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Nursing Technologies > 1.3 Vital Signs > Flashcards

1.3 Vital Signs Flashcards

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1
Q

When to check vitals

A
  • Admission to healthcare facility
  • Based on policy/procedures
  • Change in patients condition
  • Loss of consciousness
  • Before and after surgical/invasive procedure
  • Before/after activity that can increase risk (ambulance ride)
  • Before administering medication that affect cardiovascular and respiratory function
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2
Q

Normal Vital Signs

A

Oral Temp - 37C, 98.6F
Pulse Rate - 60-100 (80 avg)
Respirations - 12-20
Blood Pressure - 120/80

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3
Q

Variations in Temperature

A

Temperature varies by age, sex, physical activity, state of health, environmental temperature.

Varies during time of day

  • Lowest early morning
  • Highest late afternoon
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4
Q

Heat Production/Heat Loss

A

Heat Production - Metabolism. Epinephrine and Norepinephrine are released to rapidly later metabolism for increased heat production. Thyroid hormone also increase metabolism. Shivering
Heat Loss - Skin. Opens to release heat into environment or close to retain heat. Controlled by sympathetic nervous system.

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5
Q

Methods of Temperature Taking

A

Oral - Mouth. Nothing to eat/drink 15-30 min prior. Not used in children under 5
Rectal - Rectum. 1 inch deep for child, 1.5 inch for adult.
Axillary - Armpit. Used when Oral and Rectal cannot be. Temperature affected by air temperature and perspiration
Tympanic - Ear. Quick and easy. Pinna pulled up for adults, ear lobe pulled down for children under 3.
Temporal - Forehead. Start on right or left and move across forehead.

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6
Q

Variation in Temperature between methods

A

Oral - Gold Standard
Rectal - Higher due to closed cavity
Axillary - Lower due to perspiration and air
Temporal - Lowest due to exposure of skin to air

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7
Q

Average temperature per method

A 
Oral - 37C, 98.6F
Rectal - 37.5C, 99.5F
Axillary - 36.5C, 97.7F
Tympanic - 37.5C, 99.5F
Temporal - 34.4C, 94.0F
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8
Q

Factors Affecting Temperature

A

Circadian Rhythm - Predictable fluctuations in body temperature and BP. (Lower in AM, Higher in PM)

Age/Biological Sex - Older adults may be lower in temp. Very old/very young are sensitive to changes in environmental temperature. Women temperature fluctuates more than men because of hormones. Usually warmer.

Physical Activity - Physical exertion increases body temperature. Increased metabolism.

State of Health

Environmental Temperature

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9
Q

Mechanisms of Heat Transfer

A

Radiation - Diffusion of heat by electromagnetic waves. Body gives off heat from uncovered surfaces.

Convection - Dissemination of heat by motion between areas of unequal density. (Fan)

Evaporation - Sweat

Conduction - Transfer of heat to another object during direct contact. (Ice Pack)

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10
Q

Afebrile/Pyrexia/Febrile/Hyperpyrexia

A

Afebrile - Normal Body Temperature
Pyrexia - Fever
Febrile - Elevated Body Temperature (Fever)
Hyperpyrexia - Equal or greater than 41C/106F. (Emergency)

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11
Q

Types of Fevers

A

Intermittent - Temp returns to normal at least once every 24 hours
Remittent - Temp does not return to normal and fluctuates few degrees up and down
Sustained/Continuous - Temp stays above normal with little variation
Relapsing/Recurrent - Temp returns to normal for one or more days with episodes of fever every few days

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12
Q

Pulse

A

Controlled by autonomic nervous system/SA node
Sympathetic - Speeds Heartrate
Parasympathetic - Slows Heartrate
Pulse Rate - Number of contractions in 1 minute

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13
Q

Pulse Sites

A 
Temporal - On the temple (Forehead)
Carotid - Neck
Brachial - Inner elbow
Radial - Inner wrist closest to thumb
Femoral - Groin/Abdomen
Popliteal - Behind Knee
Posterior Tibial - Inner Ankle
Dorsalis Pedis - On top of foot
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14
Q

Apical Pulse

A

Left side of chest over point of heart.

Check when patient takes medication altering heartrate or peripheral pulse is difficult to take. (Irregular, feeble, extremely rapid)

Count heartbeat for a full minute.

