27 ATI - Vital Signs Flashcards
____ are measurements of the body’s most basic functions and include temperature, pulse, respiration, and blood pressure.
vital signs
Many facilities also consider pain level and ______ vital signs.
oxygen saturation
____ reflects the balance between heat the body produces and heat lost tot he environment.
temperature
_____ is the measurement of the heart rate and rhythm. It corresponds to the bounding of blood flowing through various points in the circulatory system.
pulse
Pulse provides information about ______.
circulatory status
_____ is the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the blood and cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute.
respiration
_______ reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relation (diastole) of the heart.
blood pressure
Systolic blood pressure (SBP) occurs during _______ systole of the heart, when the ventricles force blood into the aorta and pulmonary artery, and it represents the max amount of pressure exerted on the arteries when ejection occurs.
ventricular
Diastolic blood pressure (DBP) occurs during ventricular diastole of the heart, when the ____ relax and exert minimal pressure against the arterial walls, and represents the minimum amount of pressure exerted on the arteries.
ventricles
The neurological and ______ systems work together to regulate body temperature. Disease or trauma of the hypothalamus or spinal cord will alter temperature control.
cardiovascular
Core measurement sites
rectum tympanic membrane temporal artery pulmonary artery esophagus urinary bladder
The skin, mouth, and _____ are surface temperature measurement sites.
axillae
_____ results from increases in basal metabolic rate, muscle activity, throxine output, testosterone, and sympathetic stimulation, which increase _____.
heat production
heat production
Heat loss through the body occurs through ___- which is the transfer of heat from the body directly to another surface (when the body is immersed in cold water)
conduction
Heat loss through the body occurs through ______ is the dispersion of heat by air currents (wind blowing across exposed skin)
convection
Heat loss through the body occurs through ______ which is the dispersion of heat through water vapor (perspiration).
evaporation
Heat loss through the body occurs through ______ is a transfer of heat from one object to another object without contact between them (heat lost form the body to a cold room(
radiation
Heat loss through the body occurs through ______ which is visible perspiration on the skin.
diaphoresis
An oral temperature range in both C and F.
36 to 38 C
96.8 to 100.4 F
The average is 37C or 98.6 F
Rectal temperatures are usually ____C or ___F higher than oral and tympanic temperatures.
.5C or .9F
Axillary temperatures are usually ____C or ____F lower than oral and tympanic temperatures.
.5C or .9F
Temporal temperatures are close to ____, but they are nearly 0.5C or 1 F higher than oral, and 1C higher than axillary temps.
rectal
A client’s usual temp serves as a ____ for comparison.
baseline
______ have a large surface to mass ration, so they lose heat rapidly to the environment. A _____ temperature should be between 36.5 or 37.5C and ____ to ____ F.
Newborns
newborn
97.7F to 99.5 F
Older adult clients experience a loss of subcutaneous fat that result in lower body temperatures and feeling cold. Their average body temperature is ___c or ___F.
36C or 96.8F
Older adult clients are more likely to develop adverse effects from ______ in environmental temps (heat stroke, hypothermia). It also takes longer for the body temperature to register on a _____ due to changes in temperature regulation.
extremes
thermometer
_____ changes can influence temperature. In general, temperature rises slightly with ovulation and menses. With menopause, intermittent body temperature can increase by up to ___ C or ____ F.
hormonal changes
4C or 7.2 F
Exercise, activity, and _____ can contribute to the development of hyperthermia.
dehydration
______ can cause elevations in temperature. Fever is the body’s response to infectious and inflammatory processes.
Illness and injury
___ causes an increase in the body’s immune response.
fever
Fevers causes an increase in ____ production.
