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Nursing Semester 1 > Chapter 30: Vital Signs > Flashcards

Chapter 30: Vital Signs Flashcards

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1
Q

List times when a patients vital signs are normally assessed:

A

A) On admission to a healthcare agency, to establish baselines

B) Part of a physical assessment

C) During an inpatient stay, as routine monitoring

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2
Q

Most frequent and routine measurements obtained by health care providers:

A

Temperature

Pulse

Blood pressure

Respiratory rate

Oxygen saturation

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3
Q

Average temperature range:

A

96.8-100.4 degrees F

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4
Q

Average oral/tympanic temperature

A

98.6 F

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5
Q

Average rectal temperature:

A

99.5 F

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6
Q

Average axillary temperature

A

97.7 F

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7
Q

Average pulse:

A

60 to 100 beats/min, deep and regular

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8
Q

Average adult respiration

A

12 to 20 breaths/min, deep and regular

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9
Q

Average blood pressure

A

Systolic <120

Diastolic <80

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10
Q

Average pulse pressure:

A

30-50 mm HG

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11
Q

Average core temperature for elderly

A

95-97 F as a result of decreased immunity

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12
Q

Lowest temperature is at ____ while highest temperature is at ____

A

Lowest: 6 am

Highest: 4 pm

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13
Q

Which part of brain controls body temperature?

A

Hypothalamus

Senses minor changes in body temperature

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14
Q

Anterior hypothalamus controls

A

heat loss

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15
Q

Posterior hypothalamus controls

A

heat production

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16
Q

When metabolism decreases,

A

less heat is produced.

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17
Q

Heat production occurs during

A

rest, voluntary movements, involuntary shivering and non shivering thermogenesis

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18
Q

7 factors that can cause an individual’s body temperature to change:

A

Age
- Newborn’s temp unstable baseline temp drops with age, infants and elderly more susceptible to environmental temp extremes

Exercise
-Increases body temperature

Hormonal fluctuations
-Women’s temp higher at ovulation

Circadian rhythms
- lowest temp: 6 am, highest 4pm

Stress
- levels of extreme temps affect core body temp

Environment

Smoking
-causes vasoconstriction that can decrease temp of skin

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19
Q

Factors influencing vital signs (9)

A

Infection

renal disease

Respiratory disease

Cardiovascular disease

Physical Environment

Emotional state of patient

Medications

Food and fluid intake

Activity level and tolerance

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20
Q

Pain SOCRATES meaning:

A

Site
Where is pain located?

Onset
When did pain start? gradual or sudden?

Character
Quality of pain? Stabbing, burning, aching in nature?

Radiation
Does pain radiate anywhere?

Associations
signs and symptoms associated with pain

Time Course
Any pattern to pain?

Exacerbating/relieving factors
What makes it worse or help it?

Severity
0-10 scale

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21
Q

Patterns of fever (SIRR)

A

Sustained: constant body temp that has little fluctuation

Intermittent: Fever spikes interspersed with usual temp levels. (Temp returns to acceptable value at least once in 24 hours)

Remittent: fever spikes and falls without a return to acceptable temperature levels

Relapsing: periods of febrile episodes and periods with acceptable temperature values (febrile episodes often longer than 24 hours)

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22
Q

Hyperthermia:

A

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

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23
Q

Malignant hyperthermia

A

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

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24
Q

5 types of thermometers

A

Electric thermometer (oral/anus/axillary)

temporal artery thermometer (forehead of child typically)

tympanic thermometer (Ear)

disposable paper thermometers

temperature sensitive strips

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25
Q

5 sites commonly used to measure body temperature

A

Oral (most common)
-under tongue

Axillary
-frequently used for healthy newborns

Tympanic

Temporal

Rectal

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26
Q

Examples of nursing diagnoses for patients with body temperature alterations include (5)

A

Risk for imbalanced body temperature

hyperthermia

hypothermia

ineffective thermoregulation

risk for hypothermia

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27
Q

Pulse is the

A

palpable bounding of blood flow in a peripheral artery

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28
Q

Infant heart rate

A

120-160 beats/min

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29
Q

Toddler heart rate

A

90-140 beats/min

30
Q

Preschooler heart rate

A

80-110 beats/min

31
Q

School-age child heart rate

A

75-100 beats/min

32
Q

Adolescent heart rate

A

60-90 beats/min

33
Q

Adult heart rate

A

60-100 beats/min

34
Q

Factors that influence pulse rate (7)

A

Exercise

Temperature

Emotions

Medications

Hemorrhage

Postural changes

Pulmonary conditions

35
Q

Tachycardia:

