TOPIC 3

97問 • 1年前

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Indicators of the body’s physiological status and response to physical activity, environmental conditions and emotional stressors

vital signs

Vital signs establish baseline values for

elderly, very young, debilitated, pts limited aerobic activities for wks or mos, pts with cardiovascular problems, pts recovering from recent trauma or disease that affects cardiopulmonary system

Factors of vital signs

level of physical activity, env temp, age, emotional status, physiologic status

Response to activity

confusion, fatigue, lethargy, slow reactions, decreased response to verbal and tactile, nausea, syncope or vertigo, diaphoresis, pallor or erythema, LOC, decreased bp, pupil size change

Why take VS

diagnostic label, prognosis and POC, evaluate progress through reexamination, evaluate effectiveness, determine the need for referral

Body temperature is usually _____ in the early morning and _______ in the afternoon

lower, higher

Body temperature tends to ________ slightly with agr and is _______ slightly in the very young

decrease; increase

Body temperature may _____ slightly in a hot environment and ______ slightly in a cold environment

increase; decrease

Body temperature _________ with a major or systemic infectious process

increases

Body temperature usually ______ slightly with physical activity but ___________ as the person becomes better conditioned

increases, reaches a plateau

Body temperature _________ during stressful or emotional periods

increases

Body temperature values are slightly higher if measured in the _____ and slightly lower if measured in the ______ when compared with _______ values

rectum, axilla, oral

Body temperature is slightly higher at the time of _______, and a pregnant woman’s body temp tends to be slightly ______ than usual

ovulation, higher

Body temperature measurement may be inaccurate if measured orally within ____________ mins of ingestioj of warm or cold substances

14-30

Human oral core or body temperature

96.8 to 99.3, 36 to 37.3

Most generally accepted single value

37, 98.6

Human rectal temperature

97.8 to 100.3, 36.6 to 38.1

Fever

>98.6, >37

Pyrexic

>100, >38

Hyperpyrexic

>106, >41.1

Body temp alternates at regular intervals between periods of fever and periods of normal temperatures

intermittent

Elevated body temp that fluctuates more than 3.6f(2c) within 24 hr period but remains above normal

remittent

Periods of fever are interspersed with normal temperatures

relapsing

Each last at least one day

relapsing

Recurrent fever

relapsing

Body temp may fluctuate slightly but is constantly elevated above normal

constant

A person whose body temperature is elevated before treatment can continue with the exercise

false

A person whose body temperature is lower than normal BEFORE treatment should be _______ to be certain the treatment is tolerated and to determine whether the temperature changes during or at the conclusion of the activity

monitored

A patient whose body temperature becomes _______ than normal DURING treatment may also be demonstrating an abnormal response to treatment

lower

Two or three ______ __________ should be taken

serial measurements

Most common and convenient location to measure a person’s temp

oral

Most accurate measurement of body temp

rectal

Used for infants or young children who are unable to maintain the thermometer under the tongue or safely hold it between the lips

rectal, ear canal, temporal lobe

For unconscious patients or for patients who are unable to maintain the thermometer in the mouth

rectal, ear canal

Least desirable sites because air currents may reduce the accuracy of the measurement

axilla, inguinal

Measures body temp on the basis of HEAT generated by the ear canal and its sureounding tissue

ear thermometer

Useful for infants, toddlers and older persons for whom it is difficult to use an oral thermometer

ear thermometer

Require batteries as the power source and disposable lens filters are used

ear thermometer

Ear thermometer: the ______ _______ should be cleaned thoroughly or discarded after each use to prevent cross contamination or false reading of the unit

lens filter

Temperature value is obtained from a liquid crystal display in a window on one side of the thermometer

ear thermometer

When a person has been lying on his or her ear, that should not be used for measurement until it has been exposed to the air for _________ so the ear canal temp can become stable

