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NUR 101 Assessment #2 > Measuring Vital Signs > Flashcards

Measuring Vital Signs Flashcards

1
Q

?

  • Are a means of assessing vital or critical physiological functions
  • Variations reflect a person’s state of health and/or functional ability of body systems
  • Importance of accurate assessments, interpretation, and documentation cannot be overemphasized
A

Vital signs

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2
Q

Facility Standards for Monitoring

A

Hospital: every 4-8 hours

Home health setting: each visit

Clinic: each visit

SNFs: weekly to monthly

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3
Q

?

  • Is degree of heat maintained by the body
  • Difference between heat produced by the body and heat lost to the environment
A

Temperature

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4
Q

?

  • Temperature deep within the body
  • Not routinely used as requires an invasive procedure
A

Core Temperature

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5
Q

Rectal measurements are used to represent ___ temperatures, while oral and axillary reflect ___ temperatures

A

CORE, SURFACE

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6
Q

The “traditional” normal body temperature was ___ ?

A

98.6°F

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7
Q

Older lit has a lower level (mean normal oral temperature) of ___ ?

A

97.3°F

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8
Q

Recent lit has a mean body temperature of ___. with a range of ___ to ___

A
  1. 9°F
  2. 5°F - 98.8°F
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9
Q

Core Temperature cont’d

Typically, 1-2°F higher than skin temp
Temp varies based on age
Rectal sites measures ___ temp

A

core

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10
Q

Surface Temperature

___ (↑ or ↓) than core temp ?
Use oral and axillary method

A

Lower

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11
Q

?

  • Process of maintaining a stable temperature
  • Constant body temperature = balance between heat production and heat loss
  • Center of control is the ___
A

Thermoregulation

hypothalamus

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12
Q

?

Is the amount of energy needed to maintain the body at rest

A

Basal metabolic rate (BMR)

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13
Q

?

High thyroxine, more heat, patient feels warm even in cool environment

A

Hyperthyroidism

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14
Q

?

Low thyroxine, less heat, patient feels cold

A

Hypothyroidism

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15
Q

Skeletal muscle movement

  • Muscles need fuel
  • Breakdown (___) of fats and carbs in muscles produce energy and heat
A

catabolism

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16
Q

?

Is usually seen in infants and disappears in the first few months after birth

A

Non-shivering thermogenesis

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17
Q

?

Is the transfer of heat through currents of air or water

A

Convection

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18
Q

?

Is loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air

A

Radiation

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19
Q

?

Is the transfer of heat from a warm to a cool surface by direct contact

A

Conduction

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20
Q

?

Water is converted to vapor and lost from the skin (as perspiration) or the mucous membranes (through the breath)

A

Evaporation

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21
Q

Factors That Influence Body Temperature

  • Developmental level (infants and older adults more susceptible)
  • Environment (warm, cold, high humidity, hot baths)
  • Gender (lower when progesterone levels are low and increases when progesterone levels are high; hot flashes during menopause)
A

Factors That Influence Body Temperature cont’d

  • Exercise (sweat evaporates and helps cool body)
  • Emotions, stress
  • Circadian rhythm
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22
Q

Variances in Temperature

Fever (aka ?)

  • High body temp (greater than ___)
  • Occurs in response to pyrogens (e.g. bacteria)
  • Pyrogens induce secretions of substances (___) that reset the hypothalamic thermostat at a higher temp
A

pyrexia

100°F

prostaglandins

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23
Q

Variances in Temperature cont’d

?
- Abnormally high body temp; fever greater than ___

A

Hyperpyrexia

105.8°F

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24
Q

Variances in Temperature cont’d

?

  • Core temp below normal (less than ___)
  • Associated with extended exposure to cold (e.g. extreme weather, immersion in cold water, or lack of shelter and clothing)
A

Hypothermia

95°F

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25
Q

Course of Fever

3 phases

Initial: febrile episode or onset
Second: course
Third: defervescence or crisis

A

Describing a fever

  • Intermittent
  • Remittent fever
  • Constant (sustained) fever
  • Relapsing (or recurrent) fever

* Antipyretic medications (i.e. acetaminophen, ibuprofen)

26
Q

Advantages & Disadvantages of Various Thermometers

  • Glass thermometers
  • Electronic thermometers
  • Infrared electronic thermometers
  • Disposable chemical thermometers
A

Advantages & Disadvantages of Various Sites for Measuring Temperature

  • Temporal artery
  • Rectal
  • Oral
  • Axillary
  • Tympanic membrane
  • Disposable (i.e. forehead)
27
Q

?

