EXAM 2- Vital Signs Flashcards
6 vital signs
- temperature
- pulse
- blood pressure
- respiratory rate
- oxygen saturation
- pain
when would you measure vital signs?
- 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
normal temperature range for adults
96.8 - 100.4
normal oral/ tympanic/ temporal temperature
97.6 - 99.6
normal rectal temperature
98.6 - 100.4
normal axilla temperature
96.8 - 98.6
normal pulse bpm range
60-100 bpm
normal respiration rate range
12-20 breaths per minute
normal blood pressure range for adults
< 120/80 mmHg
pre-hypertensive bp range
stysolic 120-139
diastolic 80-89
hypertensive bp range
systolic > 140
diastolic > 90
hypotensive bp range
systolic < 90 and asymptomatic
what does body temp measure?
tha constant balance between heat produced & heat lost
temperature sites
- oral
- rectal
- axillary
- tympanic membrane (ear)
- temporal artery (forehead>side of face)
- esophageal (endoscopy procedures)
- pulmonary artery
- urinary bladder (special catheters)
how does the neural and vascular system control/regulate temp?
- anterior hypothalamus - controls heat loss (sweat)
- posterior hypothalamus - controls heat production (shivering when cold creates energy> heat via vasoconstriction)
what is the thermostat of the body?
anterior/posterior hypothalamus
methods of heat loss
- radiation
- conduction
- convection
- evaporation
- diaphoreses (pale, sweaty)
examples of heat production
- BMR (basal metabolic rate)
- shivering
how does the skin help regulate temp?
- insulation
- vasoconstriction
- sensation
radiation
transfer of heat from surface of one object to surface of another without direct contact
ex: sun radiation
radiation
transfer of heat from surface of one object to surfae of another without direct contact
ex: sun radiation
conduction
transfer of heat from one object to another with direct contact
ex: heating pad on skin
convection
transfer of heat away by air movement
ex: when your temp is high, the room air will transfer your heat out
evaporation
transfer of heat energy when a liquid is changed to gas
sweating
evaporation
transfer of heat energy when a liquid is changed to gas
sweating
diaphoresis
visible perspiration
sweat
how does age affect body temp?
infants & elderly have poor core temp control
how do hormone levels afect body temp?
temp fluctuates with cycle stage
ex: menopause causes hot flashes
how does the environment affect body temp?
prolonged exposure exausts the hypothalamus eventually
heat stroke, frostbite, hyper/hypothermia
how does exercise affect body temp?
increased metabolism creates heat
how does circadian rhythm affect body temp?
temp is lowered in sleep
?
pyrexia
fever
for adults, fevers are usually not harmful if under what temp?
102.2 ºF
true or false:
fever is an important defense mechanism
true
true or false:
temp should be taken once for a pt with a fever
false
temp should be taken several times throughout the day
what does fever cause?
- increase in metabolism & oxygen demand
- increased HR & RR
febrile
fever
afebril
no fever/ without fever
FUO
fever of unknown origin
hyperthermia
inability to promote heat loss or reduce production
leads to heat stroke
heat stroke
dangerous heat emergency/ high mortality rate
* body temp >104 ºF
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)
heat exhaustion
diaphoresis results in excess water & electrolyte loss
the body needs to replace them
heat exhaustion
diaphoresis results in excess water & electrolyte loss
the body needs to replace them
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)
ºF to ºC formula
C = (F - 32) x (5/9)
round to one decimal
ºC to ºF formula
F = (9/5 x C) + 32
round to one decimal
assessing oral temp
- most common
- appx. one degree lower than core temp
- may be glass or electronic
true or false:
oral temp is easily influenced by hot/cold foods & drinks
true
assessing rectal temp
- adult: insert 1.5”
- child: insert 1”
- infant: insert 0.5”
feces may give inaccurate readings
which assessment of temp is the most accurate?
rectal
assessing axillary temp
- safest method
- must be left in place for 5-10 minutes
- moisture in axillary area may reduce temp
assessing tympanic temp
- rapid
- unaffected by PO intake
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)
how long should you wait to take an oral temp if a pt has drank hot coffee?
