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Nursing 200 > Chapter 29 Vital Signs > Flashcards

Chapter 29 Vital Signs Flashcards

1
Q

Vital Signs:

A

indicators of health status, measures effectiveness of circulatory, respiratory, neural, endocrine body functions

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2
Q

body temperature =

A

heat produced -heat lost

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3
Q

core temperature:

A

middle body

relatively constant - temp of deep tissues

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4
Q

thermoregulation:

A

regulate the balance between heat lost and heat produced

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5
Q

BMR:

A

-Basal metabolic rate: depends on body surface area

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6
Q

Nonshivering thermogenesis:

A

occurs primarily in neonates (cannot shiver)

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7
Q

Diaphoresis:

A

visible perspiration primarily occurring on the forehead and upper thorax, although you can see it in other places on the body

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8
Q

Factors affecting body temperature:

A

age, exercise, hormone level, circadian rhythm, stress, environment, temperature alteration

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9
Q

Temperature Alterations:

A

fever, hyperthermia, heatstroke, heat exhaustion, hypothermia

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10
Q

fever

A

infection, based on several temperature readings at different times of the day

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11
Q

pyrexia:

A

occurs because heat-loss mechanisms are unable to keep pace with excessive heat production, resulting in an abnormal rise in body temperature

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12
Q

Pyrogens

A

bacteria/viruses elevate body temperature

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13
Q

febrile

A

pertaining to or characterized by an elevated body temperature

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14
Q

afebrile

A

when the fever “breaks” the patient

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15
Q

fever of unknown origin (FUO)

A

refers to fever with an undetermined cause

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16
Q

hyperthermia:

A

an elevated body temp related to the inability of the body to promote heat loss or reduce heat production

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17
Q

Malignant hyperthermia;

A

hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs

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18
Q

Heatstroke:

A

body temp of 40 C—prolonged exposure to the sun or high environmental temp

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19
Q

Heat exhaustion:

A

occurs when profuse diaphoresis results in excess water and electrolyte loss

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20
Q

Hypothermia

A

classified by core temp measurements – heat loss during prolonged exposure to cold overwhelms the ability of the body to produce heat

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21
Q

thermometers:

A

celsius and fahrenheit

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22
Q

Antipyretics:

A

medications that reduce fever

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23
Q

Cardiac output:

A

the volume of blood pumped by the heart during 1 minute

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24
Q

heart rate for

A

infant: 120-160
toddler: 90-140
preschooler: 80-110
school-aged children: 75-100
adolescent: 60-90
adult: 60-100

