Skills for Nursing Ch. 21, 22, 24
orthostatic blood pressure - (correct Answer) - a blood pressure taken in 3 different positions w/5 mins
between each - lying, sitting and standing
20/10/10 --done when patient is dizzy/lightheaded/pale/sweaty/pass out
pain - (correct Answer) - COLDERRS:
-Characteristic
-Onset
-Location
-Duration
-Exacerbation
-Radiation
-Relief
-Score
blood pressure - (correct Answer) - the pressure that is exerted by the blood against the walls of blood
vessels; systolic/diastolic; avoid stroke side, iv side, lymph node removed side
normal: 120/80 or less
prehypertension: norm to 139/89
hypertension: 140/90 to 159/99
stage 2 hypertension: 160/110
hypotension: 90/60
Temperature - (correct Answer) - A measure of how hot or cold something is.
normal: 97.5 to 99.5 degrees average: 98.6
pulse - (correct Answer) - 60-100 bpm;
produced by cardiac contractions, pressure against arterial walls, normally started by SA node;
women's rate is usually faster than mens
respiration - (correct Answer) - 12-20 normal; controlled by pons and medulla oblongata; watch depth
, and expansion and rate; triggered by increase CO2 or serum hydrogen ion concentration or decreased
O2; works with feedback mechanisms
oxygen saturation - (correct Answer) - percentage of hemoglobin that is bound to oxygen
90% or higher
blood glucose - (correct Answer) - normal: 70-110 mg/dL
vital signs - (correct Answer) - indication as to what is going on with the patient
body heat - (correct Answer) - normal bi-product of metabolism
increase voluntary muscle movement increase heat
pyrogens (invasion of pathogens) - (correct Answer) - makes body temperature increase in order to try to
get rid of it
basic metabolic rate - (correct Answer) - level of energy required when the body is at rest
average depends on body surface area; effected by thyroid hormone, epinephrine, norepinephrine, and
testosterone
men tend to have higher rate than women
thyroid hormone with bmr - (correct Answer) - increase TH increase BMR; decrease TH decrease BMR
Hypothalamus - (correct Answer) - thermostat to control body temperature; vasoconstriction= return
heat (shivering)
vasodilation= decrease heat (sweat)
Heat loss through environment - (correct Answer) - radiation, conduction, convection, evaporation;
occurs with skin exposure to environment
pyrexia - (correct Answer) - fever (temp higher than 100.2 degrees F);
normal regulation mechanisms can not keep up with heat produced by the body; pyrogens (bacteria,
etc.) increase body temp---Febrile
diaphoresis - (correct Answer) - profuse sweating
Hyperthermia - (correct Answer) - fever higher than 100.2
hypothermia - (correct Answer) - Abnormally low body temperature often associated with exposure to
cold and windy environments
High fever for for too long - (correct Answer) - can cause brain damage
Oral, Rectal, and Axillary temp differences - (correct Answer) - axillary 1 degree < oral 1 degree < rectal 1
degree
orthostatic blood pressure - (correct Answer) - a blood pressure taken in 3 different positions w/5 mins
between each - lying, sitting and standing
20/10/10 --done when patient is dizzy/lightheaded/pale/sweaty/pass out
pain - (correct Answer) - COLDERRS:
-Characteristic
-Onset
-Location
-Duration
-Exacerbation
-Radiation
-Relief
-Score
blood pressure - (correct Answer) - the pressure that is exerted by the blood against the walls of blood
vessels; systolic/diastolic; avoid stroke side, iv side, lymph node removed side
normal: 120/80 or less
prehypertension: norm to 139/89
hypertension: 140/90 to 159/99
stage 2 hypertension: 160/110
hypotension: 90/60
Temperature - (correct Answer) - A measure of how hot or cold something is.
normal: 97.5 to 99.5 degrees average: 98.6
pulse - (correct Answer) - 60-100 bpm;
produced by cardiac contractions, pressure against arterial walls, normally started by SA node;
women's rate is usually faster than mens
respiration - (correct Answer) - 12-20 normal; controlled by pons and medulla oblongata; watch depth
, and expansion and rate; triggered by increase CO2 or serum hydrogen ion concentration or decreased
O2; works with feedback mechanisms
oxygen saturation - (correct Answer) - percentage of hemoglobin that is bound to oxygen
90% or higher
blood glucose - (correct Answer) - normal: 70-110 mg/dL
vital signs - (correct Answer) - indication as to what is going on with the patient
body heat - (correct Answer) - normal bi-product of metabolism
increase voluntary muscle movement increase heat
pyrogens (invasion of pathogens) - (correct Answer) - makes body temperature increase in order to try to
get rid of it
basic metabolic rate - (correct Answer) - level of energy required when the body is at rest
average depends on body surface area; effected by thyroid hormone, epinephrine, norepinephrine, and
testosterone
men tend to have higher rate than women
thyroid hormone with bmr - (correct Answer) - increase TH increase BMR; decrease TH decrease BMR
Hypothalamus - (correct Answer) - thermostat to control body temperature; vasoconstriction= return
heat (shivering)
vasodilation= decrease heat (sweat)
Heat loss through environment - (correct Answer) - radiation, conduction, convection, evaporation;
occurs with skin exposure to environment
pyrexia - (correct Answer) - fever (temp higher than 100.2 degrees F);
normal regulation mechanisms can not keep up with heat produced by the body; pyrogens (bacteria,
etc.) increase body temp---Febrile
diaphoresis - (correct Answer) - profuse sweating
Hyperthermia - (correct Answer) - fever higher than 100.2
hypothermia - (correct Answer) - Abnormally low body temperature often associated with exposure to
cold and windy environments
High fever for for too long - (correct Answer) - can cause brain damage
Oral, Rectal, and Axillary temp differences - (correct Answer) - axillary 1 degree < oral 1 degree < rectal 1
degree
