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Cardiovascular, ECG and Vital Signs > Chapter 4 Vital Signs > Flashcards

Chapter 4 Vital Signs Flashcards

1
Q

Vital Signs

A

Objective guideposts that provide measurement of essential life-sustaining functions, such as: Temperature, pulse, respiration, blood pressure, and pulse oximetry

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2
Q

TPR

A

Temperature, pulse, respiration

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3
Q

Symptoms

A

subjective evidence of a disease, such as pain or headache.

-Felt by the patient

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4
Q

Signs

A

objective evidence of a disease, can be measured by a physician, such as a fever

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5
Q

In which provinces of Canada are MLTs legally allowed to check, record or measure vital signs and ECG?

A

BC and ON

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6
Q

Vital Signs are usually checked during each office visit to establish….

A
  • patient’s state of health

- baseline measurement

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7
Q

What is a baseline measurement?

A

The initial vital signs measurements of a patient that is healthy. This is used to compare future vital sign measurements

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8
Q

Guidelines for Measuring Vital Signs: (4)

A
  • be familiar with normal ranges for vital signs
  • make sure equipment is in proper working order
  • eliminate or minimize factors that affect vital signs ie. exercise, emotional states
  • use an organized approach when measuring vital signs ie. start with temperature, followed by pulse and etc.
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9
Q

Body temperature is regulated by which body part?

A

The hypothalamus AKA body thermostat in the brain which connects the pituitary gland to the nervous system.
- regulates our temperature by 1-2 degrees Fahrenheit only

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10
Q

how does the hypothalamus regulate body temperature?

A

Hypothalamus reduces temperature by sending a message to perspire.

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11
Q

What is the normal temperature range?

A

36.1-37.2 degrees Celsius or 97-99 degrees Fahrenheit

Remember infants and young children generally have higher temperature than adults because their thermoregulatory system not yet fully established

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12
Q

What are the most important baseline measurements?

A

blood pressure and pulse

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13
Q

Is the hypothalamus a gland?

A

no, it is a nerve tissue

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14
Q

Temperature is maintained by a balance of

A

heat lost from the body, and heat produced in the body

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15
Q

the most Heat in the body is produced by

A

voluntary muscle contractions (skeletal muscles) and involuntary muscle contractions (digestive system)

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16
Q

Other body heat is produced by:

A

cell metabolism, fever and strong emotional states

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17
Q

Heat is lost through these bodily functions:

A

urine and feces, moisture droplets from lungs, perspiration

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18
Q

Heat is also lost through:

A

Radiation, convection and conduction

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19
Q

Radiation

A

transfer of heat in form of waves to cooler surroundings

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20
Q

Convection

A

transfer of heat through air currents

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21
Q

Conduction

A

transfer of heat from one object to another by direct contact

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22
Q

Purpose of measuring body temperature:

A
  • establish patients baseline

- check patient’s state of health

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23
Q

Average body temperature is

A

98.6 degrees Fahrenheit or 37 degrees Celsius

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24
Q

Baseline measurement

A

patient’s initial vital sign’s measurement used to compare future measurements

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25
Q

Fever pyrexia temperature

A

above 100.4 degrees Fahrenheit or above 38 degrees Celsius

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26
Q

Low grade fever temperature

A

99 to 100.4 degrees Fahrenheit or

37.2 -38 degrees Celsius

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27
Q

Hyperpyrexia Temperature

A

above 105.8 degrees Fahrenheit or 41 degrees Celsius

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28
Q

Generally fatal temperature

A

above 109.4 degrees Fahrenheit ( 43 degrees Celsius)

or

93.2 degrees Fahrenheit (34 degrees Celsius)

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29
Q

Hypothermia Temperature

A

below 97 degrees Fahrenheit or 36.1 degrees Celsius

aka subnormal

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30
Q

Where can we take the most accurate temperature in adults?

A

rectal

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31
Q

Variations in body temperature can be caused by:

A

environment, diurnal variations, extreme emotional states, exercise, patient’s normal body temperature, pregnancy

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32
Q

diurnal variation:

A

during sleep, body metabolism and muscle contractions slow down

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33
Q

Fever

A

common symptom of illness, particularly inflammation or infection, increased temperature above the normal range

-usually self-limiting- temperature goes back to normal when illness is over

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34
Q

Febrile

A

person who has a fever above 100.4 degrees Fahrenheit

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35
Q

Afebrile

A

person who doesn’t have a fever

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36
Q

pyrogen

A

any substance that produces fever; resets hypothalamus causes temperature to rise

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37
Q

onset fever

A

when temperature begins to rise

  • may be slow or sudden
  • causes coldness, chills, increase in pulse and respiration
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38
Q

Three patterns that describe the course of a fever:

A

continuous, intermittent and remittent

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39
Q

continuous fever

A

body temperature fluctuates minimally always remains elevated

ie. scarlet fever or pneumococcal pneumonia

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40
Q

intermittent fever

A

body temperature alternately rises and falls at times returns to normal or even becomes subnormal

ie. bacterial infections and viral infections

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41
Q

remittent fever

A

wide range of temperature fluctuations occurs - all or above normal

ie. influenza, pneumonia, endocarditis

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42
Q

Malaise

A

a vague sense of body discomfort, weakness and fatigue

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43
Q

Why do we try to avoid dehydration during a fever?