White blood cell count (WBC)
Fevers cause a decrease in plasma ____ concentration to reduce bacteria growth.
iron
Fevers cause a stimulation of ______ to suppress virus production.
interferon
Recent food or fluid intake and _____ can interfere with accurate oral measurements of body temperature. It is best to wait 20 to 30 minutes before measuring ______.
smoking
oral temperature
______, stress, and environmental conditions can also affect body temperature.
circadian rhythm
Electronic thermometers use a probe to measure oral, rectal, or axillary temperatures. Place a ____ probe cover on the probe, insert the probe, and when you hear the signal, note the digital reading then discard the probe cover.
disposable
____ temperatures require a device specifically for measuring temp at the ____ membrane (eardrum)
tympanic
tympanic
Disposable, single use thermometers are for oral or ____ temp measurement. They reduce the risk of cross infection.
axillary
Procedures for taking Oral temperatures First perform hand hygiene, provide privacy and apply _____. Gently place the thermometer under the tongue in the ____ lateral to the center of the lower jaw. Leave it in place until you hear the signal.
clean gloves
posterior sublingual pocket
Oral temperatures should be used for clients who are ____ of age and older.
4 years
___ temperatures should not be sued for clients who breathe through their mouth or have experienced trauma to the face or mouth.
oral
Procedures for taking rectal temperatures first perform hand hygiene, provide privacy, and apply clean gloves. Assist the client to ____ position with the upper leg flexed. Wearing gloves, expose the anal area while keeping other body areas covered. Spread the buttocks to expose the anal opening. Ask the client to breathe slowly and relax when placing a ______ thermometer (with a rectal probe) into the anus in the direction of the umbilicus 2.5 to 3.5 cm (1 to 1.5 inches) in adults. If you encounter resistance, remove it immediately. Once inserted, hold the thermometer in place until you hear the signal. Clean the anal area to remove feces or lubricant. Use the rectal site to obtain a second measurement if the temp is above ____ C or ____V.
Sim’s
lubricated
37.2C or 99F
Rectal temperatures should not be used for clients who have diarrhea, are on bleeding precautions (such as those who have a low platelet count), or have _____.
rectal disorders
A rectal measurement of temperature is more accurate than axillary. However, because of the risk of rectal perforation, the American Academy of Pediatrics recommends screening infants ___ old and younger by measuring temperature initially.
3 month
____ in the rectum can cause inaccurate readings.
stool
Procedures for taking axillary temperature. Perform hand hygiene, provide privacy, and apply clan gloves. Place the thermometer (with an oral probe) in the center of the client’s clean, ____. Lower the arm over the probe. Hold the arm down, keeping the thermometer in position until you hear the signal.
dry axilla
Procedures taking tympanic temperature. First perform hand hygiene, provide privacy, and apply clean gloves. Pull the ear up and back (for an adult) or ______ (for a child who is younger than 3 years old), Place the thermometer probe snugly into the client’s ____ and press the scan button. Leave it in place until you hear the signal. Carefully remove the thermometer from the ear canal and read the temperature. _____ temperature can affect readings.
down and back
outer ear canal
ambient
The American Academy of Pediatrics advises against the use of electronic ear thermometers for infants _____ and younger due to the inaccuracy of readings.
3 months old
Excess _____ can alter the reading of a tympanic temperature measurement. If noted, use the other ear or select another site for temperature assessment.
earwax
Procedures for taking a temporal temperature. First perform hand hygiene, provide privacy, and apply clean gloves. Remove the protective cap and wipe the lens of the scanning device with alcohol to make sure it is clean. While pressing the scan button, hold the probe flat against the forehead while moving it gently across the ____ over the temporal artery, and then touch the skin behind the _____. Release the scan button to display the temperature reading.
forehead
earlobe
With temporal temperatures depending on the facility policy, either use disposable probe covers or clean the probe with a _____ between clients.
disinfectant wipe
Fever is usually not harmful unless it exceeds ____C or ____F.
39C or 102.2 F
_____ is an abnormally elevated body temperature.
Hyperthermia
Hypothermia is a body temperature less than _____C or ____F.
