Normal Vitals crash course Flashcards
what is the normal temperature in farehit and it Celsius for adults
94.4-99.5 F
35.8-37.5 C
what is the normal pulse
60-100 beats per minute
what is the normal respirations
12-20 breaths per minute
what is the normal blood pressure
120/80
what is the normal temp for oral thermometers
Oral: 96.6–99.5°F
35.8- 37.5
what is the normal temp for rectal themometers
Rectal: 97.4–100.5°F (core temperature)
36.3- 38.5
what is the nomral temp for the axillary route
Axillary: 95.6–98.5°F
35.3-36.9
what is the normal temperature for the tympanic route
Tympanic: 98.2–100.9°F (core temperature)
In an adult, pull the pinna upward and back
In a child, pull the pinna downward and back
what is t si the normal temperature of the temporal artery
Temporal artery: 98.7–100.5°F (core temperature)
37.0-38.0
what does each number stand for
0
1+
2+
3+
0 =absent or unable to palpate
1+=pulse diminished, weaker than expected
2+=Easily palpable, normal pulse
3+=Full bounding pulse, bounding
what is tachycardia
more than 100 beats per minute
what is bradycardia
less than 60 beats per minute
where can you take the pulse
radial
carotid
apical
what do you need to remember when you take carotid pulse
never press both of the at the same time
what affects pulse
-age
-physical activity
-Fever - For every 1.0°C body temp increase, heart rate increases by 7-10 beats per min to meet increased metabolic needs and compensate for peripheral dilation.
-Medications
-Hypovolemia (HR increases and BP decreases_
-Stress
-Position changes
-Pathology
what should cap refill time be and what does it measure, what is caused when circulation is compromised
2 seconds or less
-measures the perfusion of the tcapillary beds of the toes and the finger nails
if the circulation is compromised, pallor or cyanosis may be present
what is pallor
Paleness of skin when compared with another part of the body
what is cyanosis
A bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood
-present in gums, nails and lips
what is ventilation
movement of air in and out of lungs
where are vitals taken
Admission
Transfer
Before and after med
After operations
When pt status changes
Use nursing judgement never trust the first measurement
what is diffusion
gases move from high pressure to low pressure
what is perfusion
Exchange of oxygen and carbon dioxide between circulating blood and tissue cells
-if poor then brown skin and spotty
what is the rate and rhythm of respirations
bradypnea and tachypnea
what is the depth of resperation
normal, deep, shallow
what is the quality of breathing
normally relaxed and silent
what is eupnea
normal, unlabored respiration; one respiration to four heartbeats
what is tachypnea
increased rate; may occur in response to an increased metabolic rate
what is bradypnea
decreased rate; occurs in some pathologic conditions
what is apnea
period when you stop breathing
what is dyspnea
difficult or labored breathing
what is orthopnea
changes in breathing when sitting or standing
what is hyperventilation
Rapid and deep breathing resulting in excess loss of CO2 (hypocapnea). Patient may complain of feeling light-headed and tingly (respiratory alkalosis)
-this is why you have the pt breath into a bag so Co2 moves back into the body
what is hypoventilation
Rate and depth are decreased and CO2 is retained (respiratory acidosis)
what is pulse oximetry
Spot Oxygen saturation. Non-invasive
-SaO2 isthe percentage of available binding sites on hemoglobin that are bound with oxygen in arterial blood. The O2 dissociation curve (and hence the SaO2 for a givenPaO2) is affected by PaCO2, body temperature, pH and other factors
what is the normal O2 saturation is Colorado and in the NCLEX
In Colorado, normal is greater than or equal to 90%. The rest of the country (and NCLEX questions) Greater than or equal to 95%
what is the maximum pressure
when left ventricle contracts and pushes blood through aortic valve into the aorta (systole/systolic pressure)
what is the lowest pressure
when the heart rests between beats (diastole/diastolic pressure)
what regulates BP
cardiac output–> heart muscle strength
blood volume–> amount of blood the heart can hole
peripheral vascular resistance–> how elastic are the blood vessels
what factors affecting blood rpessure
-Age. Older may have a widening pulse pressure -which is normal
-Circadian rhythm
-Biologic sex
-Food intake
-Exercise
-Weight
-Emotional state
-Body position and movement variations
-Drugs/medications
-Talking or laughing. Have patient be quiet during measurement
what happens when the cuff size is too small
high reading
what happens when the bp cuff is too big
low reading
what is the 1st korotkoff sound
systolic pressure
what is the change or cesation of sound occurs
diastolic pressure
what is orthostatic hypotension and what is it caused by
when the bp bottoms out while the pt is trying to sit or stand
-Caused by dehydration, blood loss, or problems of the neurologic, cardiovascular, or endocrine systems
why is hypertension known as the silent killer
your first symptoms in a stroke
what is primary hypertension
No known cause
Characterized by an increase above normal in both systolic and diastolic pressures
what is secondary hypertneison
Caused by other disease conditions
Common causes include kidney disease, adrenal cortex disorders, and aorta disorders
what meds can decrease bp
Diuretics (to decrease fluid volume)
Beta-adrenergic blockers (to block sympathetic stimulation and decrease cardiac output)
Vasodilators and calcium channel blockers (to relax smooth muscles of arterioles and decrease peripheral vascular resistance)
ACE inhibitors (to prevent vasoconstriction by angiotensin II and decrease circulatory fluid volume by reducing aldosterone production)