A

dehydration will affect electrolytes, we need electrolytes to keep the heart contracting and relaxing

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44
Q

subsiding stage

A

temperature returns to normal

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45
Q

Assessment sites of body temperature: (5)

A

mouth, axilla, rectum, ear and forehead

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46
Q

Qualifications of good temperature assessment sites:

A
  • site should have abundant blood supply
  • as closed as possible (prevents air from interfering)
  • site depends on patient’s age, condition and state of consciousness
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47
Q

which temperature site is good for toddlers and preschoolers?

A

the axillary temperature

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48
Q

When recording temperature how do we indicate the axillary temperature was taken?

A

it should be marked with an “A” after temperature

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49
Q

If the axillary temperature measures 99 degrees Fahrenheit, what would the measurement of the oral temperature be?

A

99 degrees fahrenheit + 1 degree = 100 degrees Fahrenheit

-because the auxillary route measures 1 degree lower than the oral

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50
Q

Why is the rectal temperature the most accurate?

A
  • rectum is highly vascular
  • provides the most closed activity
  • measures 1 degree higher than the oral route
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51
Q

If the rectal route measures 100 degrees Fahrenheit, what is the oral temperature?

A

100 degrees fahrenheit - 1 degree = 99 degrees fahrenheit

because the rectal route measures 1 degree higher than the oral route

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52
Q

Who is the rectal temperature recommended for?

A

infants, and young children, unconscious patients, mouth-breathing patients

never with newborns

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53
Q

Aural temperature is taken with a _____________________________ thermometer

A

tympanic membrane

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54
Q

The aural temperature is recommended for:

A

children under 6 years of age,

uncooperative patients, patients who can’t get oral temperature taken

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55
Q

When taking aural temperature what should be done for adults and children?

A

For adults hold top of ear up and back, for children hold bottom of ear down and back

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56
Q

Forehead temperature measures temperature along the __________________________

A

Temporal artery (major artery of head)

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57
Q

Forehead temperature compared to oral and axillary temperature?

A

forehead temperature is approximately 1 degree Fahrenheit higher than oral temperature

and is approximately 2 degree Fahrenheit higher than axillary temperature

note: why 2 Fahrenheit

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58
Q

There are four types of thermometers:

A

electronic, tympanic, temporal artery and chemical

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59
Q

What color probe for the oral, axillary and rectal thermometor?

A

oral and axillary thermometer have a blue probe and rectal thermometer have a red probe

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60
Q

How should disposable plastic probe covers be disposed?

A

in regular waste

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61
Q

What is the purpose of disposable plastic covers?

A

prevents transmission of microorganisms between patients, and protect the lens of the probe

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62
Q

Why are Mercury glass thermometers no longer used?

A
  • breaks easily
  • mercury can damage the nervous system
  • harmful to wildlife
  • many cities have banned use and sale of mercury
63
Q

Where is the tympanic Membrane thermometer used?

A

in the aural site

64
Q

Does the tympanic membrane thermometer measure the temperature of the blood?

A

NO, it measures the thermal energy of the tympanic membrane. ( the wave of the tympanic membrane)

65
Q

When should we not use the tympanic membrane thermometer?

A
  • patients with inflammation of external ear canal
  • when the ear contains a discharge such as blood or pus
  • excessive cerumen buildup that occludes the canal
66
Q

How to place tympanic membrane thermometer in ear properly?

A

straighten the ear canal,

  • for adults and children older than 3 years pull auricle upward and backward
  • for children younger than 3 years, pull ear pinna downward and backward

Then insert probe tightly enough to seal opening of ear

67
Q

When recording aural temperature what must be recorded?

A
  1. the temperature result and unit
  2. which ear was temperature taken, left or right
  3. normal reference range
  4. any additional notes
68
Q

What is the procedure for measuring the temporal artery thermometer?

A

-scan button is continually depressed, probe is slowly moved across forehead

69
Q

a falsely low temporal artery reading can be caused by:

A
  • a dirty probe lens
  • sweating of the forehead
  • scanning the forehead too quickly
  • not keeping the button pressed while scanning
70
Q

Continuous Fever

A

body temperature fluctuates minimally but remains elevated

71
Q

Remittent fever

A

Wide range of body temperature , but remains above normal

72
Q

intermittent fever

A

body temperature rises and falls and at times returns to normal or becomes subnormal

73
Q

How to clean lens of tympanic membrane thermometer?

