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nursing 314: assessing and promoting wellness > 1: Vital signs > Flashcards

1: Vital signs Flashcards

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1
Q

What is the first step of the nursing process?

A

Assessment!

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2
Q

most common objective assessment done by nurses

A

Vital signs

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3
Q

objective assessment

A

When nurses asses an individual

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4
Q

Subjective assessment

A

When a patient tells us the problem

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5
Q

Range for temperature

A

98.6-100.4 F

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6
Q

Range for pulse

A

60-100 bpms

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7
Q

range for respirations

A

12-20

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8
Q

range for blood pressure

A

<120/<80

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9
Q

Pulse/heart rate reflects

A

Heart contraction. beats/min

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10
Q

Cardiac output

A

blood flow per minute

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11
Q

Radial

A

wrist

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12
Q

Apical

A

apex of the heart, 4th-5th ICS

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13
Q

carotid

A

along sternocleidomastoid muscle

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14
Q

Places for circulation assessment rather than vitals

A
  • brachial
  • femoral
  • popliteal
  • posterior
  • doralis pedis
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15
Q

Assess all four for pulse

A

Rate
Rhythm
Strength
Symmetry

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16
Q

what do you do if you palpate an irregular pulse

A

Listen to apical pulse for a full minute

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17
Q

Stroke volume

A

amount of blood the LV pumps out with each contraction

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18
Q

Cardiac output=

A

(Heart rate)(stroke volume)

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19
Q

what will happen to the Cardiac output when someone is dehydrated

A

heart rate increases, therefore CO increases

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20
Q

what will happen to the CO if a med decreases the HR?

A

Decrease in CO

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21
Q

Bradycardia

A

slow, less than 60bpm

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22
Q

Tachycardia

A

fast, more than 100 bpm

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23
Q

how to assess rhythm

A

regular or irregular?

  • regularly irregular (predictable)
  • irregularly irregular (unpredictable)
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24
Q

how to assess quality of pulse

A 
Bounding (4+)
Strong (3+)
Normal (2+)
Diminished (1+)
Absent (0)
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25
Q

actors influencing pulse rate

A
  • exercise
  • temperature
  • emotions
  • medications
  • hemorrhage/fluid loss
  • postural changes
  • pulmonary conditions
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26
Q

improved physical condition =

A

Decrease heart rate

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27
Q

fever affects on HR

A

Fever= Increase in HR

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28
Q

Hypothermia affects on hr

A

Hypothermia decreases HR

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29
Q

Emotions affect of HR

A

pain/anxiety = increases HR

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30
Q

Hemorrhage/fluid loss affects on HR

A

Increases Heart rate

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31
Q

change from standing to sitting affects on HR

A

Sit to stand increases HR

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32
Q

impaired O2 could lead to

A

increased HR

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33
Q

if circulation is compromised, what may be present

A

pallor or cyanosis

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34
Q

pallor

A

paleness of skin

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35
Q

cyanosis

A

bluish or grayish discoloration due to excessive CO2 and deficient O2

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36
Q

systolic pressure

A

peak pressure exerted against arterial walls as ventricles contract & eject blood

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37
Q

Diastolic pressure

A

Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest

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38
Q

Pulse pressure

A

difference between the systolic and diastolic pressures

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39
Q

Blood pressure is the result of interaction of

A
  • Cardiac output
  • peripheral vascular resistance
  • blood volume
  • blood viscosity
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40
Q

Decrease in radius =

A

increase in resistance, increase blood pressure

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41
Q

increase in radius =

A

decrease in resistance = decreased pressure

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42
Q

increase in blood volume=

A

increase in blood pressure

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43
Q

Decrease in blood volume =

A

Decrease in Blood pressure

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44
Q

physiological factors that influence BP

A 
age
stress
ethnicity 
gender 
medications
activity 
weight 
smoking
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45
Q

2 ways of measuring BP

A
  1. indirect or noninvasive

2. direct method

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46
Q

Indirect method or noninvasive

A

external devices like a BP cuff

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47
Q

direct method

A
  • done in critical care setting
  • catheter threaded into an artery
  • connected to electric monitoring system
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48
Q

1st korotkoff sound

A

systolic BP

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49
Q

5th korotkoff sound

A

silence, corresponding with diastole

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50
Q

which do you use to assess BP?

A

Systolic number

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51
Q

What is more common, hypertension or hypotension?

A

Hypertension

52
Q

What causes hypertension

A
  • thickening of walls
  • loss of elasticity
  • family history
  • risk factors
53
Q

Normal rang for BP

A

less than 120/80

54
Q

Elevated BP

A

120-129 and <80

55
Q

Hypertension stage 1

A

Systolic:130-139 or Diastolic:80-89

56
Q

Hypertension stage 2

A

> 140 or >90

57
Q

Hypotension

A

systolic BP <90

58
Q

symptoms of hypotension

A
  • pallor
  • clamminess
  • confusion
  • increased HR
  • decreases urine output
59
Q

orthostatic or postural hypotension

A

sudden drop in BP when going from a lying to sitting/standing

60
Q

Conditions not appropriate for electronic BP measurement

A 
irregular heart rate
vascular obstruction
shivering/tremors 
seizures 
inability to cooperate 
blood pressure less than 90 systolic
61
Q

Temp range for oral

A

98.6

62
Q

average rectal temp

A

99.5

63
Q

axillary temp

A

97.7

64
Q

Etiology of hypotension

A

Vascular dilation, inadequate pumping of heart, loss oxblood volume (Hemorrhage/dehydration)

65
Q

Clinical presentation of hypotension

A
  • Pallor
  • Clamminess
  • Confusion
  • Increased HR
  • Decreased urine output
  • weakened pulse
66
Q