Most reliable in children under 2

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15
Q

Force of Pulse

A 
Strength of heart's stroke volume. 
0 - Absent Pulse
1+ - Weak, Thready
2+ - Normal
3+ - Full, bounding
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16
Q

Respirations

A

Movement of air in and out of lungs

Diffusion - Exchange of oxygen from alveoli and blood

Perfusion - Exchange of oxygen between blood and tissue

Regular Rate - 12-20

17
Q

Assessing Respiration Rate/Depth/Rhythm

A

Assess by observing chest/shoulder rise/fall

Auscultation - Listening to breathing via stethoscope
(Count for 15-30 seconds than multiply)

Observe sternal notch if difficult to see chest/shoulder

18
Q

Signs of Respiratory Disease

A

Orthopnea - Difficulty breathing

Tachypnea - Rapid Breathing

19
Q

Blood Pressure

A

Systolic Pressure - Highest point of pressure when ventricle contracts

Diastolic Pressure - Lowest point of pressure when ventricle relaxes

Measured in mmHG

Pulse Pressure - (Stroke Volume) Systolic (minus) Diastolic.

20
Q

Factors Affecting Blood Pressure

A
  • Age/Gender/Race
  • Circadian Rhythm
  • Food Intake
  • Exercise
  • Weight
  • Emotional State
  • Body Position
21
Q

Blood Pressure Readings

A 
Normal - 120/80
Elevated - 120-129/80
Stage 1 Hypertension - 130-139/80-89
Stage 2 Hypertension - 140+/90+
Hypertensive Crisis - 180+/120+
22
Q

Taking Blood Pressure

A

Done with stethoscope and sphygmomanometer

2 step method

  • Palpate heart rate.
  • Use cuff and pressurize until you no longer feel pulse
  • Release pressure than repressurize until 20 mmHg above when you no longer felt pulse
  • Take blood pressure
23
Q

Assessing Weight

A
  • Ask patient to remove heavy clothing (shoes/sweater)
  • For repeated weights, try to take them at the same time of day each time
  • Record weight in both kg and lb
24
Q

BMI

A

Underweight - Less than 18.5
Normal Weight - 18.5 - 24.9
Overweight - 25 - 29.9
Obese - Greater than 30

25
Q

Pain

A

Acute pain - Rapid onset, varies in intensity and duration

Chronic pain - Limited, Intermittent, or Persistent. Lasts beyond normal healing period. Remission and exacerbation are common.

Idiopathic pain - No identifiable cause

25
Q

Pain

A

Acute pain - Rapid onset, varies in intensity and duration

Chronic pain - Limited, Intermittent, or Persistent. Lasts beyond normal healing period. Remission and exacerbation are common.

Idiopathic pain - No identifiable cause

26
Q

Origin of Pain

A

Physical - Can be identified
Psychogenic - Cannot be identified
Referred - Perceived distant from point of origin

27
Q

Transduction/Transmission/Modulation

A

Transduction - Activation of pain receptors
Transmission - Conduction along the pathways
Modulation - Inhibition or modification of pain

28
Q

Responses/Factors to Pain

A

Sympathetic Nervous System governs response to pain

Factors influencing include

  • Cultural/Ethnic variables
  • Family/Sex/Gender/Age
  • Religious Beliefs
  • People to support
  • Anxiety/other stressors
  • Past pain experiences
29
Q

Assessment/measure of pain

A
  • Patient verbalization and description of pain
  • Duration/location of pain
  • Quantity/Intensity/Quality of pain
  • Chronology of pain
  • Aggravating/alleviating factors
  • Physiological indicators of pain
  • Behavioral response
  • Effect of pain on activities and lifestyles
30
Q

Assessment of pain (cont.)

A

Usually on a scale of 0-10

Neonates (newborn)
Neonatal Infant Pain Scale (NIPS)
Neonatal Pain, Agitation, Sedation Scale (N-Pass)
- Assesses posturing, ability to soothe, and respiratory patterns in baby.

31
Q

Pharmacologic Interventions for Pain

A 
Oral Medication
Injectable Medication
Patient-Controlled Analgesia (PCA)
Local Anesthesia
Epidural Anesthesia
32
Q

Non-Pharmacologic Interventions for Pain

A
  • Distraction
  • Imagery
  • Relaxation
  • Massage
  • Pressure/acupuncture
  • Animal-facilitated therapy
33
Q

Non-Pharmacologic Interventions for Pain

A
  • Distraction
  • Imagery
  • Relaxation
  • Massage
  • Pressure/acupuncture
  • Animal-facilitated therapy

Nursing Technologies (17 decks)

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