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NUR1023 > Chapter 26 - Vital Signs > Flashcards

Chapter 26 - Vital Signs Flashcards

Week 1

1
Q

Why are vital signs important?

A

They are a means of assessing vital or critical physiological functions

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2
Q

What can variations in vital signs reflect?

A

A person’s state of health and/or functional ability of the body systems

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3
Q

What is important to emphasize in assessments, interpretation, and documentation of vital signs?

A

ACCURACY

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4
Q

List the vital signs and their respective acronyms (if applicable)

A

Temperature (T)
Pulse (P)
Respiration (R)
Blood pressure (BP)
Pain (often included as fifth sign)
Pulse oximetry

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5
Q

How often are vital signs assessed?

A

On a regular basis

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6
Q

Why are vital signs assessed upon admission to any health care facility or institution?

A

To establish a baseline

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7
Q

What needs to be assessed any time there is a change in the patient’s condition?

A

Vital signs

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8
Q

What needs to be assessed any time there is a loss of consciousness?

A

Vital signs

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9
Q

When do vital signs need to be assessed in regards to any surgical or invasive diagnostic procedure?

A

Before and after

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10
Q

When do vital signs need to be assessed in regards to activity that may increase risk, such as ambulation after surgery?

A

Before and after

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11
Q

When do vital signs need to be assessed in regards to administering medications that affect cardiovascular and respiratory function?

A

Before

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12
Q

What is considered the normal range for oral temperature in healthy adults?

A

35.8-37.5°C or 96.4–99.5°F

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13
Q

What is considered the normal range for pulse rate in healthy adults? What is average?

A

60 to 100 (80 average)

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14
Q

What is considered the normal range for respirations in healthy adults?

A

12 to 20 breaths/min

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15
Q

What is considered the normal range for blood pressure in healthy adults?

A

Less than 120/80

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16
Q

What is the primary source for heat production?

A

Metabolism

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17
Q

What factors can increase metabolism?

A

Hormones, muscle movements, and exercise

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18
Q

What hormones are released when additional heat is required, thus altering metabolism?

A

Epinephrine and norepinephrine

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19
Q

What can the thyroid hormone and shivering also increase?

A

Heat production

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20
Q

What occurs when energy production decreases?

A

Heat production increases

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21
Q

What is thermogenesis?

A

The human body’s constant production of heat

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22
Q

What is the primary source of heat loss?

A

Skin

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23
Q

What occurs when sweat evaporates?

A

Heat loss

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24
Q

What can occur as a result of warming and humidifying inspired air?

A

Heat loss

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25
Q

What can occur as a result of urine and feces elimination?

A

Heat loss

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26
Q

What factors can affect body temperature?

A

Circadian rhythms
Age and gender
Physical activity
State of health
Environmental temperature

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27
Q

What is afebrile?

A

Without fever

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28
Q

What is pyrexia?

A

With fever (febrile)

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29
Q

What is the normal range for body temperature (axillary) in a newborn?

A

35.5-39.5°C or 96.0–99.5°F

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30
Q

What is the normal range for body temperature (oral) in a 1 year old?

A

37.7°C or 99.7°F

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31
Q

What is the normal range for body temperature (oral) in a 3 year old?

A

37.2°C or 99.0°F

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32
Q

What is the normal range for body temperature (oral) in a 5 year old?

A

37.0°C or 98.6°F

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33
Q

What is the normal range for body temperature in an adult?

A

Oral: 37.0°C or 98.6°F
Axillary: 36.4°C or 97.6°F
Rectal: 37.6°C or 99.6°F

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34
Q

What is the normal range for body temperature (oral) in a 70+ year old?

A

36.0°C or 96.8°F

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35
Q

What is normal oral temperature for healthy adults?

A

35.9–37.5°C; 96.6–99.5°F

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36
Q

What is the normal rectal temperature for healthy adults?

A

36.3–38.1°C; 97.4–100.5°F
*1°F higher/ Core Body Temperature

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37
Q

What is the normal axillary temperature for healthy adults?

A

35.4–36.9°C; 95.6–98.5°F

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38
Q

What is the normal tympanic temperature for healthy adults?

A

36.8–38.3º C; 98.2–100.9°F

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39
Q

What is the normal forehead (temporal artery) temperature for healthy adults?

A

36.3–38.1°C; 98.7–100.5°F

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40
Q

What are the advantages of assessing temperature orally? Disadvantages and contraindications?

A
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41
Q

What are the advantages of assessing temperature temporally? Disadvantages and contraindications?

A
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42
Q

What are the advantages of assessing axillary temperature? Disadvantages and contraindications?

