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
2
Q
What can variations in vital signs reflect?
A
A person’s state of health and/or functional ability of the body systems
3
Q
What is important to emphasize in assessments, interpretation, and documentation of vital signs?
A
ACCURACY
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
5
Q
How often are vital signs assessed?
A
On a regular basis
6
Q
Why are vital signs assessed upon admission to any health care facility or institution?
A
To establish a baseline
7
Q
What needs to be assessed any time there is a change in the patient’s condition?
A
Vital signs
8
Q
What needs to be assessed any time there is a loss of consciousness?
A
Vital signs
9
Q
When do vital signs need to be assessed in regards to any surgical or invasive diagnostic procedure?
A
Before and after
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
11
Q
When do vital signs need to be assessed in regards to administering medications that affect cardiovascular and respiratory function?
A
Before
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
13
Q
What is considered the normal range for pulse rate in healthy adults? What is average?
A
60 to 100 (80 average)
14
Q
What is considered the normal range for respirations in healthy adults?
A
12 to 20 breaths/min
15
Q
What is considered the normal range for blood pressure in healthy adults?
A
Less than 120/80
16
Q
What is the primary source for heat production?
A
Metabolism
17
Q
What factors can increase metabolism?
A
Hormones, muscle movements, and exercise
18
Q
What hormones are released when additional heat is required, thus altering metabolism?
A
Epinephrine and norepinephrine
19
Q
What can the thyroid hormone and shivering also increase?
A
Heat production
20
Q
What occurs when energy production decreases?
A
Heat production increases
21
Q
What is thermogenesis?
A
The human body’s constant production of heat
22
Q
What is the primary source of heat loss?
A
Skin
23
Q
What occurs when sweat evaporates?
A
Heat loss
24
Q
What can occur as a result of warming and humidifying inspired air?
A
Heat loss
25
What can occur as a result of urine and feces elimination?
Heat loss
26
What factors can affect body temperature?
Circadian rhythms
Age and gender
Physical activity
State of health
Environmental temperature
27
What is afebrile?
Without fever
28
What is pyrexia?
With fever (febrile)
29
What is the normal range for body temperature (axillary) in a newborn?
35.5-39.5°C or 96.0–99.5°F
30
What is the normal range for body temperature (oral) in a 1 year old?
37.7°C or 99.7°F
31
What is the normal range for body temperature (oral) in a 3 year old?
37.2°C or 99.0°F
32
What is the normal range for body temperature (oral) in a 5 year old?
37.0°C or 98.6°F
33
What is the normal range for body temperature in an adult?
Oral: 37.0°C or 98.6°F
Axillary: 36.4°C or 97.6°F
Rectal: 37.6°C or 99.6°F
34
What is the normal range for body temperature (oral) in a 70+ year old?
36.0°C or 96.8°F
35
What is normal oral temperature for healthy adults?
35.9–37.5°C; 96.6–99.5°F
36
What is the normal rectal temperature for healthy adults?
36.3–38.1°C; 97.4–100.5°F
*1°F higher/ Core Body Temperature
37
What is the normal axillary temperature for healthy adults?
35.4–36.9°C; 95.6–98.5°F
38
What is the normal tympanic temperature for healthy adults?
36.8–38.3º C; 98.2–100.9°F
39
What is the normal forehead (temporal artery) temperature for healthy adults?
36.3–38.1°C; 98.7–100.5°F
40
What are the advantages of assessing temperature orally? Disadvantages and contraindications?
41
What are the advantages of assessing temperature temporally? Disadvantages and contraindications?
42
What are the advantages of assessing axillary temperature? Disadvantages and contraindications?
43
What are the advantages of assessing temperature rectally? Disadvantages and contraindications?
44
What is regulated by the autonomic nervous system through the cardiac sinoatrial node?
Pulse
45
What increases heart rate?
Sympathetic stimulation
45
What decreases heart rate?
Parasympathetic stimulation
46
What is pulse rate?
The number of contractions over a peripheral artery in one minute
47
What factors affect pulse rate?
Age
Biologic sex
Physical actvity
Body temperature
Stress
Medications
Presence of disease
Blood volume
48
What are the sites for detecting pulse?
Temporal
Carotid
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
49
What are the steps to obtain a pulse rate (peripheral)?
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
50
What are the characteristics of the peripheral pulse (what to collect)?
Rate
Phythm
Aplitude/quality
51
What is considered a normal pulse rate?
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.
52
What is bradycardia?
Rate less than 60 bpm
53
What is tachycardia?
Rate greater than 100 bpm
54
What is a pulse deficit?
Hear a heartbeat but do not feel a beat at pulse point?
55
Which pulse site is located on the inside of the elbow?
Brachial
56
True or false: the normal pulse rate for adolescents and adults ranges from 60 to 100 bpm
True
57
What is pulse rhythm?
The pattern of the beats and the intervals between them
58
What are the types of pulse rhythm?
Regular and irregular
59
What is a grade 0 pulse strength?
absent, unable to palpate
60
What is a grade +1 pulse strength?
Diminished, weaker than expected
61
What is a grade +2 pulse strength?
Within normal limits; brisk, expected
62
What is a grade +3 pulse strength?
Bounding
63
What is the most accurate pulse rate?
Apical
64
What are the steps to obtain a pulse rate (apical)?
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
What is defined by one series of LUB and DUB sounds?