Is the rhythmic expansion of an artery produced when a bolus of oxygenated blood is forced into it by a contraction of the heart

A

Pulse

28
Q

Pulse rate

  • Measured in beats per minute (bpm)
  • Normal range for healthy adults = __ to __ bpm
    Average = __ to __ bpm
A

60 to 100 bpm

70 to 80 bpm

29
Q

Pulse cont’d

The “wave” that begins when the ___ contracts and ends when the ___ relaxes

Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system

A

left ventricle, ventricle

30
Q

___ is the peak of the wave, or contraction of the heart

___ is the trough or resting phase of the heart

A

systole

diastole

31
Q

___ is the quantity of blood pumped out by each contraction of the left ventricle

Cardiac output = ___ x ___

___ nervous system: regulates heart rate

A

Stroke volume

stroke volume x pulse (heart) rate

autonomic

32
Q

Factors That Influence Pulse Rate

  • Developmental level
  • Gender
  • Exercise
  • Food intake
  • Stress
A

Factors That Influence Pulse Rate cont’d

  • Fever
  • Disease
  • Blood loss
  • Position change
  • Medication
33
Q

Obtaining a Pulse Rate

___ is most accurate

Use a stethoscope to auscultate the number of heartbeats at the apex of the heart

A watch or clock with a second hand or digital display is required

A heartbeat is one series of the LUB and DUB sounds

A

Apical

34
Q
A
35
Q

When to Measure an Apical Pulse

  • The radial pulse is weak or irregular
  • The rate is < than 60 beats/min or > than 100 beats/min
  • The patient is taking cardiac medications
  • The patient is an infant or child up to age 3 (because peripheral pulses may be difficult to palpate)
A
36
Q

Variances in Pulse Rates

  • Pulse ___: hear a heartbeat but do not feel a beat at a pulse point
  • Pulse rate:

___: rate less than 60 bpm

___: rate greater than 100 bpm

  • Pulse rhythm: does the rate have a regular or irregular rhythm?
  • Pulse quality:

> What is the quality of the pulse?

> Volume = force

Absent? Weak or Thready? Normal? Bounding?

> Are pulses bilaterally equal?

> If absent or weak, check for cyanosis or pallor

A

deficit

Bradycardia

Tachycardia

37
Q

___ - a bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood

___ - paleness of skin when compared with another part of the body

A

Cyanosis

Pallor

38
Q

Analysis/Nursing Diagnosis

  • Peripheral Tissue Perfusion Alteration
  • Risk for Impaired Skin Integrity
  • Risk for Impaired Tissue Integrity
  • Deficient Fluid Volume
  • Decreased Cardiac Output
A

Outcomes and Interventions

Nursing Outcomes Classifications (NOC) Standardized Outcomes Vital Signs

  • Nursing Interventions Classification (NIC)

Dysrhythmia management

Vital signs monitoring

39
Q

Respiration

The exchange of oxygen and carbon dioxide in the body

2 separate processes

* Pulmonary ventilation

  • Pulmonary ventilation; breathing
  • Active movement of air in and out of the respiratory system
A

* Chemical

  • External respiration - exchange of O2 and CO2
  • Gas transport - transport of O2 and CO2
  • Internal respiration - exchange of gases between capillaries and tissues
40
Q

Respiration: Rate and Regulation

Rate varies with age, exertion, emotions, and other factors

Regulators

  • Level of CO2 in the blood
  • Central chemoreceptors (located in respiratory centers)
  • Peripheral chemoreceptors (located in carotid and aortic bodies)
A

Mechanics of Respiration/Pulmonary Ventilation

41
Q

Factors That Influence Respirations

  • Developmental level / Fever
  • Exercise / Hemoglobin
  • Pain / Disease
  • Stress / Medication
  • Smoking / Positions
A

Counting the Respiratory Rate

  • Nurse should count respiratory rate (RR) after taking the radial pulse
  • Patient can alter the rate and pattern of respirations
  • RR must be accurate, especially in older adults
42
Q

Variations in Assessment Findings

Rate

___ - cessation of breathing

___ - abnormally slow

___ - abnormally fast

Depth

  • Deep, shallow, normal
A

Apnea

Bradypnea

Tachypnea

43
Q

Variations in Assessment Findings cont’d

Rhythm

  • Assessment of the pattern of respirations
  • Abnormal: Cheyne-Stokes, Biot’s

Effort

  • Work of breathing

___: labored breathing

___: inability to breathe when horizontal

A

Dyspnea

Orthopnea

44
Q
A
45
Q

Variations in Breath Sounds

___ - high-pitched continuous musical sounds, usually heard on expiration

___ - a piercing, high-pitched sound heard primarily during inspiration

___ - labored breathing that produces a snoring sound

___ - low-pitched continuous sounds caused by secretions in the large airways

___ - discontinuous sounds usually heard on inspiration; may be high-pitched popping sounds or low-pitched bubbling sounds

A

Wheeze

Stridor

Stertor

Rhonchi

Crackles

46
Q

Associated Assessment

Chest and abdominal movement

  1. ?

