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NURS 305 > Chapter 30: Vital Signs > Flashcards

Chapter 30: Vital Signs Flashcards

1
Q

What are the vital signs?

A
  1. Temperature
  2. Pulse
  3. Respiration
  4. Oxygen Saturation
  5. Blood Pressure
  6. Pain
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2
Q

Vital Signs measure the effectiveness of:

A
  1. The circulatory system
  2. The respiratory system
  3. The neural system
  4. The endocrine system
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3
Q

What causes vital signs to change?

A
  1. Temperature of environment
  2. Physical Exertion
  3. Effects of Illness
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4
Q

What are the guidelines to taking vital signs?

A
  1. The RN is always responsible for the measurement of VS. (nurse analyzes and interpret the significance)
  2. Ensure the equipment is functional and appropriate for the patient.
  3. Know the patient baseline if possible.
  4. Know your patient therapies. (Certain medications and therapies can alter VS)
  5. Know the frequency at which it is essential to take VS. (according to unit policy and patient condition)
  6. Communicate significant changes!
  7. Patient and family teaching.
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5
Q

Body Temperature

A

Heat Produced - Heat Lost = Body Temperature aka Thermoregulation

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6
Q

Temperature Range for Adults: Average Temperature Range

A

36° to 38° C (96.8° to 100.4° F)

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7
Q

Temperature Range for Adults: Average oral/tympanic

A

37° C (98.6° F)

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8
Q

Temperature Range for Adults: Average rectal

A

37.5° C (99.5° F)

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9
Q

Temperature Range of Adults: Axillary

A

36.5° C (97.7° F)

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10
Q

Core temperature

A

Temperature of the deep tissues

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11
Q

Sites of Temperature Measurement

A
  • Axillary
  • Rectal
  • Oral
  • Tympanic membrane (core)
  • Temporal artery
  • Esophageal (core)
  • Pulmonary artery (core)
  • Bladder (core)
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12
Q

Body temperature is controlled by the

A

Hypothalamus (between cerebral hemispheres)

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13
Q

Anterior Hypothalamus controls

A

Heat loss.

  • vasodilation-increased blood flow to skin and extremities-cooling.
  • sweating
  • inhibition of heat production
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14
Q

Posterior hypothalamus controls

A

Heat production.

  • vasoconstriction-reduced blood to skin and extremities.
  • muscle contraction stimulates heat production through shivering
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15
Q

Heat produced by the body is a by-product of

A

Metabolism, which is the chemical reaction in all body cells. Food is the primary fuel source.

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16
Q

BMR

A

Basal Metabolic Rate

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17
Q

What is BMR?

A

Heat produced by body at absolute rest.

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18
Q

BMR is affected by what?

A

The thyroid hormone, Testosterone by promoting the breakdown of glucose and fat.

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19
Q

Voluntary movements

A

Such as exercise (muscle contraction/sweating) increases metabolic rate/heat production. Also, increases heart rate and O2 demand.

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20
Q

Shivering

A
  • Involuntary body response that can increase heat production 4-5 times that of the normal.
  • increases energy expenditure up to 400%.
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21
Q

In vulnerable populations, shivering ….

A

Seriously drains energy resources, resulting in further physiological deterioration.

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22
Q

the heat produced by shivering …

A

helps equalize body temperature and the shivering ceases.

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23
Q

Forms of Heat Loss

A
  1. Radiation
  2. Conduction
  3. Convection
  4. Evaporation
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24
Q

Radiation

A

Heat transfer from the surface of one object to another without direct contact.

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25
Q

____ of the surface area of the human body radiates heat to the environment.

A

85%

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26
Q

Conduction

A

Transfer of heat from one object to another with direct contact.

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27
Q

Radiation increases as

A

The temperature difference between the objects increases.

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28
Q

What nursing actions can enhance heat loss during a fever?

A

By removing clothing or blankets?

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29
Q

Nursing considerations to minimize heat loss through radiation?

A

Covering the body with dark, closely woven clothing.

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30
Q

Nursing actions to decrease heat loss by conduction?

A
  • Patient making contact with materials warmer than skin.

- Applying several layers of clothing.

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31
Q

Nursing actions that increase heat loss by conduction?

A
  • Applying an ice pack or bathing a patient with a cool cloth.
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32
Q

Convection

A

Transfer of heat through air movement. Ex. Fans. Fans increase heat loss with moistened skin.

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33
Q

Evaporation

A

Liquid changed to gas. Approximately 600 to 900 ml/day lost due to evaporation.

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34
Q

Evaporation: Sensible loss

A

Sweating (diaphoresis)

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35
Q

Evaporation: Insensible loss

A

Respiration/lungs

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36
Q

Diaphoresis

A

Visible perspiration primarily occurring on the forehead and upper thorax.