A heartbeat
66
What is ventilation?
Movement of air in and out of lungs
67
What is inhalation?
Breathing in
68
What is exhalation?
Breathing out
69
What is the exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood?
Diffusion
70
What is the exchange of oxygen and carbon dioxide between circulation blood and tissue cells?
Perfusion
71
What factors affect respiration?
Age
Exercise
Acid-base balance
Brain lesions
Altitude
Respiratory disease
Anemia
Anxiety
Medications
Pain
72
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
True
73
What changes in response to tissue demands?
Rate and depth of breathing
74
Rate and depth of breathing is activated by impulses from ________________
Chemoreceptors
75
What is the most powerful respiratory stimulant?
Carbon dioxide
76
What is normal, unlabored respiration; one respiration to four heartbeats?
Eupnea
77
What is increased respiratory rate; may occur in response to an increased metabolic rate?
Tachypnea
78
What is decreased respiratory rate; occurs in some pathologic conditions?
Bradypnea
79
What is defined by periods when no breathing occurs?
Apnea
80
What is defined by difficult or labored breathing?
Dyspnea
81
What are changes in breathing when sitting or standing?
Orthopnea
82
What population is respiratory rate accuracy especially important?
Older adults
83
What should the nurse count after taking the radial pulse?
Respiratory rate (RR)
84
What can the patient easily alter in regards to respirations?
Rate and pattern
85
What is respiratory rate?
Breaths per minute
86
What is respiratory depth?
Movement of chest wall (deep, normal, shallow)
87
What is respiratory rhythm?
Breathing pattern (regular, irregular)
88
What is respiratory effort?
Amount of effort (effortless, dyspnea, orthopnea)
89
What tool (external device) is used to measure oxygenation?
Pulse oximetry
90
What is pulse oximetry?
A noninvasive method of monitoring respiratory status
91
What is a normal finding for pulse oximetry?
95-100%
92
What is blood pressure?
Force of the moving blood against arterial walls
93
What is the maximum pressure when left ventricle contracts and pushes blood through aortic valve into the aorta?
Systole/systolic pressure
94
What is the lowest pressure when the heart rest between beats?
Diastole/diastolic pressure
95
What is the difference between systolic and diastolic pressure called?
Pulse pressure
96
What can regulate blood pressure (Short term)?
Neural (nerve) or humoral (pertaining to body fluids)
97
What can affect blood pressure?
Cardiac output (strength of heart contracctions)
98
What can slow heart rate?
Stimulation of the vagus nerve (parasympathetic impulses)
99
What can increase heart rate?
Sympathetic stimulation
100
What in the heart monitors pressure and signals the cardiovascular center of the brain?
Baroreceptors
101
What does renin-angiotensin-aldosterone system raise?
Pressure
102
What is normal blood pressure?
Systolic: less than 120 mmHg
Diastolic: less than 80 mmHg
103
What is elevated blood pressure?
Systolic: 120-129 mmHg
Diastolic: 80 or less
104
What is considered stage I hypertension?
Systolic: 130-139 mmHg
OR
Diastolic: 80-89 mmHg
105
What is considered stage II hypertension?
Systolic: 140 mmHg or higher
OR
Diastolic: 90 mmHg or higher
106
What is considered a hypertensive crisis?
Systolic: greater than 180 mmHg
AND/OR
Diastolic: greater than 120 mmHg
107
What factors affect blood pressure?
Age
Race
Circadian rhythm
Biologic sex
Food intake
Exercise
Weight
Emotional state
Body position
Drugs/medications
108
What is hypotension?
Less than 90/60 mmHg
109
What can result as a side effect of medications?
Decreased blood pressure (hypotension)
110
What is the inability of the body to maintain or return pressure back to normal?
Hypotension
111
What results from an inadequate physiologic response to position changes?
Orthostatic hypotension (postural hypotension)
112
What occurs when rising from an erect position?
Orthostatic hypotension
113
What is caused by dehydration, blood loss, or problems of the neurologic, cardiovascular, or endocrine systems?
Orthostatic hypotension
114
What equipment is used to assess blood pressure?
Stethoscope and sphygmanometer
115
What can happen if the blood pressure cuff is too narrow?
The reading will be too high
116
What can happen if the blood pressure cuff is too wide?
The reading will be too low
117
What site should not be used for assessing blood pressure?
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
What type of sounds do you listen for with a stethoscope when assessing blood pressure?
Korotkoff
119
What is the first sound when assessing blood pressure?
Systolic pressure
120
What is the cessation of sounds when assessing blood pressure?
Diastolic pressure
121
What arteries are commonly used when assessing blood pressure?
Brachial and popliteal
122
What must you do while inflating the cuff to ensure that the cuff is inflated higher than the systolic blood pressure?
Palpate the artery
123
How much more do you inflate the cuff when assessing blood pressure?
30 mmHg above the point where the pulse can no longer be felt
124
What is important to know when assessing pain?
Pain history
125
What is the direct observation of behaviors, physical signs of tissue damage, secondary physiological responses?
Pain assessment
126
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?”
Pain assessment
127
Who is responsible for interpretation of vital sighs, vital sign trends, and decisions based on abnormal vital sign findings?
The nurse
128
Who can delegate the activity of taking vital signs?
The nurse
129
What is a student nurse responsible for functioning within?
Own scope of knowledge