35C or 95F
_______ nervous system controls the heart rate.
autonomic
____ nervous system lowers the heart rate.
parasympathetic
______ nervous system raises the heart rate.
sympathetic
Assess the wave like sensations or impulses you feel in a _____ arterial vessel or over the apex of the heart as a gauge of cardiovascular status.
peripheral
____ is the number of times per minute you feel or hear the pulse.
rate
_____ is the regularity of impulses. A premature, late heartbeat or a missed beat can result in a irregular interval between impulses and can indicate altered electrical activity of the heart. Typically, you should detect an impulse at regular intervals.
rhythm
______ reflects the volume of blood ejected against the arterial wall with each heart contraction and the condition of the arterial vascular system. The strength of the impulse should be the same from beat to beat. Grade strength on a scale of ___ to ___.
Strength (amplitude)
0-4
Grade strength of a 0 =
absent, unable to palpate
Grade strength of a 1+ =
diminished, weaker than expected
Grade strength of 2+ =
Brisk, expected
Grade strength of 3+ =
Increased, strong
Grade strength of 4+ =
full volume, bounding
______ is when peripheral pulse impulses should be symmetrical in quality and quantity from the right side of the body to the left. Assess strength and _____ to evaluate the adequacy of the vascular system.
equality
equality
An inequality or absence of pulse on one side of body can indicate a ______ (thrombus, aortic dissection)
disease state
______ is an irregular heart rhythm, generally with an irregular radial pulse.
dysrhythmias
_____ is the difference between the apical rate and the radial rate. With dysrhythmias the heart can contract ineffectively, resulting in a beat at the apical site with no pulsation at the radial pulse point.
pulse deficit
To determine the ______ accurately, two clinicians should measure the apical and radial pulse rates simultaneously.
pulse deficit
To determine the ______ accurately, two clinicians should measure the apical and radial pulse rates simultaneously.
pulse deficit
To determine the ______ accurately, two clinicians should measure the apical and radial pulse rates simultaneously.
pulse deficit
For infants the expected pulse rate is ____ to ____.
120 to 160/min
The rate gradually decreases as infants grows older. The average pulse for a 12-14 year old child expected pulse rate is ____ to ____.
80 to 90/min
The strength of the pulsation can _____ in older adult clients due to poor circulation or cardiac dysfunction, which makes the peripheral pulses more difficult to palpate.
weaken
The expected reference range for an adult client’s pulse is ____ at rest.
60 to 100/min
_______ is a rate greater than the expected range or greater than 100/min.
tachycardia
Factors leading to tachycardia
Exercise
Fever, heat exposure
Medication: epinephrine, levothyroxine beta2-adrenergic agonists (albuterol)
Changing position from lying down to sitting or standing
Acute pain
Hyperthyroidism
Anemia, hypoximia
Stress, anxiety, fear
Hypovolemia, shock, heart failure, homorrhage
_____ is a rate less than the expected range or slower than 60/min.
bradycardia
Factors leading to Bradycardia
Long-term physical fitness
Hypothermia
Medications: digoxin, beta-blockers (propanolo), calcium channel blockers (verapamil)
Changing position from standing or sitting to lying down
Chronic sever pain
Hypothyroidism
Relaxation
To determine the pulse you first perform hand hygiene and provide privacy. Locate the radial pulse on the _____ thumb side of the forearm at the wrist. Assess the pulsation for rate, rhythm, amplitude, and quality. If the peripheral pulsations regular, count the rate for ____ and multiply by 2. If the pulsation is irregular, count for a full minute and compare the result to the apical pulse rate.
radial
30 seconds
Locate the apical pulse at the 5th intercostal space at the left midclavicular line. Use this site for assessing the heart rate of an infant, rapid rates (faster than 100/min), irregular rhythms, and rates prior to the administration of _______. Place the stethoscope on the chest at the 5th intercostal space at the left midclavicular line. If the rhythm is regular, count for 30 sec and multiply by 2. If the rhythm is irregular, or the client is receiving cardiovascular medications, count for 1 full minute
cardiac medications
With ______ nurses should monitor for pain, anxiety, restlessness, fatigue, low bp, and low oxygen saturation. Also, monitor for potential adverse effects of medications and prevent injury.