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37
Q

What are the factors that affect body temperature?

A
  1. Age
  2. Exercise
  3. Hormone Levels
  4. Circadian Rhythm
  5. Stress
  6. Environment
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38
Q

A persons control over body temperature depends on:

A
  1. The degree of temperature extreme
  2. The person’s ability to sense feeling comfortable or uncomfortable
  3. Thought processes or emotions
    A person’s mobility or ability to remove or add clothes.
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39
Q

Why do women generally experience greater fluctuations in body temperature than men?

A

Hormonal variations during the menstrual cycle cause body temperature fluctuations.

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40
Q

During the menstrual cycle,

A

Progesterone levels rise and fall cyclically. When they are low, the body temperature is a few tenth of a degree below the baseline level. The lower temperature persists until ovulation occurs.

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41
Q

During ovulation,

A

Greater amounts of progesterone enter the circulatory system and raise the body temperature to previous baseline levels or higher.

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42
Q

Body temperature changes in women during menopause

A

Periods of intense body heat and sweating lasting from 30 seconds to 5 minutes occur. Skin temperature can increase up to 4 degrees C, referred to as hot flashes. It is. A used by instability of the gasometer controls for vasodilation and vasoconstriction.

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43
Q

Circadian Rhythm

A

Normal Body Rhythms. Temperature is usually highest around 4pm and lowest in the early morning.

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44
Q

How does stress affect body temperature?

A

Physical and emotional stress can increase body temperature.

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45
Q

Why does our environment affect the body temperature of infants and older adults more?

A

Because the temperature regulating mechanisms of infants and older adults are less efficient.

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46
Q

Temperature Alterations

A
  1. Fever
  2. Hyperthermia
  3. Heatstroke
  4. Heat Exhaustion
  5. Hypothermia
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47
Q

Fever

A

(Pyrexia) caused by pyrogens (bacteria/viruses)

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48
Q

Stages of a Fever

A

Stage 1: chills, shivers and feels cold
Stage 2: The plateau: chills subside and body feels warm/dry
Stage 3: Heat loss responses: skin warm/flushed (vasodilation), diaphoresis

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49
Q

What happens during a fever?

A

You see an increase in cellular metabolism, oxygen consumption, body metabolism, Heart Rate and Respiratory Rate.

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50
Q

Body metabolism increases ____ for every ______ during a fever.

A

10% for every degree Celsius

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51
Q

Hyperthermia

A

Increased body temperature due to inability of the body to promote heat loss or reduce heat production.

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52
Q

Hyperthermia is caused by..

A
  • Disease or trauma to the hypothalamus which impairs heat-loss mechanisms
  • Malignant hyperthermia
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53
Q

Malignant hyperthermia

A

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

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54
Q

Heatstroke

A

Body temperature of 40 degrees C (104 degrees F) or more.

Dangerous heat emergency

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55
Q

Heat depresses

A

Hypothalamic function

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56
Q

What are the signs/symptoms of heatstroke?

A
  • HOT DRY SKIN (most important)
  • confusion
  • delirium
  • nausea
  • muscle cramps
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57
Q

Patients at risk for heatstroke include

A
  • the very young and the very old

- those who have cardiovascular disease, hypothyroidism, diabetes or alcoholism.

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58
Q

Heat Exhaustion

A

When profuse diaphoresis results in fluid and electrolyte loss.

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59
Q

What is the prescription (RX) for Heat Exhaustion?

A

Restoring fluid and electrolytes and moving to a cooler environment

60
Q

Hypothermia

A

Decreased body temperature. May be unintentional or intentional.

61
Q

Mild Hypothermia

A

Core temperature: 34 to 36 degrees C

62
Q

Moderate Hypothermia

A

Core temperature: 30 to 34 degrees C

63
Q

Severe Hypothermia

A

Core temperature below 30 degrees C

64
Q

Induced Hypothermia

A

Used in some surgical, emergency cardiac and neurological procedures to decrease metabolic demand. Ex) open heart surgery and ROSC (return of spontaneous circulation after cardiac arrest)

65
Q

Frostbite

A

Ice crystals form in cells leading to permanent circulatory and tissue damage

66
Q

What are the steps of the nursing process?

A
  1. Assess
  2. Nursing Diagnosis
  3. Plan
  4. Implement
  5. Evaluate
67
Q

Assessing the Patient

A

Thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care.

68
Q

Diagnosis

A

After assessment, cluster defining characteristics to form a nursing diagnosis. Once diagnosis is determined, accurately select the related factor for problem-focused diagnosis.