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25
tachycardia
abnormally elevated HR
26
bradycardia
slow HR
27
pulse deficit
contraction of the heart that fails to transmit a pulse wave to the peripheral pulse
28
dysrhythmia
interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm
29
What vital signs are taken?
Main 4: Temperature, pulse, respiratory rate, blood pressure Sometimes 5th sign is: Pain Oxygen saturation also frequently measured (oxygenate organs and how well tissues are)
30
Vital signs are used to:
Monitor patient’s condition Identify problems Evaluate response to intervention
31
Guidelines for measuring vitals include:
Ensure that equipment is functional and is appropriate for the size and age of the patient. Appropriately delegate measurement - have to follow up on them. Be able to understand and interpret values. Know the patient’s usual range of vital signs. Determine the patient’s medical history, therapies, and prescribed medications. Control or minimize environmental factors that affect vital signs.
32
Other Guidelines:
Use an organized, systematic approach when taking vital signs. (Pulse, respiration, BP, Temp) Know the acceptable ranges for your patients before administering medications, and use vital sign measurements to determine indications for medication administration. Communicate findings (new parameters) Accurately document findings. Analyze the results of vital sign measurement. Instruct the patient or family caregiver in vital sign assessment and the significance of findings.
33
Goal of body temp
to obtain a representative average temp of core body tissues
34
acceptable temp range:
98.6° F to 100.4° F or 36° C to 38° C | no single temp is normal for all people
35
Surface temperature measurement sites
Skin - forehead Oral cavity Axilla -0.5 C lower than oral temp
36
Core temperature measurement sites
Tympanic membrane - ear Urinary bladder Rectal - 0.5 C higher than oral temp,
37
The nurse is checking the patient’s core temperature. Which site is the nurse using?
B. Tympanic membrane
38
electronic thermometer
rechargeable battery powered displayed unit: blue probe = oral and axillary, red probe = rectal
39
1.You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to
D. Wait 30 minutes and take an oral temperature.
40
Goal of assessing radial pulse:
: to assess the integrity of the cardiovascular system
41
Which arteries are commonly used for a radial pulse?
radial and carotid arteries
42
Character of pulse:
rate, rhythm, strength, and equality
43
normal HR:
60-90 bpm
44
Respiration includes:
ventilation, diffusion, per-fusion, physiological control, mechanics, and rate
45
ventilation =
Movement of gases into and out of the lung.
46
diffusion =
Movement of oxygen and carbon monoxide between alveoli (deep lungs) and red blood cells
47
Perfusion =
Distribution of red blood cells to and from the pulmonary capillaries
48
Physiological control =
hypoxemia (low blood level of oxygen)
49
Mechanics of breathing =
eupnea (good breathing)
50
Normal rate of respiration
12-20
51
Measuring Oxygen Saturation (pulse oximetry)
Noninvasive measurement of arterial blood oxygen saturation A probe with a light-emitting diode (LED) measures oxygenated hemoglobin molecules Probes can be applied to the earlobe, finger, toe, bridge of nose, or forehead Normal pulse oximetry (SpO2) is greater than 95%
52
Assessing Arterial BP
hypertension, hypotension, blood pressure equipment (sphygmomanometer and stethoscope)
53
hypertension =
prehypertension = 140/90
54
hypotension =
orthostatic (BP drops when you stand up)
55
normal rate for BP
130/80
56
Factors influencing BP:
Age, ethnicity (hispanics, african americans), stress, gender, daily variation (10a-10pm at highest, lowest is sleep and 3am), activity, weight, smoking, medications
57
Evidence Based Practice: Automatic BP machines =
Do not give the same results as manual methods (stethoscope/sphygmomanometer) Systolic and diastolic values are lower Used when frequent assessment is required Critically ill/ potentially unstable patients During/ after invasive procedures Therapies requiring frequent monitoring
58
Patient Conditions Not Appropriate for Electronic Blood Pressure Measurement
Irregular heart rate Peripheral vascular obstruction (e.g., clots, narrowed vessels) Shivering Seizures Excessive tremors Inability to cooperate Blood pressure less than 90 mm Hg systolic
59
Benefits of electric BP measurement =
Detection of new problems (prehypertension) Patients with hypertension can provide to their health care provider info about patterns of BP. Self-monitoring helps adherence to therapy.
60
Disadvantages of electric BP measurement =
Improper use risks inaccurate readings. Unnecessary alarming of patient Patients may inappropriately adjust medications.
61
Recording Vital Signs
Record values on electronic or paper graphic. Record in nurses’ notes any accompanying or precipitating symptoms. Document interventions initiated on the basis of vital sign measurement. If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action.
62
Safety Guidelines for Skills:
Cleaning devices between patients decreases the risk for infection. Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown. Analyze trends for vital signs, and report abnormal findings. Determine the appropriate frequency of measuring vital signs based on the patient’s condition.
63
pain is ....
subjective (whatever the patient says it is)
64
ALWAYS obtain
baseline vitals
65
When to take Vital signs: Box 5-1
1. on admission to a health agency | 2. routine schedule
66
temp drops when you
sleep
67
Advantages and disadvantages everything but temporal: box 5-3
Oral: easily accessible
68
newborns lose heat from their
head
69
puberty = unstable
temps
70
normal adults = temp
96.8F
71
women have greater fluctuations in
temp because of hormones, hot flashes
72
1am-4am =
body at lowest temp
73
maximum temp at
6 pm
74
Table 5-1: Pulse sites
temporal, apical, ulnar, femoral, popliteal
75
Factors influencing character of respiration
exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function (decreased level = anemia)
76
pg 91 5-2 classification of BP for adults 18 +
normal = systolic-
77
Diaphragm is used for
high pitch sounds
78
bell is used for
low pitched sounds

Nursing 200 (23 decks)

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