tachycardia
With _____ nurses should monitor for hypotension, chest pain, syncope, diaphoresis, dyspnea, and altered mental stated. Monitor for potential adverse effects of medications and prevent injury.
bradycardia
______ in the carotid arteries and the aorta primarily monitor carbon dioxide (CO2) levels of the blood.
chemoreceptors
Rising CO2 levels trigger the respiratory center of the brain to ______ the respiratory rate. The ____ rate rids the body of excess CO2. For clients who have chronic obstructive pulmonary disease (COPD), a low oxygen level becomes the primary respiratory drive.
increase
increased
_____ is the exchange of oxygen and carbon dioxide in the lungs. Measure ventilation with the respiratory rate, rhythm, and depth.
ventilation
_____ is the exchange of oxygen and carbon dioxide between the alveoli and the red blood cells. Measure diffusion with pulse oximetry.
diffusion
_____ is the flow of red blood cells to and from the pulmonary capillaries. Measure perfusion with pulse oximetry.
perfusion
Accurate assessment of respiration involves observing the rate, ___, and rhythm of chest wall movement during inspiration and expiration. Do not inform the client that you are measuring respirations.
depth
The ____ is the number of full inspirations and expirations in 1 min. Determine this by observing the number of times the client’s chest rises and falls. the expected reference range for adults is ______.
rate
12 to 20/min
The ____ is the amount of chest wall expansion that occurs with each breath. Altered depths are deep or shallow.
depth
The _____ is the observation of breathing intervals. For adults, expect a regular ____ (eupnea) with an occasional sigh.
rhythm
rhythm
_____ is a noninvasive, indirect measurement of the oxygen saturation (SaO2) of the blood (the percent of hemoglobin that is bound with oxygen in the arteries is the percent of the saturation of hemoglobin.
pulse oximetry
The expected reference range of oxygen saturation is ___ to _____, although acceptable levels for some clients range from ____ to _____. Some illness states can even allow for an SaO2 of 85% to 89%.
95 - 100%
91-100%
Respiratory rate decreases with ____.
age
Newborns have respiratory rates of ___ to ___
35 to 40/min
School age children have respiratory rates of ___ to ____.
20 to 30/min
Men and children are diaphragmatic breathers, and abdominal movements are more noticeable. Women use more _____ muscles, and chest movements are more pronounced when they breathe.
thoracic muscles
____ in the chest wall area can decrease the depth of respirations. At the onset of acute ____, the respiration rate increases but stabilizes over time.
pain
pain
____ increases the rate and depth of respirations.
anxiety
____ causes the resting rate of respirations to increase.
smoking
______ positions allow the chest wall to expand more fully.
upright
Medications such as opioids, _____, bronchodilators, and general anesthetics decrease respiratory rate and depth. Respiratory depression is a serious adverse effect. _____ and cocaine increase rate and depth.
sedatives
amphetamines
______ to the brainstem decreases respiratory rate and rhythm
neurological injury
______ can affect the shape of the chest wall, change the patency of passages, impair muscle function, and diminish respiratory effort. With these conditions, the use of accessory muscles, such as those visible in the neck, and the respiratory rate increase.
illnesses
______ of the blood that occurs with anemia or at high altitudes results in increases in the respiratory rate and alterations in rhythm to compensate.
