CH 29 Vital Signs Flashcards
What are the 5 main vital signs and which other vital sign is commonly measured along with those?
Temp RR Pulse BP Pain
O2 saturation
Why is it important to evaluate vital signs right away upon admission?
It provides a baseline for the patient
What is AIDET?
Acknowledge Introduce Duration Explanation Thank you
What should we be sure of before bringing vital sign measurement equipment into the patients room?
The equipment is functioning properly and it is the right size
What are the 4 non-invasive places to measure temperature?
Oral, axillary, tympanic membrane, temporal artery
What is an acceptable temperature range? (Celsius and Fahrenheit)
98.6° F to 100.4° F
36° C to 38° C
What are the 3 invasive ways to take temperature?
rectal, esophageal, pulmonary
What part of the brain regulates temperature?
the hypothalamus
Between the anterior and posterior hypothalamus which regulates heat loss and which regulates heat production?
Anterior - heat loss
Posterior - heat production
Radiation
Transfer of heat from the surface of one object to another without direct contact
Conduction
transfer of heat from one object to another through direct contact
ex. ice pack/ warm blanket
Convection
Transfer of heat by air movement
ex. a fan
Evaporation
Transfer of heat when a liquid evaporates
ex. sweating
What is the word for sweating profusely?
Diaphoresis
Pyrexia
febrile/fever
above 38° C or 100.4° F
Afebrile
absence of fever
Hyperthermia
Higher temperature resulting from the body’s inability to promote heat loss of limit heat production
Malignant Hyperthermia
a hereditary condition of uncontrolled heat production that occurs when certain people receive certain anesthetic drugs
Sustained Fever
constant fever - stays above normal range
Intermittent Fever
fever spikes intermittently with usual temperature levels
Remittent Fever
fever spikes and falls without a return to normal temperature levels
Relapsing
periods of febrile episodes and periods with acceptable temperature values
Rectal temperatures are …
usually a half a degree to a degree higher than oral temperatures
Axillary temperatures are…
usually half a degree to a degree lower than oral temperature
Cardiac Output
The volume of blood pumped by the heart in 1 minute
HR x SV
Where can we find the apical heart rate?
Mid-clavicle, left side, 5th ICS
Where can we assess pulse? (9 places)
Carotid Temporal Brachial Radial Ulnar Femoral Popliteal Posterior Tibial Dorsalis Pedis
What are the different pulse strengths?
0 No pulse 1+ Very fine 2+ Normal pulse 3+ Stronger 4+ Bounding
Bradycardia
Less that 60 BPM
Tachycardia
More than 100 BPM
Pulse Deficit
The difference between radial and apical pulse
Can an irregular heart rhythm be regular or irregular?
Yes
Ventilation
the movement of air in and out of the lungs
Diffusion
The movement of oxygen and carbon dioxide between the alveoli and the red blood cells
Perfusion
distribution of the red blood cells that are carrying oxygen to the tissues
capillary refill
Hypoxemia
Low blood level of oxygen
Hypoxia
Low tissue level of oxygen
Eupnea
ventilation of normal rate and depth
What is about normal tidal volume?
500 mL
What nerve sends signals for diaphragm to contract, initiating inhalation?
The phrenic nerve
What things should we take note of when assessing respiration?
Rate Depth Regular/irregular Diffusion/perfusion (capillary refill, arterial blood gas) SpO2 (pulse oximeter)
SaO2
the percentage of how much hemoglobin is saturated with oxygen
should be between 95-100%
Why is the oxygen saturation of venous blood lower? (SvO2)
The tissues have already removed oxygen from the blood
Bradypnea
RR below 12
Tachypnea
RR above 20
Kussmaul
A very deep, repetitive, gasping respiratory pattern
Kussmaul
A very deep, repetitive, gasping respiratory pattern
Kussmaul
A very deep, repetitive, gasping respiratory pattern
What is the standard unit for measuring BP?
mmHg
What is pulse pressure?
The difference between systolic and diastolic pressure
What affects peripheral resistance?
tone of the vasculature and diameter of blood vessels
What 5 things (inside the body) affect blood pressure?
cardiac output peripheral resistance blood volume blood viscosity elasticity
Hypertension
over systolic 140 or diastolic 90
Hypotension
less than systolic 90
Bradycardia
Less than 60 BPM
Tachycardia
Above 100 BPM
