersion of heat through water vapor |
| radiation | transfer of heat from one object to another object w/o contact b/w them |
| newborns and temperature | large surface to mass ration, lose heat rapidly to environment. Should be maintained at 95.9 to 99.5 degrees. |
| older adult and temperature | lower body temperatures and feel cold, less subcutaneous fat. Average is 96.8 degrees. More likely to be affected by extremes in environmental temp. takes longer to register on thermometer |
| hormone and temperature | slight rise w/ ovulation and menses. menopause, intermittent body temperature may inc. up to 7.2 degrees. |
| exercise, activity and dehydration may contribute to _ | hyperthermia |
| illness and injury are often associated w/ ____ in temperature | elevation. Fever is body's response to infection and inflammatory process. |
| recent ____ or ___ intake and ____ can interfere with accurate measurement of body temperature | food, fluid, smoking |
| inaccuracy in tympanic technique for temperature | if under 3 months of age. if excessive ear wax is present |
| Harmful fever temperature | if the temperature exceeds 102.2 degrees |
| hyperthermia | abnormally elevated body temperature |
| interventions for high fever | obtain blood cultures if ordered, assess wbc counts, sedimentation rates and electrolytes if ordered, admin. antibiotics, up fluids/rest, antipyretics (tylenol). cooling blanket/tepid bath(85-90 degrees), blanket for chill, oral hygiene/dry clothes/linens |
| hypothermia | body temperature < 95 degrees an abnormally low body temp. |
| interventions for hypothermia | provide warm environment temp, heated humidified oxygen, warming blanket, friction to extremities/warmed oral or IV fluids. continuous cardiac monitoring, emergency resuscitation equipment on standby. |
| Cardiac output | how much blood is pumped from the heart (left vent) to arterial circulation in 1 minute. CO=HR x SV (stroke volume) |
| The ____ system controls heart rate | autonomic nervous system |
| The ____ system lower the heart rate | parasympathetic |
| The ___ system raises the heart rate | sympathetic |
| pulse as a vital sign is the... | measurement of heart rate and rhythem. It is the wave-like sensations/impulses felt in a peripheral arterial vessel or over the apex of the heart. |
| rate of a pulse | number of times per minute the pulse is felt or heard |
| rhythm of a pulse | regularity at which each impulse is felt. Premature or late heart beat can result in an irregular interval and can indicate abnormal electrical activity of heart. |
| strength (amplitude) of a pulse | strength of impulse should be same from beat to beat and graded on scale of 0-4. 0 absent, 1+ diminished, weaker than expected, 2+ brisk, expected, 3+ increased, 4+ full volume bounding |
| equality - peripheral pulse | impulses should be symmetrical in quality and quantity on each side of body. evaluate adequacy of vascular system |
| normal pulse range for adults | 60 - 100/ min at rest |
| tachycardia | pulse rate > 100/min |
| bradycardia | pulse rate < 60/min |
| dysrhythmia | irregular rhythm of heart that frequently is noted as an irregular radial pulse |
| pulse deficit | occurs when apical rate is greater than radial rate. |
| age impact on pulse | infant pulse rate is 120-160/min. Gradually decreases as child ages. 12-14 yr old 80-90/min. older adult weaker pulse due to poor circulation or cardiac dysfunction, harder to palpate pulse. |
| Factors leading to tachycardia | exercise, fever, medications (epinephrine, levothyroixine), changing positions (lay to sit to stand) acute pain, hyperthyroidism, anemia, hypoxemia, stress, anxiety, fear, hypovolemia, shock and heart failure lead to dec. CO w/ compensatory inc. HR |
| Factors leading to bradycardia | long term physical fitness, hypothermia, meds (digoxin, beta-blockers, ca channel blockers), changing position (stand to sit to lay), chronic pain, hypothyroidism |
| how long should you count a regular pulse for? | 30 seconds times it by 2 |
| how long should you count an irregular pulse for? | full minute and compared to apical pulse rate |
| location of apical pulse | 5th intercostal space at left midclavicular line. Use for infant HR, rapid rates (>100/min), irregular rhythms or rates prior to administration of cardiac meds. 1 full minute. |
| what should you also assess for in a client with tachycardia? | pain, anxiety, restlessness, fatigue, low bp, oxygen saturation |
| what should you also assess for in a client with bradycardia? | hypotension, chest pain, diaphoresis, dyspnea, altered mental status |
| Chemoreceptors in the carotid arteries and aorta primarily monitor _ | CO2 levels of the blood. If CO2 rises, RR inc. to rid body of excess. |
| Ventilation | exchange of o2 and co2 in lungs. Measured with RR, rhythm and depth |
| Diffusion | passage of oxygen and co2 b/2 alveoli and rbc. measure w/ pulse oximetry. |
| Perfusion | flow of blood to and from pulmonary capillaries. measure w/ pulse oximetry |
| Respiration | vital sign evaluates effectiveness of ventilatory process of oxygen and co2 exchange. |
| Respiration Rate | number of full inspirations and expirations in 1 min. Determine by observing number of times chest rises and falls. Normal in adults is 12-20 RR/Min |
| Respiration depth | amount of chest wall expansion occurs w/ each breath. abnormal depths are deep or shallow. |
| respiration rhythm | observe breathing intervals. reg rhythm w/ occasional sigh is normal in adults |