30 minutes
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
pulse
palpable/ audible bounding of blood flow noted at various points on the body
indirect measure of circulatory status
which part of the stethoscope are for low pitch? high pitch?
- bell - low pitch
- diaphragm - high pitch (most common)
radial pulse
- most common for routine vitals
- used for pt teaching
- assesses circulaiton status to the hand
apical pulse
(with stethoscope)
- if pulse is abnormal
- if taking meds that affect HR
- if radial is unaccessible
- located in 5th ICS, mid-clavicular
carotid pulse
- used if pt condition suddenly worsens
- need pulse quickly
- DON’T measure bilateral at the same time
dorsalis pedis pulse
- top of foot
- assesses circulation to foot
- via doppler if unable to palpate
- access bilaterally at the same time
pulse strength
4+, 3+, 2+ (normal), 1+ 0
4+ is bounding, 1+ is weak/thready, 0 is unable to palpate
gas exchange
- process of transporting oxygen into cells
- transporting carbon dioxide out of cells
ventilation
moving air in/out of lungs (inspiration in/ expiration out)
respirations
CO2 and O2 exchange occurs across alveoli in lungs
ischemia
insufficient oxygen to tissues
leads to cell injury/death, or hypoxia
ischemia
insufficient oxygen to tissues
leads to cell injury/death, or hypoxia
hypoxia
insufficient cell O2
hypoxemia
insufficient oxygen in blood (specifically in arteries)
respiratory acidosis
not moving CO2 out of cells, excess CO2 in cells
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
process/ problems of transport in respirations
- transfer of hemoglobin (transfers O2 and CO2 to/from cells)
- issues - low RBC (anemia), blood loss (trauma/ surgery)
process/ problems of perfusion
- allows O2 and CO2 to exchange
- heart controls perfusion
- issue - lack of perfusion/ lack of pumping blood
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)
impairment of gas exchange
occurs when the diffusion of gases (O2 and CO2) becomes impaired
what causes impaired gas exchange?
3 factors
- ineffective ventilation
- reduced capacity for gas transportation (reduced hemoglobin and/or RBC)
- inadequate perfusion
eupnea
ventilation of normal rate & depth
rate of 12-20 breaths/min
Eu (normal) + pnea (lungs)
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)
dyspnea
difficulty breathing
orthopnea
positional difficulty breathing
pt has a hard time breathing when laying down or in a certain position
bradypnea
- slower than normal rate (< 12 RPM)
- normal depth and rhythm
tachypnea
rapid, shallow breathing (> 20 RPM)
apnea
period of cessation of breathing
cheyne-stokes
rate & depth of breathing increase, tehn decrease until apnea
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)
acceptable oxygen saturation range
95-100%
true or false
the more oxygen support needed, the more critical the pt is
true
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)
your post op pt is breathing rapidly, what is the FIRST thing you should do?
assess the oxygen saturation
you measure the O2 saturation at 77%, what is the FIRST thing you should do?
check the probe
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
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
korototkoff sounds
5
- systolic
- whooshing
- crisp
- blowing softly
- silence diastolic
which artery would you palpate to obtain a manual bp?
bracial artery
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
factors that can influence bp
- age
- stress
- ethnicity/ gender
- daily variation
- medications
- activity, weight
- smoking
hypertension quick facts
- more common thatn hypotension
- thickening of walls
- loss of elasticity
- family history + risk factors
- usually no sympoms
which diagnosis is a major factor underlying strokes and heart attacks?
hypertension
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
symptoms of hypotension
- skin mottling
- clamminess
- confusion
- increased HR
- decreased urine output
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
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
PQRST for pain
- Provokes/palliates - what makes it worse/ better?
- Quality - can you describe the pain– sharp, dull, aching, etc?
- Region/radiation - where’s the pain? does it radiate?
- Severity/setting - how severe is your pain on a scale of 0-10?
- Timing - is it worse during the morning/evening, etc?
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)
when assessing pain, what would you document?
- pain levels in EMR
- any accomanying symptoms in notes
- interventions initiated (medications)
- f/u assessment
