EXAM 2- Vital Signs Flashcards
1
Q
6 vital signs
A
- temperature
- pulse
- blood pressure
- respiratory rate
- oxygen saturation
- pain
2
Q
when would you measure vital signs?
A
- on admission
- per physician order (routine, Q4)
- any change in pt condition
- before/after any procedure
- during blood transfusion
- after medications/interventions that affect vitals
3
Q
normal temperature range for adults
A
96.8 - 100.4
4
Q
normal oral/ tympanic/ temporal temperature
A
97.6 - 99.6
5
Q
normal rectal temperature
A
98.6 - 100.4
6
Q
normal axilla temperature
A
96.8 - 98.6
7
Q
normal pulse bpm range
A
60-100 bpm
8
Q
normal respiration rate range
A
12-20 breaths per minute
9
Q
normal blood pressure range for adults
A
< 120/80 mmHg
10
Q
pre-hypertensive bp range
A
stysolic 120-139
diastolic 80-89
11
Q
hypertensive bp range
A
systolic > 140
diastolic > 90
12
Q
hypotensive bp range
A
systolic < 90 and asymptomatic
13
Q
what does body temp measure?
A
tha constant balance between heat produced & heat lost
14
Q
temperature sites
A
- oral
- rectal
- axillary
- tympanic membrane (ear)
- temporal artery (forehead>side of face)
- esophageal (endoscopy procedures)
- pulmonary artery
- urinary bladder (special catheters)
15
Q
how does the neural and vascular system control/regulate temp?
A
- anterior hypothalamus - controls heat loss (sweat)
- posterior hypothalamus - controls heat production (shivering when cold creates energy> heat via vasoconstriction)
16
Q
what is the thermostat of the body?
A
anterior/posterior hypothalamus
17
Q
methods of heat loss
A
- radiation
- conduction
- convection
- evaporation
- diaphoreses (pale, sweaty)
18
Q
examples of heat production
A
- BMR (basal metabolic rate)
- shivering
19
Q
how does the skin help regulate temp?
A
- insulation
- vasoconstriction
- sensation
20
Q
radiation
A
transfer of heat from surface of one object to surface of another without direct contact
ex: sun radiation
21
Q
radiation
A
transfer of heat from surface of one object to surfae of another without direct contact
ex: sun radiation
22
Q
conduction
A
transfer of heat from one object to another with direct contact
ex: heating pad on skin
23
Q
convection
A
transfer of heat away by air movement
ex: when your temp is high, the room air will transfer your heat out
24
Q
evaporation
A
transfer of heat energy when a liquid is changed to gas
sweating
25
evaporation
transfer of heat energy when a **liquid is changed to gas**
| sweating
26
diaphoresis
visible perspiration
| sweat
27
how does age affect body temp?
infants & elderly have **poor core temp control**
28
how do hormone levels afect body temp?
temp fluctuates with cycle stage
| ex: menopause causes hot flashes
29
how does the environment affect body temp?
prolonged exposure exausts the hypothalamus eventually
| heat stroke, frostbite, hyper/hypothermia
30
how does exercise affect body temp?
increased metabolism creates heat
31
how does circadian rhythm affect body temp?
temp is lowered in sleep
| ?
32
pyrexia
fever
33
for adults, fevers are usually not harmful if under what temp?
102.2 ºF
34
# true or false:
fever is an important **defense mechanism**
true
35
# true or false:
temp should be taken **once** for a pt with a fever
false
| temp should be taken several times throughout the day
36
what does fever cause?
* increase in **metabolism & oxygen demand**
* increased **HR & RR**
37
febrile
fever
38
afebril
no fever/ without fever
39
FUO
fever of unknown origin
40
hyperthermia
**inability to promote heat loss** or reduce production
| leads to heat stroke
41
heat stroke
dangerous heat emergency/ high mortality rate
* body temp >104 ºF
42
signs/ symptoms of heat stroke
* body temp > 104 ºF
* **MOST IMPORTANT: hot/dry skin**
* confusion, excess thirst, muscle cramps
* increased HR, decreased BP
* no sweating (body has exhausted all excess fluids = dehydration)
43
heat exhaustion
diaphoresis results in excess water & electrolyte loss
| the body needs to replace them
44
heat exhaustion
diaphoresis results in excess water & electrolyte loss
| the body needs to replace them
45
hypothermia
prolonged exposure to cold decreases the body's ability to produce heat
* temp < 86-96.8 ºF
| can be accidental or intentional (slows body to allow time to heal)
46
ºF to ºC formula
C = (F - 32) x (5/9)
| round to one decimal
47
ºC to ºF formula
F = (9/5 x C) + 32
| round to one decimal
48
assessing oral temp
* most common
* appx. one degree lower than core temp
* may be glass or electronic
49
# true or false:
oral temp is **easily influenced** by hot/cold foods & drinks
true
50
assessing rectal temp
* **adult**: insert 1.5"
* **child**: insert 1"
* **infant**: insert 0.5"
| feces may give inaccurate readings
51
which assessment of temp is the most accurate?