| Pulse oximetry | measure O2 saturation of blood by infrared light that measures SaO2 (arterial oxygen saturation) by light absorption by oxygenated and deoxygenated hemoglobin in arterial blood. |
| normal pulse ox | 95-100% Acceptable levels may go from 91-100, some ilness states may allow for an SaO2 of 85-89 |
| pulse ox values may be slightly lower in what type of client | older or dark skinned client, hypothermia, poor peripheral blood flow, too much light, low hemoglobin levels, client movement, edema and nail polish |
| intervention required for pulse ox of _ | <91%. <86% emergency <80% life threatening. The lower the value the less accurate the measurement |
| Age related issues to respiration | decreases with age. newborns have rate of 30-60/min. School age children 20-30/min. adults 12-20/min |
| gender related issues to respiration | men are diaphragmatic breathers and abdominal movements are more noticeable. Women use more thoracic muscles and chest movements are more pronounced when they breath. |
| pains effect on respiration | decrease depth of respirations. Onset of acute pain, RR will increase but will return to normal over time. |
| anxiety effect on respiration | inc rate and depth of respiration |
| smoking effect on respiration | causes resting rate of respiration to increase |
| body position effect on respiration | upright allow chest wall to expand fully |
| medications effect on respiration | opioids, sedatives, bronchodilator and general anesthetics will dec. the RR and depth. can be serious adverse effect. Amphetamines/cocaine may inc rate and depth. |
| Neurological injury and respiration | injury to brain stem dec. RR and rhythm |
| illness that impacts shape of chest wall and patency of passages or those impairing muscle function will __ RR and what sign/symptom may be seen | dec, use of accessory muscles |
| anemia or high altitudes will __ in regards to oxygen, which in turn __ RR and __ | impair oxygen carrying capacity of the blood, increases, change rhythm to compensate |
| Hypoxemia | SaO2 <90%, interventions - confirm probe placement, oxygen delivery functioning and client receiving ordered levels, semi-Fowler's or fowler's position to maximize ventilation, deep breathing, assess signs such as tachypnea, tachycardia, restlessness |
| Blood pressure | force exerted by blood in arteries during heart contraction (systole) and relaxation (diastole) |
| systolic bp | occurs during ventricular systole of heart and represents max amt of pressure exerted on arteries. |
| diastolic bp | occurs during ventricular diastole of heart and represents min amt of pressure exerted on arteries. |
| principle determinants of bp are | CO and systemic vascular resistance. BP= CO x SVR. CO determined by HR, Contractility, blood volume, venous return (up any > up CO > up BP) SVR determined by amt of constriction/dilation of arteries. up in SVR > up BP |
| Normal BP | systolic bp < 120 mmHg, diastolic bp < 80 mm Hg |
| prehypertension bp | 120-139/80-89 |
| stage 1 hypertension | 140-159/90-99 |
| stage 2 hypertension | > or equal 160/greater or equal 100 |
| client w/ blood pressure of 124/92 mm Hg is classified as having what? | stage 1 hypertension bc diastolic places them in that category. determined by higher reading. |
| client with blood pressure of 146/82 mm Hg is classified as having what? | stage 1 hypertension |
| Hypotension | BP below normal systlic <90 and can be result of fluid depletion, heart failure or vasodilation |
| pulse pressure | difference bw systolic and diastolic pressure readings |
| postural (orthostatic) hypotension | BP falls when client changes position from lying to sitting or standing, may result from various causes. take client bp and hr lying down, then have sit or stand, wait 1-5 mins. reassess. if sbp dec > 20 mm Hg and dbp dec >10 with a 10-20% inc in HR |
| Age and blood pressure | infants have low bp that gradually inc with age, older children/adolescents varying bp based on body size, older adult, slightly elevated systolic due to dec. elasticity of blood vessels. |
| circadian (diurnal) rhythms and BP | bp usually lowest in early morning hours and peaking during later part of afternoon/evening |
| stress and bp | in in bp assoc. w/ fear, emotional strain and acute pain |
| ethnicity and bp | african american have higher incidence of hypertension in general and at earlier ages |
| gender and bp | adolescent to middle age men have higher bp than female. postmenopausal women have higher bp's than male |
| medications and bp | opiates, antihypertensives and cardiac meds can lower bp. cocaine, cold meds, oral contraceptives and antidepressants raise bp |
| exercise effect on bp | dec bp for several hours after |
| a shpygmomanomter cuff width should be _ | 40% of the arm circumference at the point where cuff will be wrapped. |
| BP should not be taken on an arm that __ | has an iv - side of a mastectomy |
| where should the bp cuff be applied | 2 cm above antecubital space w/ brachial artery in line w/ marking on cuff. |
| systolic pressure is measured at the _ | first clear sound |
| diastlic pressure is measured at the __ | point where sound is muffled then disappears |
| Lifestyle modification for hypertension | stop smoking, DASH diet (restrict sodum, consume K+, Ca+ and Mg, low cholesterol/sat fat), wgt ctrl, mod alcohol, inc. activity, dec. stress. |
Created by:
FSclafani
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