impaired oxygen carrying capacity
Procedures for taking the respiratory rate begin with hand hygiene and provide privacy. Place the client in ____ position, being sure the chest is visible. Have the client rest an arm across the abdomen, or place a hand directly on the client’s abdomen. Observe one full respiratory cycle, look at the timer, and then begin counting the rate. Count a regular rate for _____ and multiply by 2. Count the rate for 1 minute if irregular, faster than 20/min, or slower than 12/min. Note depth (shallow, normal or deep) and rhythm (regular or irregular)
30 seconds
Procedures for taking oxygen saturation begins with an intact, nonedemaous site for probe or sensor placement. Place the digit probe on the client’s finger. Use _____ or bridge of nose for clients who have peripheral vascular disease. A disposable sensor pad can be applied to the sole of an infant’s foot. When the readout on the pulse oximeter is _____, record this value as the oxygen saturation.
earlobe
stable
The principle determinants of blood pressure are cardiac output (CO) and _____ .
systemic (peripheral) vascular resistance (SVR)
CO is determined by heart rate, contractility, blood volume, and _____. Increases in any of these increase CO and BP. Decreases in any of these decrease CO and BP.
venous return
______ reflects the amount of constriction or dilation of the arteries, and diameter of blood vessels. Increases in SVR increase BP. Decreases in SVR decrease BP.
SVR (systemic vascular resistance)
BP classifications
Normal
Prehypertension
Stage 1 Hypertension
Stage 2 Hypertension
BP classification normal
less than 120/less than 80
BP classification prehypertension
120-139/80-89
BP classification stage 1 hypertension
140-159/90-99
BP classification stage 2 hypertension
greater than 160/ greater than 100
If either the systolic or diastolic are in different categories you classify the patient in the _____ number bracket.
highest
_____ is a bp below the expected reference range (systolic less than 90 mmHg) and can be a result of fluid depletion, heart failure, or vasodilation.
hypotension
_____ is the difference between the systolic and the diastolic pressure reading.
pulse pressure
_______ is a bp that decreases when a client changes position from lying to sitting or standing, and it can result from various causes (peripheral vasodilation, medication adverse effects, fluid depletion, anemia, prolonged bed rest).
orthostatic (postural) hypotension
Assess orthostatic changes by taking the client’s BP and HR in the _____ position. Next have the client change to the sitting or standing position, wait 1 to 3 minutes, and reassess BP and HR. The client has orthostatic hypotension if the SBP decreases more than ____ or the DBP decreases more than ____ with a 10% to 20% increase in HR. Do not delegate this procedure to an assistive personnel.
supine
20 mm Hg
10 mm Hg
_____ have a low BP that gradually increases with age.
infants
Older children and adolescents have varying BP based on body size. Larger children have a ____.
higher BP
Adult’s BP can ____ with age.
increase
Older adult clients can have a slightly elevated systolic pressure due to decreased elasticity of ______.
blood vessels
_____ affect BP, with BP usually lowest in the early morning hours and peaking during the later part of the afternoon or evening.
circadian (diurnal) rhythms
____ associated with fear, emotional strain, and acute pain can increase BP.
stress
_____ can have an affect on BP. African Americans have a higher incidence of hypertension in general and at earlier ages.
ethnicity
_____ can also affect BP. Adolescent to middle age men have higher bp than their female counterparts. Postmenopausal women have higher bp than their male counterparts.
sex
Medications such as _____, antihypertensives, and cardiac mediations can lower BP.
opiates
Cocaine, nicotine, cold medications, oral contraceptives, alcohol, and ______ can raise BP.
antidepressants
____ can cause a decrease in BP for several hours afterward.
exercise
_____ is a contributing factor to hypertension.
obesity
_____ of hypertension, lack of exercise, high sodium intake, and continuous stress can increase the risk of hypertension.
family history
The width of the cuff should be ___% of the arm circumference at the point where the cuff is wrapped.
40%
The bladder (inside the cuff) should surround 80% of the arm circumference of an adult and the whole arm for a ____.
child
Cuffs that are too large give a falsely low reading, and cuffs that are too small give a falsely ____ reading.
high
When available for monitoring clients who require frequent evaluation use ________. Measure BP first using auscultatory method to make sure the automatic device readings are valid.
automatic bp devices
Study auscultatory method
1
orthostatic hypotension method
1