rectal
52
assessing axillary temp
* safest method
* must be left in place for 5-10 minutes
* moisture in axillary area may reduce temp
53
assessing tympanic temp
* rapid
* unaffected by PO intake
54
assessing temporal temp
* most accurate compared to core/ rectal
* rapid (2-3 sec)
* fewer errors than tympanic
| follows temporal artery (mid forehead> temple> side of face> underear)
55
how long should you wait to take an oral temp if a pt has drank hot coffee?
30 minutes
56
what do you do for a fever?
| nursing interventions
* obtain **blood cultures** if ordered
* monitor VS, skin color, turgor, labs
* reduce O2 demand
* maximize heat loss (no excess clothes, linens)
* extra fluids
* tepid bath (room temp, DONT shock temp)
* oral hygiene (rapid bacteria growth, especially for intubated pts)
* dry bed linens
* antipyretic meds as ordered
57
pulse
palpable/ audible bounding of blood flow noted at various points on the body
| indirect measure of circulatory status
58
which part of the stethoscope are for low pitch? high pitch?
* **bell** - low pitch
* **diaphragm** - high pitch (most common)
59
radial pulse
* most common for **routine vitals**
* used for **pt teaching**
* assesses **circulaiton status to the hand**
60
apical pulse
| (with stethoscope)
* if pulse is **abnormal**
* if taking **meds that affect HR**
* if **radial is unaccessible**
* located in **5th ICS, mid-clavicular**
61
carotid pulse
* used if pt **condition suddenly worsens**
* need **pulse quickly**
* **DON'T measure bilateral** at the same time
62
dorsalis pedis pulse
* **top of foot**
* assesses **circulation to foot**
* via **doppler** if unable to palpate
* access **bilaterally** at the same time
63
pulse strength
4+, 3+, **2+ (normal)**, 1+ 0
| 4+ is bounding, 1+ is weak/thready, 0 is unable to palpate
63
gas exchange
* process of transporting **oxygen into cells**
* transporting **carbon dioxide out of cells**
64
ventilation
moving air in/out of lungs (inspiration in/ expiration out)
65
respirations
CO2 and O2 exchange occurs across alveoli in lungs
66
ischemia
insufficient oxygen to tissues
| leads to cell injury/death, or hypoxia
67
ischemia
insufficient oxygen to tissues
| leads to cell injury/death, or hypoxia
68
hypoxia
insufficient cell O2
69
hypoxemia
insufficient oxygen in blood (specifically in **arteries**)
70
respiratory acidosis
not moving CO2 out of cells, **excess CO2 in cells**
71
process/problems of ventilation
* **oxygen: in**, **carbon dioxide: out**
* issue - **lack of surfactant** (surfactant allows lungs to expand, not present in newborns)
* issue - meds can **open airways** for asthmatic pts
72
process/ problems of transport in respirations
* **transfer of hemoglobin** (transfers O2 and CO2 to/from cells)
* issues - low RBC (**anemia**), **blood loss** (trauma/ surgery)
73
process/ problems of perfusion
* allows **O2 and CO2 to exchange**
* heart controls perfusion
* issue - **lack of perfusion/ lack of pumping blood**
74
issues in ventilation, transport, or perfusion can lead to what?