A
  1. wipe lens with an antiseptic wipe

2. immediately wipe dry with a cotton swab

74
Q

When taking a temporal artery temperature, how to avoid inaccurate results caused by a patient whose skin is clammy, sweat that isn’t visible or a fever that just broke?

A

After scanning the forehead, continue to scan temperature of neck area behind earlobe

75
Q

do not take temporal temperature on patients with:

A

open sores or abrasions, scar tissue

76
Q

a dirty probe lens, sweating of the forehead causes what in a temporal reading?

A

falsely low temperature

77
Q

Which part of the body regulates the temperature?

A

hypothalamus

78
Q

what is the hypothalamus attached to?

A

pituitary gland

79
Q

the main source of body heat comes from?

A

skeletal muscles (voluntary and involuntary movement)

80
Q

How can the body lose heat?

A

radiation, conduction and convection

81
Q

What is the normal range of body temperature?

A

36.1 -37.2 degrees Celsius or 97-99 degrees Fahrenheit

82
Q

Mechanism of the pulse

A

when the left ventricle of the heart contracts, blood is forced into the aorta, this creates a pulsating wave that travels from the aorta through the walls of the arterial system

83
Q

We do not feel a pulse with veins. true or false

A

true, we feel the pulse in the arteries.

84
Q

pulse rate

A

measured by counting the number of beats per minute

85
Q

heart rate is determined by taking the _______

A

pulse

86
Q

factors that affect pulse:

A

age, gender, physical activity, emotional states, metabolism, fever, medications

87
Q

pulse is felt most strongly when ________________________________.

A

superficial artery is held against a firm tissue (bone).

88
Q

Most common pulse site is

A

the radial artery, located in a groove on the inner aspect of the wrist just below the thumb

89
Q

characteristics of the Apical (apex of the heart) pulse

A

stronger beat, more easily heard than other pulse sites.

  • often used in infants and children under 3 years
  • measured using a stethoscope
  • location: fifth intercostal space at left midclavicular line

Should be taken if having difficulty feeling radial pulse, or if pulse is abnormally slow or rapid

90
Q

Characteristics of the brachial (brachial artery)pulse

A
  • located in antecubital space, front of the elbow, directly beneath basilic vein
  • used to take bp, assess circulation to lower arm, measure pulse in infants during cardiac arrest
91
Q

characteristics of ulnar pulse

A
  • location: little finger on the side of the wrist

- used to assess circulation to the hand

92
Q

characteristics of temporal pulse

A

location: front of ear just below eye level
- used when radial pulse is not accessible
- not easy to measure

93
Q

characteristics of carotid pulse

A

location: anterior side of neck
- best site to find pulse quickly
- used to measure pulse in children and adults during cardiac arrest, monitor pulse during exercise

94
Q

characteristics of femoral pulse

A
  • location: middle of groin

- used to measure pulse in infants, children and adults during cardiac arrest, assess circulation to the lower legs

95
Q

characteristics of the popliteal pulse

A

location: back of the knee

- used to measure BP when the brachial artery is not accessible, assess circulation to the lower leg

96
Q

characteristics of posterior tibial pulse

A

location: inner space of ankle, posterior to ankle bone

- used to assess circulation to the foot

97
Q

characteristics of the dorsalis pedis pulse

A

location: upper surface of foot between the first and second metatarsal bones
- used to assess circulation of the foot

98
Q

Purpose of measuring pulse

A
  • establish patient’s baseline pulse rate

- assess pulse following special procedures, medications or disease processes that affect the heart

99
Q

how to locate pulse?

A

palpation; except for apical site

100
Q

assessment of pulse includes:

A

pulse rate, rhythm, volume

ie. 61 bpm, rhythmic, strong

101
Q

normal adult range of pulse

A

60-100 bpm

102
Q

the average adult range of pulse

A

70-80 bpm

103
Q

tachycardia

A

an abnormally fast heart rate of more than 100 bpm

-occurs during hemorrhaging, heart disease, vigorous exercise and strong emotional states

104
Q

bradycardia

A

an abnormally slow rate falling below 60 bpm

-normally occurs during sleep and in a trained athlete

105
Q

What to do if patient shows a bradycardic or tachycardic pulse?

A

take apical pulse

106
Q

pulse rhythm

A

time interval between heartbeats

107
Q

normal rhythm

A

same interval between beats

108
Q

dysrhythmia

A

unequal or irregular intervals between beats, also termed arrhythmia

109
Q

what will a physician order if the patient’s pulse is unequal or irregular?