A
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43
Q

What are the advantages of assessing temperature rectally? Disadvantages and contraindications?

A
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44
Q

What is regulated by the autonomic nervous system through the cardiac sinoatrial node?

A

Pulse

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45
Q

What increases heart rate?

A

Sympathetic stimulation

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45
Q

What decreases heart rate?

A

Parasympathetic stimulation

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46
Q

What is pulse rate?

A

The number of contractions over a peripheral artery in one minute

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47
Q

What factors affect pulse rate?

A

Age
Biologic sex
Physical actvity
Body temperature
Stress
Medications
Presence of disease
Blood volume

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48
Q

What are the sites for detecting pulse?

A

Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

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49
Q

What are the steps to obtain a pulse rate (peripheral)?

A

Acquire a watch or clock with a second hard or digital display
Count 30 seconds and multiply by 2
If irregular, count apical for one minute

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50
Q

What are the characteristics of the peripheral pulse (what to collect)?

A

Rate
Phythm
Aplitude/quality

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51
Q

What is considered a normal pulse rate?

A

60-100 BPM is a healthy resting heart rate for most healthy adults. The more fit you are, the lower your resting heart rate will be.

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52
Q

What is bradycardia?

A

Rate less than 60 bpm

53
Q

What is tachycardia?

A

Rate greater than 100 bpm

54
Q

What is a pulse deficit?

A

Hear a heartbeat but do not feel a beat at pulse point?

55
Q

Which pulse site is located on the inside of the elbow?

A

Brachial

56
Q

True or false: the normal pulse rate for adolescents and adults ranges from 60 to 100 bpm

A

True

57
Q

What is pulse rhythm?

A

The pattern of the beats and the intervals between them

58
Q

What are the types of pulse rhythm?

A

Regular and irregular

59
Q

What is a grade 0 pulse strength?

A

absent, unable to palpate

60
Q

What is a grade +1 pulse strength?

A

Diminished, weaker than expected

61
Q

What is a grade +2 pulse strength?

A

Within normal limits; brisk, expected

62
Q

What is a grade +3 pulse strength?

A

Bounding

63
Q

What is the most accurate pulse rate?

A

Apical

64
Q

What are the steps to obtain a pulse rate (apical)?

A

Use a stethoscope to auscultate the number of heartbeats at the apex of the heart
Use a watch or clock with a second hand or digital display to keep track of the time

65
Q

What is defined by one series of LUB and DUB sounds?

A

A heartbeat

66
Q

What is ventilation?

A

Movement of air in and out of lungs

67
Q

What is inhalation?

A

Breathing in

68
Q

What is exhalation?

A

Breathing out

69
Q

What is the exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood?

A

Diffusion

70
Q

What is the exchange of oxygen and carbon dioxide between circulation blood and tissue cells?

A

Perfusion

71
Q

What factors affect respiration?

A

Age
Exercise
Acid-base balance
Brain lesions
Altitude
Respiratory disease
Anemia
Anxiety
Medications
Pain

72
Q

True or false: changes in the rate and depth of inhalation and exhalation are brought about by the inhibition or stimulation of the respiratory muscles by respiratory centers in the medulla and pons

A

True

73
Q

What changes in response to tissue demands?

A

Rate and depth of breathing

74
Q

Rate and depth of breathing is activated by impulses from ________________

A

Chemoreceptors

75
Q

What is the most powerful respiratory stimulant?

A

Carbon dioxide

76
Q

What is normal, unlabored respiration; one respiration to four heartbeats?

A

Eupnea

77
Q

What is increased respiratory rate; may occur in response to an increased metabolic rate?

A

Tachypnea

78
Q

What is decreased respiratory rate; occurs in some pathologic conditions?

A

Bradypnea

79
Q

What is defined by periods when no breathing occurs?

A

Apnea

80
Q

What is defined by difficult or labored breathing?

A

Dyspnea

81
Q

What are changes in breathing when sitting or standing?

A

Orthopnea

82
Q

What population is respiratory rate accuracy especially important?

A

Older adults

83
Q

What should the nurse count after taking the radial pulse?

A

Respiratory rate (RR)

84
Q

What can the patient easily alter in regards to respirations?

A

Rate and pattern

85
Q

What is respiratory rate?

A

Breaths per minute

86
Q

What is respiratory depth?

A

Movement of chest wall (deep, normal, shallow)

87
Q

What is respiratory rhythm?

A

Breathing pattern (regular, irregular)

88
Q

What is respiratory effort?