* **ischemia** (insufficient oxygen in blood)
* **hypoxia** (insufficient oxygen in tissues)
* **hypoxemia** (insufficient O2 in blood/ arteries)
75
impairment of gas exchange
occurs when the diffusion of gases (O2 and CO2) becomes impaired
76
what causes impaired gas exchange?
| 3 factors
* ineffective ventilation
* reduced capacity for gas transportation (reduced hemoglobin and/or RBC)
* inadequate perfusion
77
eupnea
ventilation of normal rate & depth
| rate of 12-20 breaths/min
## Footnote
**Eu** (normal) + **pnea** (lungs)
78
factors that can influence respirations
* exercise
* acute pain - shallow breaths
* anxiety
* smoking
* bed position (sitting up opens airway/ allows lungs to expand)
* medications (albuterol increases breaths/min, opioids decrease breaths/min)
* neurological injury (spine, vent, trach)
* hemoglobin function (low hemoglobin = high RPM)
79
dyspnea
difficulty breathing
80
orthopnea
positional difficulty breathing
| pt has a hard time breathing when laying down or in a certain position
81
bradypnea
* slower than normal rate (< 12 RPM)
* normal depth and rhythm
82
tachypnea
rapid, shallow breathing (> 20 RPM)
83
apnea
period of cessation of breathing
84
cheyne-stokes
rate & depth of breathing increase, tehn decrease until apnea
85
how do we assess diffusion & perfusion?
* indirect measurement of oxygen saturation (with **pulse oximetry**)
* measured with light absorption with photo detector
* pulse saturation (**Sp02**) estimates arterial saturation (**Sa02)**
86
acceptable oxygen saturation range
95-100%
87
# true or false
the more oxygen support needed, the more critical the pt is
true
88
factors that can affect pulse ox readings
* nail polish
* temp of extremity (cold = low/inaccurate readings due to low blood flow)
* lighting
* skin pigmentation (darker skin is harder to read)
89
your post op pt is breathing rapidly, what is the FIRST thing you should do?
assess the oxygen saturation
90
you measure the O2 saturation at 77%, what is the FIRST thing you should do?
check the probe
91
blood pressure
the force exerted against the blood vessels by the blood
* measured in millimeters of mercury (**mmHg**)
* **systolic** - maximum pressure
* **diastolic** - minimal exertion
* **pulse pressure** - systolic minus diastolic
92
factors that affect bp
| 5
* **cardiac output** - volume of blood ejected from the heart (more output = higher bp)
* **peripheral resistance** - ex: plaque (higher bp)
* **blood volume** - higher bp
* **viscosity** - blood thickness (more RBC = higher viscosity)
* **elasticity** - expanding/ contracting
93
korototkoff sounds
| 5
1. **systolic**
2. whooshing
3. crisp
4. blowing softly
5. silence **diastolic**
94
which artery would you palpate to obtain a manual bp?
bracial artery
95
upon first assessing a pt, how long should they rest and how many times should you take their bp to obtain a baseline?
* rest at least 5 minutes before assessing
* record in both arms initially, use same arm routinely after that if possible
96
factors that can influence bp
* age
* stress
* ethnicity/ gender
* daily variation
* medications
* activity, weight
* smoking
97
hypertension quick facts
* more common thatn hypotension
* thickening of walls
* loss of elasticity
* family history + risk factors
* usually no sympoms
98
which diagnosis is a major factor underlying strokes and heart attacks?
hypertension
99
hypotension quick facts
* dilation of arteries
* loss of blood volume
* decrease of blood flow to vital organs (kidneys first)
* can be orthostatic/ postural as well
| systolic < 90 mmHg
100
symptoms of hypotension
* skin mottling
* clamminess
* confusion
* increased HR
* decreased urine output
101
after obtaining an abnormal electric/automatic bp, what is the FIRST thing you should do?
recheck with a manual bp
| they are more susceptible to error, unable to detect low bp accurately
102
alternate bp sites
* **thigh** - supine position (not ideal), bent knee, systolic is usually higher than 10-40 mmHg
* **arterial line** - catheter inserted in an artery
103
PQRST for pain
* **P**rovokes/palliates - what makes it worse/ better?
* **Q**uality - can you describe the pain– sharp, dull, aching, etc?
* **R**egion/radiation - where's the pain? does it radiate?
* **S**everity/setting - how severe is your pain on a scale of 0-10?
* **T**iming - is it worse during the morning/evening, etc?
104
when should you assess pain?
* often
* before procedures, activity, and medicate if available
* at elast 30min after pain meds
* do not assume your pt's pain level (it is subjective)
105
when assessing pain, what would you document?
* pain levels in EMR
* any accomanying symptoms in notes
* interventions initiated (medications)
* f/u assessment
