Ch 8 Assessing General Status and Vital Signs (Nursing Assessment) – Flashcards

-cardiovascular -neurological -peripheral vascular -respiratory

-98.6 degrees fahrenheit

strenuous exercise, stress, ovulation

prolonged exposure to cold, hypoglycemia, hypothyroidism, starvation

infection, malignancies, trauma, blood/endocrine/immune disorders

it decreases with age -95 - 97.5 in the elderly

-created by the shock wave of the contaction of the ventricles travelling along the arterial fibers -use pads of fingers

-rate -rhythm -amplitude -contour -elasticity

-patient should be unaware you are assessing respirations -evaluate as a continuation of the apical or radial pulse

-rate -rhythm -depth

12-20 breaths/min

abnormally slow breathing rate

abnormally fast breathing rate

-pressure exerted on arterial walls -varies with the cardiac cycle -highest with systole-ventricular contraction -lowest with diastole-ventricular relaxation

-cardiac output (higher pressure, increases BP) -peripheral vascular resistance (increased resistance, increased BP) -circulating blood volume (increased volume, increased BP) -viscosity (thicker, pressure increases) -elasticity of vessel walls (increased stiffness, increases BP) -time of day -caffeine, nicotine -emotions -pain -temperature -body position

-the difference between systolic and diastolic pressure -reflects stroke volume -less than 30 or above 50 indicated cardiovascular disease

when the ventricles are relaxed

measurement of the blood pressure in the arteries, when the ventricles are contracted

30 - 50 mmHg

-5th vital sign -identify: location, intensity, quality, duration, alleviating or aggravating factors, COLDSPA -subjective

-name, address, phone number -age -gender -usual blood pressure -history of fever -history of pain -present health concern

-physical development -body build -fat distribution gender -sexual development -compared stated age with apparent age -skin condition and color -posture and gait (musculoskeletal system)

96.9-99.9 degrees fahrenheit

1 degree lower

1 degree higher

1.4 degrees higher

60 - 100

rate greater then 100 beats/min -may occur with fever, medications, stress, and other abnormal states, such as cardiac dysrhythmias

rate less than 60 beats/min -sitting/standing for long periods may cause the blood to pool and decrease the pulse rate. heart block or dopped beats can also manifest as bradycardia

-men: gait may be wider based with arms held outward -women: narrow base and may waddle, steps shorten, with decreased speed and arm swing -mobility may be decreased, gait rigid -normal body temp. is lower -arteries may feel more rigid, hard, and bent -respiratory rate may range from 15-22 -respiratory rate may increase with a shallower inspiratory phase because vital capacity and inspiratory reserve volume decrease -rigid, arteriosclerotic arteries account for higher systolic blood pressure (systolic over 140 but diastolic under 90 - isolated systolic hypertension) -widening of the pulse pressure due to less elastic peripheral arteries

120-139 / 80-89

less than 120 / less than 80

140-159 / 90-99

over 160 / over 100

taking vital signs