A

Amount of effort (effortless, dyspnea, orthopnea)

89
Q

What tool (external device) is used to measure oxygenation?

A

Pulse oximetry

90
Q

What is pulse oximetry?

A

A noninvasive method of monitoring respiratory status

91
Q

What is a normal finding for pulse oximetry?

A

95-100%

92
Q

What is blood pressure?

A

Force of the moving blood against arterial walls

93
Q

What is the maximum pressure when left ventricle contracts and pushes blood through aortic valve into the aorta?

A

Systole/systolic pressure

94
Q

What is the lowest pressure when the heart rest between beats?

A

Diastole/diastolic pressure

95
Q

What is the difference between systolic and diastolic pressure called?

A

Pulse pressure

96
Q

What can regulate blood pressure (Short term)?

A

Neural (nerve) or humoral (pertaining to body fluids)

97
Q

What can affect blood pressure?

A

Cardiac output (strength of heart contracctions)

98
Q

What can slow heart rate?

A

Stimulation of the vagus nerve (parasympathetic impulses)

99
Q

What can increase heart rate?

A

Sympathetic stimulation

100
Q

What in the heart monitors pressure and signals the cardiovascular center of the brain?

A

Baroreceptors

101
Q

What does renin-angiotensin-aldosterone system raise?

A

Pressure

102
Q

What is normal blood pressure?

A

Systolic: less than 120 mmHg
Diastolic: less than 80 mmHg

103
Q

What is elevated blood pressure?

A

Systolic: 120-129 mmHg
Diastolic: 80 or less

104
Q

What is considered stage I hypertension?

A

Systolic: 130-139 mmHg
OR
Diastolic: 80-89 mmHg

105
Q

What is considered stage II hypertension?

A

Systolic: 140 mmHg or higher
OR
Diastolic: 90 mmHg or higher

106
Q

What is considered a hypertensive crisis?

A

Systolic: greater than 180 mmHg
AND/OR
Diastolic: greater than 120 mmHg

107
Q

What factors affect blood pressure?

A

Age
Race
Circadian rhythm
Biologic sex
Food intake
Exercise
Weight
Emotional state
Body position
Drugs/medications

108
Q

What is hypotension?

A

Less than 90/60 mmHg

109
Q

What can result as a side effect of medications?

A

Decreased blood pressure (hypotension)

110
Q

What is the inability of the body to maintain or return pressure back to normal?

A

Hypotension

111
Q

What results from an inadequate physiologic response to position changes?

A

Orthostatic hypotension (postural hypotension)

112
Q

What occurs when rising from an erect position?

A

Orthostatic hypotension

113
Q

What is caused by dehydration, blood loss, or problems of the neurologic, cardiovascular, or endocrine systems?

A

Orthostatic hypotension

114
Q

What equipment is used to assess blood pressure?

A

Stethoscope and sphygmanometer

115
Q

What can happen if the blood pressure cuff is too narrow?

A

The reading will be too high

116
Q

What can happen if the blood pressure cuff is too wide?

A

The reading will be too low

117
Q

What site should not be used for assessing blood pressure?

A

Do not use an arm that has an IV access device, renal dialysis fistula, skin graft trauma, a cast, or dressing

Do not use a paralyzed arm or on the same side of previous breast or shoulder surgery

118
Q

What type of sounds do you listen for with a stethoscope when assessing blood pressure?

A

Korotkoff

119
Q

What is the first sound when assessing blood pressure?

A

Systolic pressure

120
Q

What is the cessation of sounds when assessing blood pressure?

A

Diastolic pressure

121
Q

What arteries are commonly used when assessing blood pressure?

A

Brachial and popliteal

122
Q

What must you do while inflating the cuff to ensure that the cuff is inflated higher than the systolic blood pressure?

A

Palpate the artery

123
Q

How much more do you inflate the cuff when assessing blood pressure?

A

30 mmHg above the point where the pulse can no longer be felt

124
Q

What is important to know when assessing pain?

A

Pain history

125
Q

What is the direct observation of behaviors, physical signs of tissue damage, secondary physiological responses?

A

Pain assessment

126
Q

What vital signs are being measured when asked:
“On a scale of 0-10, with 0 being no pain and 10 being severe pain, how would you rate your pain?”

A

Pain assessment

127
Q

Who is responsible for interpretation of vital sighs, vital sign trends, and decisions based on abnormal vital sign findings?

A

The nurse

128
Q

Who can delegate the activity of taking vital signs?

A

The nurse

129
Q

What is a student nurse responsible for functioning within?

A

Own scope of knowledge

NUR1023 (7 decks)

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