L2 Vital Signs Flashcards
VITAL SIGNS is also known as?
Vitals
ARE A GROUP OF THE FOUR TO SIX MOST IMPORTANT MEDICAL SIGNS THAT INDICATE THE STATUS OF THE BODY’S VITAL (LIFE-SUSTAINING) FUNCTIONS.
VITAL SIGNS
THESE MEASUREMENTS ARE TAKEN TO HELP ASSESS THE GENERAL PHYSICAL HEALTH OF A PERSON, GIVE CLUES TO POSSIBLE DISEASES, AND SHOW PROGRESS TOWARD RECOVERY.
Vital signs
THE NORMAL RANGES FOR A PERSON’S VITAL SIGNS VARY WITH AGE, WEIGHT, GENDER, AND OVERALL _______.
HEALTH
THERE ARE FOUR PRIMARY VITAL SIGNS:
BODY TEMPERATURE,
BLOOD PRESSURE,
PULSE (HEART RATE),
AND BREATHING RATE (RESPIRATORY RATE),
BODY TEMPERATURE, BLOOD PRESSURE, PULSE (HEART RATE), AND BREATHING RATE (RESPIRATORY RATE), OFTEN NOTATED AS TEMP, BP, HR, AND RR. HOWEVER, DEPENDING ON THE CLINICAL SETTING, THE VITAL SIGNS MAY INCLUDE OTHER MEASUREMENTS CALLED THE “____________”.
FIFTH VITAL SIGN
REFLECTS CHANGES IN BODY FUNCTIONS THAT OTHERWISE MIGHT NOT BE OBSERVED
VITAL SIGNS
VITAL SIGNS may include?
TEMPERATURE
PULSE
RESPIRATION
BLOOD PRESSURE
PAIN
VITAL SIGNS: FACILITY STANDARDS
• HOSPITAL:
- EVERY ____ HOURS
• HOME HEALTH
- EACH VISIT
• CLINIC
- EACH VISIT
• SKILLED FACILITY
- DAILY AND AS NEEDED
4-8
What is this?
• UPON ADMISSION TO ANY HEALTHCARE AGENCY
• BASED ON AGENCY INSTITUTIONAL POLICY AND PROCEDURES
• ANY TIME THERE IS A CHANGE IN THE PATIENT’S CONDITION
• BEFORE AND AFTER SURGICAL OR INVASIVE DIAGNOSTIC PROCEDURES
• BEFORE AND AFTER ACTIVITY THAT MAY INCREASE RISK
• BEFORE AND AFTER SURGICAL OR INVASIVE DIAGNOSTIC PROCEDURES
• BEFORE AND AFTER ACTIVITY THAT MAY INCREASE RISK
BEFORE ADMINISTERING MEDICATIONS THAT AFFECT CARDIOVASCULAR OR RESPIRATORY FUNCTIONING
WHEN TO ASSESS VS
What is this?
• WASH HANDS BEFORE AND AFTER A PROCEDURE TO MAINTAIN ASEPSIS
• GATHER EQUIPMENT NEEDED INCLUDING A WATCH WITH A SECOND HAND TO MAXIMIZE TIME AND REDUCE EFFORT
• GREET CLIENT AND INTRODUCE ONESELF TO PROMOTE CLIENT’S SENSE OF WELL-BEING
SPECIAL NURSING INTERVENTIONS
• THE BALANCE BETWEEN THE HEAT PRODUCED BY THE BODY AND THE HEAT LOST FROM THE BODY
BODY TEMP
• TEMPERATURE OF THE DEEP TISSUES OF THE BODY MEASURED BY TAKING ORAL AND RECTAL TEMPERATURE
CORE TEMPERATURE
TEMPERATURE OF THE SKIN, SUBCUTANEOUS TISSUE AND FAT MEASURED BY TAKING AXILLARY TEMPERATURE
SURFACE TEMPERATURE
PULSE SITES:
• TEMPORAL
• CAROTID
• APICAL
• BRACHIAL
• RADIAL
• FEMORAL
• POPLITEAL
• DORSALIS PEDIS
• POSTERIOR TIBIALIS
FACTORS AFFECTING THE PULSE RATE
• Hormones
• AGE
• SEX/GENDER
• EXERCISE
• FEVER
• MEDICATION
• HEMORRHAGE
• STRESS
• POSITION CHANGES
ASSESSMENT OF THE PULSE:
• SYSTOLIC PRESSURE MINUS DIASTOLIC PRESSURE
• PULSE PRESSURE
ASSESSMENT OF THE PULSE:
• PULSE PRESSURE
PRIMARY SOURCE OF METABOLISM
• HORMONES, MUSCLE MOVEMENTS, AND EXERCISE INCREASE METABOLISM
• EPINEPHRINE AND NOREPINEPHRINE ARE RELEASED AND ALTER METABOLISM
• ENERGY PRODUCTION DECREASES AND HEAT PRODUCTION INCREASES
HEAT PRODUCTION