2-3 mins

If the temperature of the ear canal is not permitted to acclimate, a falsely high reading may occur

true

Temperatures in both ears are the same, so both both ears can be measured alternately

false

SELECT ALL THAT APPLY FOR EAR THERMOMETER PROCEDURE

do not attempt to take a temp with an ear thermometer in an ear where an earache is suspected, pull up and back on the ear for person older than 1 yr

Has a probe connected to a unit containing battery that measures a person’s temp and provides digital reading

oral thermometer

SELECT ALL THAT APPLIES FOR ORAL THERMOMETER PROCEDURE

instruct the patient to open his or her mouth, position the probe under the tongue, breathe through the nose

Indirect measure of the contraction of the left ventricle of the heart and indicates the rate at which the heart is beating

pulse

Movement of blood in an artery, which can be palpated at various sites of the body or measured through auscultation over the apex of the heart with a stethoscope

pulse

Normal adult pulse

60-100 bpm

Newborn normal pulse

100-130 bpm

Aged 1-7 yrs old normal pulse

80-120 bpm

The normal resting pulse can be established for each patient by repeated measurement of the pulse at the same site and under different conditions

false

Most common sites for pulse

radial, carotid

Pulse: when access to radial site is restricted

temporal, carotid

Pulse: when measuring own pulse

carotid, radial

Peripheral sites are inaccessible or difficult to palpate

apical

Assess LE pulse

inguinal, popliteal, tibial, pedal

High BP =

low pulse

Anterior and adjacent to ear

temporal

Inferior to the mandible and anterior to the SCM

carotid

Medial to the biceps im the antecubital fossa or on the medial aspect of the mid shaft of humerus

brachial

At the wrist on the volar forearm medial to the stylus process of the radius

radial

Femoral triangle slightly lateral and anterior to the inguinal crease

femoral

Midline of post knee crease between the tendons of hamstrings

popliteal

Along the midline or slightly medial on the dorsum of the foot

dorsal pedal

On the medial aspect of the foot inferior to the medial malleolus

post tibial

Men pulse rates are usually slightly higher than female

false

Pulse rate tend to increase with a major infectious process

true

Pulse rate after exercise should revert to the person’s resting pulse rate within ________ mins after cessation of exercise

3-5

Even beats with a good force to each beat

strong and regular

Even beats with a poor force to each beat

weak and regular

Both strong and weak beats occur during the period of measurement

irregular

Weak force to each beat and irregular beats

thready

>100 bpm

tachycardia

<60 bpm

bradycardia

No perceptible pulse even with maximum pressure

absent

Barely perceptible; easily obliterated with slight pressure; fades in fades out

thready

Difficult to palpate; slightly stronger than thready, can be obliterated with light pressure

weak

Easy to palpate; requires moderate pressure to obliterate

normal

Very strong; hyperactive; is not obliterated with moderate pressure

bounding

An exception to light pressure when checking pulse is the popliteal artery

true

In most persons, the radial and brachial pulse will be equal

false

Aoical and radial pulse may differ in pts with cardiac disease or peripheraal arterial disease

true

Two persons should monitor the two pulses simultaneously

true

Any difference in apical and radial pylse =

pulse deficit

Select the best answer

apical>radial

Measures the level of blood oxygen saturation, monitors pulse rate and calculates HR

pulse ox

Normal blood oxygen saturation

95-100%

Hypoxemia

<90%

Before applying pulse oximeter, make sure the patient is not wearing fingernail polish

true

noninvasive examination

pulse ox

External conditions such as ______,________,_______ can affect the readings of pulse ox

lighting, altitude, temperature

Hospitals, in addition to patient monitoring devices, and has an alarm system that sounds when abnormal valves are reached

stationary digital pulse ox

Fingertip prove and a handheld base unit that displays the results

hand held ox

Sometimes include a large memory bank that stores data or data can be downloaded onto computer

handheld ox

Compact units that usually operate with a single button

finger ox

In general, oximeters accurately measure oxygen saturation between 70-90% regardless of the type of oximeter used

false

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Kyla Rafols · 71問 · 2年前

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