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Nursing 200 > Chapter 29 Vital Signs > Flashcards

Chapter 29 Vital Signs Flashcards

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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
Q

tachycardia

A

abnormally elevated HR

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26
Q

bradycardia

A

slow HR

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27
Q

pulse deficit

A

contraction of the heart that fails to transmit a pulse wave to the peripheral pulse

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28
Q

dysrhythmia

A

interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm

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29
Q

What vital signs are taken?

A

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)

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30
Q

Vital signs are used to:

A

Monitor patient’s condition
Identify problems
Evaluate response to intervention

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31
Q

Guidelines for measuring vitals include:

A

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.

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32
Q

Other Guidelines:

A

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
Q

Goal of body temp

A

to obtain a representative average temp of core body tissues

34
Q

acceptable temp range:

A

98.6° F to 100.4° F or 36° C to 38° C

no single temp is normal for all people

35
Q

Surface temperature measurement sites

A

Skin - forehead
Oral cavity
Axilla -0.5 C lower than oral temp

36
Q

Core temperature measurement sites

A

Tympanic membrane - ear
Urinary bladder
Rectal - 0.5 C higher than oral temp,

37
Q

The nurse is checking the patient’s core temperature. Which site is the nurse using?

A

B. Tympanic membrane

38
Q

electronic thermometer

A

rechargeable battery powered displayed unit: blue probe = oral and axillary, red probe = rectal

39
Q

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

A

D. Wait 30 minutes and take an oral temperature.

40
Q

Goal of assessing radial pulse:

A

: to assess the integrity of the cardiovascular system

41
Q

Which arteries are commonly used for a radial pulse?

A

radial and carotid arteries

42
Q

Character of pulse:

A

rate, rhythm, strength, and equality

43
Q

normal HR:

A

60-90 bpm

44
Q

Respiration includes:

A

ventilation, diffusion, per-fusion, physiological control, mechanics, and rate

45
Q

ventilation =

A

Movement of gases into and out of the lung.

46
Q

diffusion =

A

Movement of oxygen and carbon monoxide between alveoli (deep lungs) and red blood cells

47
Q

Perfusion =

A

Distribution of red blood cells to and from the pulmonary capillaries

48
Q

Physiological control =

A

hypoxemia (low blood level of oxygen)

49
Q

Mechanics of breathing =

A

eupnea (good breathing)

50
Q

Normal rate of respiration

A

12-20

51
Q

Measuring Oxygen Saturation (pulse oximetry)

A

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
Q

Assessing Arterial BP

A

hypertension, hypotension, blood pressure equipment (sphygmomanometer and stethoscope)

53
Q

hypertension =

A

prehypertension = 140/90

54
Q

hypotension =

A

orthostatic (BP drops when you stand up)

55
Q

normal rate for BP

A

130/80

56
Q

Factors influencing BP:

A

Age, ethnicity (hispanics, african americans), stress, gender, daily variation (10a-10pm at highest, lowest is sleep and 3am), activity, weight, smoking, medications

57
Q

Evidence Based Practice: Automatic BP machines =

A

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
Q

Patient Conditions Not Appropriate for Electronic Blood Pressure Measurement

A

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
Q

Benefits of electric BP measurement =

A

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
Q

Disadvantages of electric BP measurement =

A

Improper use risks inaccurate readings.
Unnecessary alarming of patient
Patients may inappropriately adjust medications.

61
Q

Recording Vital Signs

A

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
Q

Safety Guidelines for Skills:

A

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
Q

pain is ….

A

subjective (whatever the patient says it is)

64
Q

ALWAYS obtain

A

baseline vitals

65
Q

When to take Vital signs: Box 5-1

A
  1. on admission to a health agency

2. routine schedule

66
Q

temp drops when you

A

sleep

67
Q

Advantages and disadvantages everything but temporal: box 5-3

A

Oral: easily accessible

68
Q

newborns lose heat from their

A

head

69
Q

puberty = unstable

A

temps

70
Q

normal adults = temp

A

96.8F

71
Q

women have greater fluctuations in

A

temp because of hormones, hot flashes

72
Q

1am-4am =

A

body at lowest temp

73
Q

maximum temp at

A

6 pm

74
Q

Table 5-1: Pulse sites

A

temporal, apical, ulnar, femoral, popliteal

75
Q

Factors influencing character of respiration

A

exercise, acute pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function (decreased level = anemia)

76
Q

pg 91 5-2 classification of BP for adults 18 +

A

normal = systolic-

77
Q

Diaphragm is used for

A

high pitch sounds

78
Q

bell is used for

A

low pitched sounds

Nursing 200 (23 decks)

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