Exists when tissues are drawn in beneath the sternum (breastbone)

  1. ?

Exists when tissues are drawn in above the clavicle (shoulder girdle)

  1. ?

Refers to the visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe

A
  1. Substernal retraction
  2. Suprasternal retraction
  3. Intercostal retraction
47
Q

Assessment: Associated Signs

Hypoxia

Cyanosis

Cough

A

When you assess respiration, it’s important to assess for clinical signs of oxygenation and perfusion

Hypoxia → pallor, cyanosis, fatigue, dizziness, restlessness, changes in BP

Cyanosis → tongue and oral mucosa are good indicators

Cough → constant, intermittent, productive, nonproductive, hacking, whooping

48
Q

Tools to Measure Oxygenation

?

Noninvasive method of monitoring respiratory status

Uses an external device that measures oxygen saturation

?

Directly measures the partial pressures of O2, CO2, and blood pH

A

Pulse oximetry

Arterial blood gases (ABG’s)

49
Q

Ventilation and Oxygenation

?

Rate and depth of respirations are decreased and CO2 is retained

?

Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea)

Client may complain of feeling light-headed and tingly

A

Hypoventilation

Hyperventilation

50
Q

Blood Pressure

An important indicator of overall cardiovascular health

Pressure of blood as it is forced against arterial walls during cardiac contraction

? Is minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest

? Is peak pressure exerted against arterial walls as the ventricles contract and eject blood

A

Diastolic pressure

Systolic pressure

51
Q

Blood Pressure cont’d

Measured in millimeters of mercury (mmHg)

Recorded as systolic pressure over diastolic pressure (120/80 mmHg)

Pulse pressure: the difference between the systolic and diastolic pressures

A

Blood Pressure cont’d

Normal

Elevated

Stage I hypertension

Stage II hypertension

Hypertensive Crisis

52
Q

What is “normal” range blood pressure?

A

<120 and <80

53
Q

What is “elevated” blood pressure?

A

120-129 and ≤80

54
Q

What is hypertension stage I blood pressure?

A

130-139 or 80-89

55
Q

What is hypertension stage II blood pressure?

A

≥140 or ≥90

56
Q

What is hypertensive crisis blood pressure?

A

>180 and/or >120

57
Q

Blood Pressure Regulation

* Influenced by 3 factors

  1. Cardiac function (increased, decreased stroke volume)
  2. Peripheral vascular resistance
    - Blood viscosity [thickness] (high, low hematocrit)
    - Arterial size
    - Arterial compliance [elasticity]
  3. Blood volume (5L)
A
  • Cardiac output is the volume of blood pumped by the heart per minute, and it reflects the functioning of the heart
  • Peripheral vascular resistance refers to arterial and capillary resistance to blood flow as a result of friction between blood and the vessel walls
58
Q

Factors That Influence Blood Pressure

  • Developmental stage / Pain
  • Gender / Race
  • Family history / Obesity
  • Lifestyle / Diurnal variations
  • Exercise / Medications
  • Body position / Diseases
  • Stress / Genetic variations
A

Korotkoff’s Sounds

1st sound

  • As you deflate the cuff, a sound that occurs during systole (systolic BP)
  • Is a tapping sound that corresponds to a palpable pulse

2nd sound

  • As you further deflate the cuff, a soft swishing sound caused by blood turbulence
59
Q

Korotkoff’s Sounds cont’d

3rd sound

  • Begins midway through the blood pressure and is a sharp, loud rhythmic sound

4th sound

  • Similar to the 3rd sound, but softer, fading, and muffled

5th sound

  • Silence, corresponding with diastole (diastolic blood pressure)
A

Hypotension and Hypertension

  • Are medical diagnoses
  • Are symptoms
  • May be etiology of a nursing diagnosis

* Risk for Falls related to orthostatic (postural) hypotension, or Fear of Falling related to fainting 2° orthostatic (postural) hypotension

* Risk for Unstable Blood Pressure, when the patient is “susceptible to fluctuating forces of blood flowing through arterial vessels which may compromise health”

  • Treated as collaborative problems
60
Q

Hypertension cont’d

  • Is a major cause of illness and death in the US
  • Increases the stress on the heart and blood vessels
  • If untreated, can lead to heart, renal, cerebral, or respiratory complications
  • Severity is directly related to the degree of elevation
  • Primary or essential hypertension

* Diagnosed when there is no known cause for the increase

* Accounts for at least 90% of all cases of hypertension

* Clients may not know they have hypertension

A

NUR 101 Assessment #2 (7 decks)

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