69
Q

Planning

A

Integrate knowledge gathered from assessment and patient history to develop an individualized plan of care. Match the patient needs with interventions that are supported and recommended.

70
Q

Implementation

A

….

71
Q

Evaluation

A

The effectiveness of your interventions.

72
Q

Pulse

A

Indicator of circulatory status. Palpable bounding of blood flow in a peripheral artery.

73
Q

Cardiac Output

A

The amount of blood pumped by the heart in one minute.

74
Q

As HR increases…

A

There is less time for the heart to fill and leads to a decrease in blood pressure.

75
Q

What are the most common locations for pulse assessment?

A

Radial and apical sites.

76
Q

When a patient’s condition suddenly worsens, the ______ is recommended for quickly finding and assessing the pulse.

A

Carotid site

77
Q

Why is the carotid recommended for assessing a pulse when a patient’s condition suddenly worsens?

A

The heart continues delivering blood through the carotid artery to the brain as long as possible. When cardiac output declines significantly, peripheral pulses weaken and are difficult to palpate.

78
Q

When a patient takes a medication that affects HR, the _________ provides a more accurate assessment of heart function.

A

Apical pulse

79
Q

What is the best site for assessing an infant or young child’s pulse?

A

Brachial or apical site because other peripheral pulses are deep and difficult to palpate accurately

80
Q

Pulse deficit

A

The difference between the apical and radial pulse

81
Q

Certain medications, such as digoxin, require an assessment of the ___

A

Apical pulse

82
Q

The Bell of the Stethoscope is used for

A

Heart/valve sounds (low pitch sounds)

83
Q

The Diaphragm of the Stethoscope is used for

A

Heart, bowel and lung sounds (high pitch sounds)

84
Q

What are the Pulse Characters?

A
  1. Rate
  2. Rhythm
  3. Strength
  4. Equality
85
Q

Pulse Rates

A

Normal: 60-100
Tachycardia: above or equal to 100 beats per minute
Bradycardia: <60 beats/min

86
Q

Pulse Rhythm

A
  • Regular/irregular

- Rhythms also have names: sinus, Afib, Aflutter, etc.

87
Q

Pulse Strength

A
  • 0 (absent)
  • 1+ (weak)
  • 2+ (normal)
  • 3+ (strong)
  • 4+ (bounding)
88
Q

Pulse Equality

A

Bilaterally.

A pulse in one extremity is sometimes unequal in strength or absent in many disease states.

89
Q

Tachycardia, bradycardia and dysrhythmias are defining characteristics of many nursing diagnoses, including the following:

A
  • Activity Intolerance
  • Anxiety
  • Deficient/excess fluid volume
  • Impaired Gas Exchange
  • Acute Pain
90
Q

The body’s survival depends on

A

O2 to body cells and CO2 to be removed from cells

91
Q

Assess all symmetrical pulses simultaneously except for the _________

A

Carotid pulse

92
Q

Dysrhythmias

A

Abnormal rhythm indicated by an interval interrupted by an early, late or missed beat

93
Q

Respiration involves

A
  1. Diffusion
  2. Ventilation
  3. Perfusion
94
Q

Ventilation

A

Movement of gases in and out of the lungs (RR).

95
Q

Ventilation is driven by

A

Levels of oxygen, carbon dioxide and hydrogen ions

96
Q

The most important factor in the control of ventilation (respiratory rate) is ..

A

The level of CO2 in the arterial blood

97
Q

Diffusion

A

Movement of oxygen and CO2 between alveoli (lungs) and RBC’s

98
Q

Perfusion

A

Distribution of RBC’s to and from the pulmonary capillaries

99
Q

Hypoxemia

A

Low levels of arterial O2.

100
Q

How does Hypoxemia help patients with chronic lung disease?

A
  • Controls Ventilation.
  • The chemoreceptors in the carotid artery and aorta of patients with chronic lung disease become sensitive to Hypoxemia.
  • If the oxygen levels fall, these receptors signal the brain to increase the rate and depth of ventilation.
101
Q

COPD

A

Bronchitis
Asthma
Emphysema

102
Q

What would happen to a COPD patient who is given too much oxygen?

A

Is fatal for patients with chronic lung disease

103
Q

Assessment of Ventilation

A

Easy to assess but most often the most casually measure.

Asses: Rate, Depth, Rhythm

104
Q

Eupnea

A

Normal rate and depth of ventilation

105
Q

Tachypnea

A

RR > 20 regular

106
Q

Bradypnea

A

RR < 12 regular

107
Q

Apnea

A

Absent reparations - respiratory arrest

108
Q

Hyper/Hypoventilation

A

Leads to hyper/hypocarbia (CO2)

109
Q

Cheyenne-Strokes

A

Irregular, usually ominous sign

110
Q

Oxygen Saturation or Pulse Oxyimetry (SpO2)

A

Photo detection that detects the amount of O2 bound to hemoglobin molecules *however cannot differentiate O2 from CO in the presence of CO poisoning.

