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118 - INP > Class 8 - Vital Signs and Assessment > Flashcards

Class 8 - Vital Signs and Assessment Flashcards

1
Q

afebrile

A

the end of a fever

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2
Q

antecubital fossa

A

elbow pit

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3
Q

apical pulse

A

one of the 8 common arterial pulse sites. it can be found in the left center of your chest, just below the nipple

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4
Q

axillary

A

armpit

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5
Q

baseline

A

info sound at the beginning of a study or other initial known value which is used for comparison with later data

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6
Q

bradycardia

A

slow HR

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7
Q

bradypnea

A

slow breathing

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8
Q

diastolic

A

“bottom number” pressure in the arteries when the heart rests between beats

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9
Q

tachypnea

A

shallow breathing, take more breaths than normal in a given moment

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10
Q

laboured breathing

A

abnormal respiration: increased effort to breathe, including the use of accessory muscles of respiration, grunting, or nasal flaring

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11
Q

cheyne-stokes breathing

A

respiratory congestion, variety of breathing. 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. this pattern reverses, breathing slows and becomes shallow, climaxing in apnea before respiration resumes

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12
Q

febrile

A

a fever

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13
Q

hypertension

A

high blood pressure, long term condition

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14
Q

hypotension

A

low blood pressur

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15
Q

pulse deficit

A

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

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16
Q

systolic

A

“first number”

peak of maximum pressure when ejection occurs at contraction

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17
Q

tachycardia

A

abnormally fast HR

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18
Q

tachypnea

A

fast breathing

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19
Q

turgor

A

degree of elasticity of skin

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20
Q

peripheral pulse

A

a pulse recorded in the arteries (radial or pedal) in the distal portion of the limbs

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21
Q

holistic/comprehensive assessment

A

should consider all of the patients needs in order to identify actual and potential problems

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22
Q

quick priority assessment

A

carried out to gain an abbreviated overall assessment

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23
Q

focused or selective assessment

A

uses knowledge of the patients history and presenting problem

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24
Q

sources of info

A

primary and secondary

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25
Q

assessment data

A

objective and subjective

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26
Q

vital signs

A

important measurements of an individuals condition

  • includes temperature, pulse respirations and BP
  • accuracy in measurement and reporting vital signs is critical.
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27
Q

to analyze vital signs you must use knowledge of the clients

A
  1. Usual values (baseline)
  2. Medical History
  3. Current Therapies
  4. Prescribed Medications
28
Q

when should vital signs be assessed?

A
  • AM and when admitted (baseline)
  • PRN - condition- fall- distress
  • surgery
  • as ordered
29
Q

temperature assessment

A
  • a measurement of body heat

- the balance between heat produced by the body and what you are losing

30
Q

signs of pyrexia

A
  • chills
  • shivering
  • flushing
  • thirst
  • dry skin
  • decreased output
  • warm skin
  • diaphoresis
  • tachycardia
  • tachypnea
  • headache
  • disorientation
  • irritability
  • photosensitivity (sensitive to light)
31
Q

factors that affect temperature

A
  • age
  • exercise
  • hormone level
  • circadian rhythm (body over 24 hours)
  • stress
  • environment
32
Q

tympanic route

A
  • easily accessible site, leaves disruptive
  • rapid results
  • unaffected by oral intake or smoking
  • requires proper positioning
  • measurement is more variable
  • taken in the ear
33
Q

precluding oral route

A
  • unconscious patient/intubated/jaw wired shut (oral surgery or injury)
  • disoriented, shivering, teeth chattering, at risk for seizure, coughing
  • infants/caution in young children
  • patients with hyperactive gag reflex
  • mouth breather/ after smoking
34
Q

rectal temperature may have to be taken if client….

A
  • is unconscious or semiconscious
  • is not able to breath through the nose
  • is confused
  • has facial paralysis
  • has a sore mouth
  • is prone to seizures
35
Q

axilla temperatures

A

are taken under the arm

  • least accurate of the three methods
  • average axilla temp: 36.5 degrees
  • must hold in place for several minutes
36
Q

pulse assessment

A

brachial, radial, apical temporal, popliteal, femoral, carotid, tibial, dorsalis pedis
find landmark for vital signs
- the beat of the heart as felt through a peripheral artery
- includes the number of heart beats as well as strength and rhythm

37
Q

taking a pulse…

A
  • usually assess radial pulse (inside the wrist at the base of thumb)
  • most accurate if measured for 1 minute
  • assess pulse volume and strength for each beat
  • note any abnormalities in rate and rhythm
38
Q

respirations

A
  • inhaling sends oxygen to all body cells and exhaling rids the body of CO2
  • the rate of respirations increases or decreases according to the oxygen needs of the body
39
Q

normal respiration

40
Q

low respiration

A

less than 10

41
Q

high respiration

42
Q

bradypnea

A

low rate of breathing

43
Q

tachypnea

A

high rate of breathing

44
Q

apnea

A

no breaths

45
Q

eupnea

A

good breathing

46
Q

dyspnea

A

bad breathing

47
Q

orthopnea

A

shortness of breathing when laying flat

48
Q

assessing respirations

A
  • observe the rate and rhythm over a minute
  • note the depth and character
  • normally respirations will increase if patient is being observed
49
Q

oxygen saturation (sp02)

A
  • assessed with a pulse oximeter
  • estimates arterial blood oxygen saturation
  • if number seems weird, check equipment
50
Q

normal range of oxygen saturation

51
Q

life threatening range of oxygen saturation

A

less than 70%

52
Q

surgical range of oxygen saturation

53
Q

medical range of oxygen saturation

54
Q

COPD range of oxygen saturation

55
Q

blood pressure

A

the force exerted on the walls of the arteries by the pulsing blood under pressure from the heart

56
Q

optimal blood pressure

57
Q

normal blood pressure

58
Q

high normal blood pressure

A

130-139 systolic, 85-89 diastolic

59
Q

grade 1 hypertension blood pressure

A

140-159 systolic, 90-99 diastolic

60
Q

grade 2 hypertension blood pressure

A

160-179 systolic, 100-109 diastolic

61
Q

grade 3 hypertension blood pressure

A

180+ systolic, 110+ diastolic

62
Q

pulse pressure

A

difference between systolic and diastolic, the force that the heart generates

63
Q

orhtostatic

A

low BP when you stand up from sitting or laying down

64
Q

measure BP

A

2 fingers

  • give clients a few minutes to rest before checking
  • be sure you’re using the appropriate size cuff
  • patient is sitting or lying position with forearm at heart level, palm up
  • legs uncrossed
65
Q

2 step BP

A
  • palpate brachial pulse
  • position centre of cuff about 2.5 cm above pulse
  • palpate while pumping to 30mm above when pulse disappears
  • deflate slowly, still palpating, note when pulse rappers
  • deflate completely, leave cuff in place, wait 30 seconds.
  • this is your estimated (palpated) systolic bp
  • rapidly inflate cuff to 30 mmHg above palpated systolic pressure
  • place stethoscope over brachial artery
  • let pressure fall slowly and smoothly, note the point when the first clear sound is heard (sys. BP)
  • note the point at which the sound becomes muffled or disappears (diastolic BP)
  • listen 10-20 mmHg further, then deflate cuff quickly

118 - INP (16 decks)

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