A

an abnormally elected HR

ABOVE 100 beats/min in adults

36
Q

Bradycardia:

A

Slow HR

Below 60 beats/min in adults

37
Q

Document pulse strength as:

A

Bounding (4)

Full or strong (3)

Normal and expected (2)

Diminished or barely palpable (1)

Absent (0)

38
Q

Respiration is the mechanism the body uses to:

A

exchange gases between the atmosphere and the blood and the blood and the cells

39
Q

Respiration involves (3)

A

Ventilation (movement of gases in and out of the lungs)

Diffusion (movement of oxygen and carbon dioxide between the alveoli and the red blood cells)

Perfusion (distribution of red blood cells to and from the pulmonary capillaries)

40
Q

Assess ventilation by determining…

A

respiratory rate, depth, rhythm and end-tidal carbon dioxide value

41
Q

Assess diffusion and perfusion by

A

determining oxygen saturation

42
Q

Hypoxemia:

A

low levels of arterial O2

43
Q

A respiratory rate above ____ is an important risk factor for

A

27 breaths/min

cardiac arrest

44
Q

Hypothermia:

A

low body temperature
-Frostbite results from exposure to subnormal temperatures

Hypotension- decreased blood pressure

45
Q

Febrile

A

person with fever

46
Q

Heat stroke

A

when prolonged exposure to high environmental temps overwhelms the body’s heat loss mechanisms

47
Q

Heat exhaustion

A

when extreme or prolonged exposure to high environmental heat leads to profuse sweating and consequent water and electrolyte loss

48
Q

Factors that cause pulse rate to vary:

A

Age

Gender

Fever

Stress

Medications

Hypovolemia

Pathology

Electrolyte balance

Hypoxia/hypoxemia

49
Q

Dysrhythmia:

A

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

50
Q

Factors influencing character of respirations (8)

A

Exercise

Acute pain

Anxiety

Smoking

Body position

Medications

Neurological injury

Hemoglobin function

51
Q

Bradypnea:

A

rate of breathing is regular but abnormal slow (less than 12 breaths/min)

52
Q

Tachypnea:

A

rate of breathing is regular but abnormally rapid (above 20 breaths/min)

53
Q

Hyperpnea:

A

respirations are labored

increased in depth

increased in rate (greater than 20 breaths/min) (occurs normally during exercise)

54
Q

Apnea:

A

respirations cease for several seconds. Persistent cessation results in respiratory arrest

55
Q

Hyperventilation

A

rate and depth of respirations increase. Hypocarbia sometimes occurs

56
Q

Hypoventilation

A

respiratory rate is abnormally low, and depth of ventilation is depressed

Hypercarbia sometimes occurs

57
Q

Cheyne-Stokes respiration

A

respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation.

Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth

pattern reverses…breathing slows and becomes shallow concluding as apnea before respiration resumes

58
Q

Kussmaul’s respiration:

A

respirations are abnormally deep, regular and increased in rate

59
Q

Biot’s respiration

A

respirations are abnormally shallow for 2-3 breaths, followed by irregular period of apnea

60
Q

Factors affecting determination of pulse oxygen saturation (2)

A

Interference with light transmission

Interference with arterial pulsations

61
Q

SaO2 normal range:

A

95% and 100%

62
Q

Systolic pressure:

A

Contraction of the heart forces the blood under high pressure in the aorta

Peak of maximum pressure when ejection occurs

63
Q

Diastolic pressure:

A

when the ventricles relax, the blood remaining in the arteries exerts a minimum or DIASTOLIC pressure

minimal pressure exerted against the arterial walls at all times

64
Q

Pulse pressure:

A

difference between systolic and diastolic

65
Q

Hypotension:

A

occurs when the systolic BP falls to 90 mm HG or below

66
Q

Hematocrit:

A

% of red blood cells in blood, determines blood viscosity

When the hematocrit rises and blood flow slows, arterial BP increases

The heart contracts more forcefully to move the viscous blood through the circulatory system

67
Q

Hypertension:

A

Asymptomatic

Diastolic readings greater than 90 mm Hg and systolic greater than 140 mm Hg

68
Q

Orthostatic hypotension

A

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

69
Q

Factors influencing Blood pressure:

A

Age

Stress

Ethnicity

Gender

Daily Variation

Medications

Activity and Weight

Smoking

70
Q

Prehypertension:

A

Systolic 120-139

Diastolic 80-89

71
Q

Stage 2 hypertension

A

Systolic >160

Diastolic >90

Nursing Semester 1 (24 decks)

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