Orthostatic or postural hypotension

A

sudden drop of BP on moving from a lying to a sitting or standing position

67
Q

Patient conditions not appropriate for ELECTRONIC blood pressure measurement

A
  • irregular heart rate
  • peripheral vascular obstruction
  • shivering/tremors
  • seizures
  • inability to cooperate
  • blood pressure less than 90 mmHg systolic
68
Q

Benefits of patient measurement of BP

A
  • Detection of new problems (pre-hypertension)
  • Patients with hypertension can provide to their health care provider info about patterns of BP
  • Self-monitoring helps adherence to therapy
69
Q

Disadvantages of patient measurement of BP

A
  • Improper use risks inaccurate readings
  • Unnecessary alarming of patient
  • Patients may inappropriately adjust medications
70
Q

Three processes of respiration

A
  • ventilation
  • diffusion
  • perfusion
71
Q

Ventilation

A

flow of gasses in and out of lungs; the amount of air in the alveoli

72
Q

Diffusion

A

Gas exchange between alveoli & pulmonary capillaries

73
Q

Perfusion

A

Flow of blood in the pulmonary capillaries

74
Q

Hypoxemia

A

Low O2

75
Q

How is respiration controlled

A

medulla

76
Q

Respiratory rate:

A

Breaths/minute

77
Q

Ventilatory depth

A

Deep/normal/shallow

78
Q

Ventilatory rhythm

A

regular/irregular

79
Q

Ventilatory assessment with diffusion and perfusion

A

O2 saturation

80
Q

Apnea

A

Cessation of breathing –> respiratory arrest

81
Q

Bradypnea

A

< 12/min

82
Q

Tachypnea

A

> 20/min

83
Q

Hyperventilation

A

Increase rate and depth

84
Q

Hypoventilation

A

Decreased rate and depth

85
Q

Effort for dyspnea

A

Labored breathing

86
Q

Effort for orthopnea

A

inability to breathe when horizontal. many sleep in recliners rather than laying flat

87
Q

SOB

A

Shortness of breath

88
Q

Abnormal patterns of breathing q

A

Cheyne-stokes
Biot
Kussmauls

89
Q

Cheyne-stokes

A
  • Irregular rate/depth
  • Apnea/hyperventilation
  • slow/shallow increases to abnormally fast/deep and then reverses
  • Common among those who are actively dying
90
Q

Biot

A

Shallow 2-3 breathes… apnea and repeats

91
Q

Kussmauls

A

Deep, regular, increases rate

  • high acidity in blood
  • Diabetes with a high blood sugar
92
Q

What does hyperventilation result in?

A

Excess loss of CO2 (hypocapnea)

93
Q

What happens to CO2 during hypoventilation

A

Co2 is retained (Hypercapnea)

94
Q

Normal measurement of oxygen saturation

A

95-100%

95
Q

How are Arterial blood gases (ABGs) measured?

A

Directly measures the partial pressure of O2, CO2 and blood PH

96
Q

What does oxygen saturation assess

A

diffusion and perfusion of oxygen

97
Q

How does light influence oximetry accuracy

A

bright light directly on the probe can throw off oximetry

98
Q

How does shivering/tremors influence oximetry accuracy

A

Movement makes it difficult to pick up signal

99
Q

How does pulse volume influence oximetry accuracy

A

sensor detects pulsatile flow, when BP is low the pulse may be too weak

100
Q

how does vasoconstriction influence oximetry accuracy

A

reduces blood flow and the sensor may not detect signal

101
Q

How does carbon monoxide poisoning influence oximetry accuracy

A

may give a falsely high saturation reading since CO binds very well to hemoglobin and displaces oxygen

102
Q

What happens to the pulse when O2 levels are low

A

Increases

103
Q

Factors that influence respirations

A 
exercise 
acute pain 
anxiety 
smoking 
medications
104
Q

What causes low BP?

A

shock, dehydration, hemmorhage

105
Q

How to measure temperature

A

Heat produced-minus-heat lost

106
Q

Temperature is influenced by

A

physiological cycles
age, activity, environment, basal metabolic rate
site of measurement

107
Q

Afebrile

A

Person with a normal temperature

108
Q

Conduction

A

transfer with direct contact

109
Q

Example of conduction

A

Ice packs/cool cloths

110
Q

radiation

A

transfer from one surface to another without direct contact

111
Q

Example of radiation

A

heater/fireplace

112
Q

Convention

A

transfer away through air movement: fan to cool

113
Q

Evaporation

A

transfer when liquid id converted to gas

114
Q

How does heat move through the concentration gradient

A

MOVES DOWN!!! from warmer to cooler

115
Q

which endocrine gland controls/influences temperature

A

Pituitary Gland

116
Q

Pyrexia

A

Fever

117
Q

Abnormal temperature

A

100.4 due to alteration in hypothalamic set point

118
Q

What kind of reaction is a fever

A

A functional reaction, which can sometimes me good

119
Q

How can a fever be good?

A

often in response to pyrogens (fever producing cytokines)

120
Q

Pyrogens induce _____

A

Secretion of chemical mediators

121
Q

How is hyperthermia different from fever

A

Hyperthermia is caused due to dysfunctional thermoregulation. NOT INTENDED AND NOT EVER GOOD

122
Q

Hypothermia

A

Core temperature below normal

123
Q

Can you exceed 100% for SpO2?

A

No!

124
Q

Malignant Hyperthermia is

A

Genetically predisposed

125
Q

Heat exhaustion _____ heat stroke?

A

Precedes heat stroke

126
Q

vital signs delegation

A

nurses can delegate activity of vital signs but it is their responsibility to interpret

nursing 314: assessing and promoting wellness (26 decks)

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