111
Q

What is the normal oxygen saturation? SpO2

A

Normal between 95% - 100%

112
Q

SpO2 is a reliable indicator of SaO2 when

A

Saturation is >70%.

113
Q

SaO2

A

Arterial O2 saturation

114
Q

SvO2

A

Returned venous saturation

115
Q

An oxygen saturation of ____________ is a clinical emergency.

A

Less than 90%

116
Q

Blood pressure

A

Force exerted on the walls of an artery by the pulsing blood under pressure from the heart.
A good indicator for cardiovascular health.

117
Q

Systolic pressure

A

Maximum pressure created during systole (heart contraction)

118
Q

Diastolic Pressure

A

Minimum pressure in the arteries at rest.

119
Q

Normotensive BP

A

Around 120/70

120
Q

Hypertensive BP

A

> 140/90

121
Q

Hypotensive BP

A

<90/x

122
Q

Cardiac Output

A

As heart rate increases, CO decreases and BP decreases

123
Q

Peripheral Resistance

A

As PVR increases = BP increases (vascular tone)

124
Q

Blood Volume

A

As volume increases, BP increases

125
Q

Viscosity

A

As viscosity increases, BP increases (as does RBC and HCT)

126
Q

Elasticity

A

Decrease elasticity = increase in BP

127
Q

What factors influence blood pressure?

A
  1. Age (BP tends to rise with advancing age)
  2. Stress (increases)
  3. Ethnicity (increased hypertension in African Americans + twice the risk for complications: stoke and MI)
  4. Gender
  5. Daily Variation
  6. Medications
  7. Activity and Weight
  8. Smoking
128
Q

How does gender influence blood pressure?

A

In men, increase in blood pressure after puberty.

In women, increase in blood pressure after menopause.

129
Q

How does daily variation influence blood pressure?

A

Lower during sleep and higher as the day progresses.

130
Q

How does medications influence blood pressure?

A

lower BP with Antihypertensive meds.

Increase BP with breathing treatments.

131
Q

How does activity and weight influence BP?

A

Exercise overall lowers BP

Obesity increase risk for hypertension

132
Q

How does smoking influence BP?

A

Causes vasoconstriction. Increases BP.

133
Q

Hypertension

A 
BP >140/90
Often asymptomatic (a lot of people don't have symptoms) : silent killer
134
Q

Modifiable Risk Factors for Hypertension

A
  1. Obesity
  2. Cigarette smoking
  3. Alcohol consumption
  4. High sodium intake
  5. Sedentary lifestyle
  6. Continued exposure to stress
135
Q

Hypotension

A

Systolic BP <90/x

Usually an abnormal finding associated with illness.

136
Q

Causative Factors of Hypotension

A
  1. Dilation of arteries in vascular bed
  2. Loss of blood volume (hemorrhage)
  3. Failure of the heart muscle to adequately pump (MI)
137
Q

Signs and Symptoms of hypotension

A

Pallor, skin mottling, clamminess, confusion, increased HR and decreased urine output.
Can be life-threatening so report immediately.

138
Q

Orthostatic Hypotension

A

Aka postural hypotension.
Occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 20 mm Hg within 3 minutes of rising to an upright position.

139
Q

Orthostatic Hypotension is usually due to

A

A decrease in blood volume (dehydration, hemorrhage), prolonged bed rest, anemia

140
Q

VS check for orthodontic hypotension is referred to as

A

Orthodontics. BP and Pulse taken lying, sitting, standing.

141
Q

Self-Measurement of BP Advantages

A
  • Elevated BP can be detected early
  • Many home BP monitors can be applied over clothes
  • Patterns of BP in pre-hypertensive patients may be discovered
  • Allows for active participation in hypertensive treatment (helps with adherence to medications/treatments)
142
Q

Self-Measurement of BP Disadvantages

A
  • potential improper use of device/inaccurate readings

- inappropriately self-adjust medications

143
Q

Patient Teaching for Self-Measurement of BP

A
  • help patients understand the meaning and implication of readings
  • teach proper use of equipment
  • teach to record the time (same times of day preferable) and date of their readings to share with health care provider.
144
Q

How often do you measure a patient’s vital signs?

A

….

145
Q

How do hormone levels affect body temperature?

A

…..

146
Q

Why are newborns and older adults more at risk when it comes to body temperature?

A

…

147
Q

What would be the effect to patients with respiratory or cardiac problems?

A

…

NURS 305 (30 decks)

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