Fundamentals of Nursing, Vital Signs 100% Correct

Fundamentals of Nursing, Vital Signs 100% Correct Afebrile Without fever Febrile With fever Apical pulse (aka "point of maximal impulse" or PMI) Central pulse; located at the apex of the heart (aka "point of maximal impulse" or PMI). Routinely used on infants - 3yrs. Helps determine discrepancies with radial pulse. Peripheral pulse Pulse located away from the heart; wrist or foot. Apical-radial pulse Normally apical & radial pulses are identical but an apical rate greater than the radial rate can indicate that the thrust of blood from the heart is too weak to be felt peripherally. Possible indication of vascular disease. Apnea Absence of breathing Arrhythmia (aka dysrhythmia) A pulse with an irregular rhythm (aka dysrhythmia). Arterial blood pressure Measure of the pressure exerted by the blood as it flows through the arteries. Arteriosclerosis Elastic & muscular tissues of the arteries are replaced with fibrous tissue, the arteries lose much of their ability to constrict & dilate. Common in middle aged & older adults. Auscultatory gap Occurs particularly in hypertensive people; is the temporary disappearance of sounds normally heard over the brachial artery when the cuff pressure is high followed by the reappearance of the sounds at a lower level. Basal metabolic rate (BMR) Rate of energy utilization in the body required to maintain essential activities such as breathing. Rates decrease with age. Generally younger people have higher BMR. Body temperature Reflects the balance between the heat produced & lost from the body. Measured in degrees. Bradycardia Heart rate in an adult of less than 60 bpm. Bradypnea Abnormally slow respirations. Cardiac output Volume of blood pumped into the arteries by the heart and equals the result of the stroke volume (SV) times the heart rate (HR) per min. Compliance Arteries ability to contract & expand. Conduction The transfer of heat from one molecule to a molecule of lower temperature. Cannot take place without contact between the molecules & normally accounts for minimal heat loss. Constant fever Body temperature fluctuates minimally but always remains above normal. Convection Dispersion of heat by air currents. Core temperature Temperature of the deep tissues of the body such as the abdominal cavity & pelvic cavity. Remains relatively constant. Costal breathing (aka thoracic breathing) Involves external interest all muscles and other accessory muscles such as the sternocleidomastoid muscles. Can be observed by the movement of the chest upward & outward. Diaphragmatic breathing (aka abdominal breathing) Involves the contraction & relaxation of the diaphragm observed by the movement of the abdomen as a result of the diaphragms contraction & downward movement. Diastolic pressure Pressure when the ventricles are at rest. The lower pressure present at all times within the arteries. Dysrhythmia May consist of random irregular beats or a predictable pattern of irregular beats called "regularly irregular". Evaporation Continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth & skin. Exhalation (aka expiration) Breathing out or the movement of gases from the lungs to the atmosphere. Fever (aka pyrexia or hyperthermia) A body temperature above the usual range. Fever spike Temperature that that rises to a fever level rapidly following a normal temperature and then returns to normal within a few hours. Common to bacterial blood infections. Heat balance When the amount of heat produced by the body equals the amount of heat lost. Heat exhaustion Result of excessive heat & dehydration. Paleness, dizziness, nausea, vomiting, fainting, & moderately increased temperature of 101-102. Heat stroke Persons generally have been exercising in hot weather, have warm flushed skin, and often do not sweat. Usually have a temperature of 106 or higher and may be delirious, unconscious, or having seizures. Hematocrit When the proportion of red blood cells to the blood plasma is high. Highly viscous blood; thick. Hyperpyrexia Very high fever. 105.8 Hypertension A blood pressure that is persistently above normal. When the diastolic pressure is 90 mmHg or higher or when the systolic is 140 mmHg or higher. Hyperventilation Very deep rapid respirations. Hypotension Blood pressure is below normal; systolic consistently between 85-110 mmHg in an adult whose normal pressure is higher than this. Hypothermia Core body temperature below the lower limit of normal. 3 physiological mechanisms include; excessive heat loss, inadequate heat production to counteract heat loss, and impaired hypothalamic thermoregulations. Hypoventilation Very shallow respirations. Inhalation (aka inspiration) Intake of air into the lungs. Insensible water loss Continuous & unnoticed water loss. (caused by evaporation) Insensible heat loss Heat loss that accompanies the Insensible water loss. (caused by evaporation) Intermittent fever Body temperature alternates at regular intervals between periods of fever and periods of normal or sub normal temperatures. Korotkoffs sounds Five phases of sounds heard in a series when listening with a stethoscope while taking a blood pressure. 1- 1st faint clear tapping or thumping sounds are heard gradually becoming more intense. (systolic) 2- during cuff deflation when sounds have a muffled whooshing or swishing sound. 3- sounds become crisper & more intense but softer than in phase 1. 4- sounds become muffled & have a soft blowing quality. 5- level when the last sound is heard filled by silence (diastolic) Orthostatic hypotension Blood pressure that falls when the client sits or stands. Usually the result of peripheral vasodialation in which blood leaves the central body organs, especially the brain, and moves to the periphery, often causing the person you feel faint. Causes: bleeding, several burns, & dehydration. Oxygen saturation (SaO2) Arterial blood percentage of all the hemoglobin binding sites that are occupied by oxygen Pulse A wave of blood created by contraction of the left ventricle of the heart. Generally the pulse wave represents the stroke volume (SV) output or amount of blood that enters the arteries with each ventricular contraction. Pulse deficit Any discrepancy between two pulse rates. In no instance is the radial pulse greater than the apical pulse. Pulse oximeter Noninvasive device that estimates a persons arterial blood oxygen saturation (SaO2) by means of a sensor attached to a finger, toe, nose, earlobe, or forehead. Pulse pressure The difference between the diastolic and the systolic pressure. Pulse rhythm The pattern of the beats and the intervals between the beats. Equal time lapses between beats of a normal pulse. Pulse volume (aka pulse strength or amplitude) Refers to the force of blood with each beat. Can range from absent to bounding. Normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. Forceful or full blood volume that is obliterated only with difficulty is called full or bounding. A pulse that's easily obliterated with pressure from the fingertips is referred to as weak, feeble, or thready. Radiation The transfer of heat from the surface of one object to the surface of another without contact between the two objects, mostly in the format of infrared rays. Relapsing fever Short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature. Remittent fever Wide range of temperature fluctuations of more than 2 degrees difference over a 24hrs period which are all above normal. Respirations The actual of breathing. Respiratory rhythm The regularity of the expirations & inspirations. Normally they're evenly spaced. Respiratory quality (aka character) Refers to those aspects of breathing that are different from normal effortless breathing. The amount of effort and person must expert to breathe and the sound of the breathing. Sphygmomanometer Indicates the pressure of the air within the cuff bladder. 2 types; aneriod & digital. Surface temperature Temperature of the skin, subcutaneous tissue, and fat. Rises and falls in response to the environment. Systolic pressure The pressure of the blood as a result of contraction of the ventricles; pressure of the height of the blood wave. Tachycardia And excessively fast heart rate (over 100 bpms in an adult). Tachypnea (aka polypnea) Abnormally fast respirations. Tidal volume 500 mL of air expelled/taken in by an adult during normal inspiration and expiration. Vital signs Body temperature, pulse, respirations, and blood pressure. Pain level is sometimes also counted/measured as a vital sign. Prehypertension Systolic 120-139 Diastolic 80-89 Stage 1 Hypertension Systolic 140-159 Diastolic 90-99 Stage 2 Hypertension Systolic over 160 Diastolic over 100