A

apical-radial pulse, electrocardiogram, or holter monitoring

110
Q

apical-radial pulse

A

performed to determine if a pulse deficit is present

-how? by measuring the apical pulse at the same time as the radial pulse for 1 full minute

why? for the pulse deficit

111
Q

pulse deficit

A

radial pulse rate is less than the apical pulse rate

ie. one MA measures an apical pulse rate of 88, another MA measures the radial pulse of 76 bpm, therefore pulse deficit is 12 beats

which means not all heartbeats reach the peripheral arteries, caused by inefficient contraction of the heart, frequently occurs with atrial fibrillation

112
Q

pulse volume

A

strength of the heartbeat

  • should remain constant
  • normal pulse feels strong and full
113
Q

thready pulse

A

blood volume decreases, pulse feels weak

114
Q

bounding pulse

A

blood volume increases, pulse feels extremely strong and full

115
Q

Purpose of respiration

A

exchange of oxygen and carbon dioxide between the atmosphere and blood

116
Q

Respiration is divided into 2 phases

A

inhalation (diaphragm descends, lungs expand, causes air containing O2 to move into lungs)

exhalation (diaphragm ascends, lungs return to original state, causes air containing CO2 to be expelled)

1 complete respiration is one inhalation and one exhalation

117
Q

one complete respiration

A

one inhalation + one exhalation

118
Q

external respiration

A

exchange of oxygen and carbon dioxide between alveoli and blood

119
Q

alveoli

A

thin walled air sacs of the lungs in which the exchange of O2 and CO2 takes place

120
Q

roles of capillaries in respiration

A

capillaries comes in contact with alveoli, picks up oxygen and carries it to the cells of the body

121
Q

internal respiration

A

exchange of O2 and CO2 between body cells and blood

-oxygen is given off to the cells, carbon dioxide is picked up and transmitted as a waste product to lungs

122
Q

involuntary respiration is controlled by the

A

medulla oblongata

buildup of CO2 sends message to medulla, triggers respiration to occur automatically

123
Q

normal adult respiratory rate

A

12-20 rpm

124
Q

ratio of respiration per pulse beat

A

1 respiration per 4 pulse

125
Q

tachypnea

A

abnormal increase of more than 20 breaths/minute

126
Q

bradypnea

A

abnormal decrease of fewer than 12 breaths/minute

127
Q

factors that affect respiration

A

age, physical activity, medication, emotional state, fever

128
Q

respiration rhythm should be

A

even and regular

129
Q

respiration depth can be described as

A

normal, deep, shallow, determined by movement of chest

130
Q

Eupnea

A

normal respiration, 12-20 rpm, rhythm, even and regular, depth is normal

131
Q

hyperpnea

A

abnormal increase in rate and depth

  • patient exhibits very deep, rapid and labored breathing
  • occurs normally in exercise, fever and pain

-also occurs with inadequate oxygen supply in heart or lung disease

132
Q

hypopnea

A

abnormal decrease in rate and depth, often occurs with sleep disorders

133
Q

hyperventilation

A

abnormally fast and deep breathing

-usually associated with acute anxiety, causes dizziness and weakness

134
Q

hypoxia

A

a reduction in the oxygen supply to the tissues, may cause cyanosis

135
Q

cyanosis

A

bluish color of skin and mucous membranes

136
Q

apnea

A

temporary absence of respirations, may occur during sleep

137
Q

dyspnea

A

difficulty breathing or shortness of breath

138
Q

orthopnea

A

the condition in which breathing is easier when an individual is in a sitting or standing position

139
Q

blood pressure

A

measurement of force exerted by the blood on the walls of the arteries

140
Q

systole

A

phase in the cardiac cycle in which the ventricles contract

141
Q

systolic pressure

A

point of highest pressure on arterial walls

142
Q

diastole

A

phase in cardiac cycle in which the heart (ventricles) relaxes between contraction

143
Q

diastolic pressure

A

point of lesser pressure on arterial walls

144
Q

hypertension stage 1

A

140/90

145
Q

hypertension stage 2

A

160/100

146
Q

hypotension

A

low blood pressure bp reading below 95/60

147
Q

pulse pressure

A

difference between systolic and diastolic

148
Q

normal range of pulse pressure

A

30-50

149
Q

factors affecting blood pressure

A

age (as age increases bp increases), gender, diurnal variations, emotional states, physical activity, body position (sitting has higher diastolic pressure than standing), medications, pain, caffeine and smoking

150
Q

equipment needed to measure blood pressure

A

stethoscope and sphygomomanometer

151
Q

stethoscope

A

an instrument for amplifying and hearing sounds produced by the body

152
Q

how does the cuff size of the sphygomomanometer affect bp reading

A

if cuff is too small falsely high, if cuff is too large falsely low

153
Q

how to measure bp for obese patients if thigh cuff isn’t an option?

A

blood pressure can be measured at forearm using radial artery

154
Q

korotkoff sounds

A

used to determine systolic and diastolic bp reading

Cardiovascular, ECG and Vital Signs (3 decks)

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