NSG 1610 - Vitals Flashcards
What is the purpose of taking vital signs?
provides a baseline of client’s thermoregulatory, respiratory, and cardiovascular status
what is the normal stable core temperature?
37.2 degrees
what is one risk associated with taking a rectal temperature?
it may stimulate the vagus nerve which may result in bradycardia (slowed HR) and syncope (temporary LOC)
what may increase temperature?
increased metabolism, during/post-exercise, after eating, and external envrionments
what may contribute to heat loss?
heat radiation, sweat evaporation, convection (air currents), reduction (cold cloth)
at what point of the day is body temperature the lowest?
during sleep
how does age effect body temperature?
older and younger individuals may have reduced temperatures
older adults have a reduced capacity to conserve heat and detect cold due to degeneration of nerves
what range does temperature have to be above in order to be classified as hyperthermic? where must this temperature be taken?
greater than 40.0 degrees - must be taken through a rectal temperature
what range does temperature have to be above in order to be classified as hypothermic? where must this temperature be taken?
equal to or lower than 35.0 degrees - must be taken through a rectal temperature
describe febrile and afebrile, what their ranges are, and where these temperatures are taken
- febrile is a pt with a fever ranging above 38 degrees
- afebrile is a pt without a fever and temp within a normal range (35.8-38.0)
- taken through tympanic temperatures
what are the normal/average ranges of tympanic temperature?
could range from 35.8 to 38.0 degrees but averages at 36.5
what are the normal/average ranges of temporal temperature?
could range from 36.5 to 37.5 but average is 37.0 degrees
What are the five sites for temperature?
- tympanic
- temporal
- rectal
- oral
- axillary
what is the pathophysiology of a pulse?
we are feeling a pressure wave from the left ventricle of the heart
what 10 factors may influence pulse/HR?
- age
- disease
- stress
- exercise
- ethnicity
- temperature (fever will increase HR)
- acute vs chronic pain
- positional changes
- lung changes
- medical emergencies (hemorrhaging)
how does acute vs. chronic pain influence HR/pulse?
- acute pain will increase pulse rate
- chronic pain does not create changes in pulse
what is the normal range for pulse rate?
50-95 beats per minute
describe the pulse scale and what each number correlates to
0 – absent pulse (cannot feel it or not palpable)
1+ - weak or thready pulse (can barely feel it), diminished, weak, and barely palpable – easy to obliterate
2+ - normal pulse (Obliterate with slight pressure)
3+ - full and bounding pulse (obliterate with firm pressure or unable to obliterate)
list the 8 sites for pulse palpation
- carotid
- brachial
- radial
- popliteal
- dorsalis pedis
- apical
- femoral
- posterior tibial
what parts of the brain determine resp. rate?
medulla oblongata and pons
what is a normal range for resp. rate?
12-20
if resp. rate is coming out as abnormal, how long should you record for?
1 full minute
what is tachypnea?
fast resp. rate above 20
what is bradypnea?
slow resp. rate - below 12
what is dyspnea?
difficulty breathing
what is hyperpnea?
fast and elevated depth - could be caused by exercise
what is the difference between hyperventilation and hyperpnea?
Hyperpnea is breathing more deeply but not necessarily faster. It happens when you exercise or when you’re doing something strenuous. Hyperventilation is breathing very fast and deeply, and exhaling more air than you take in.
what is apnea?
no breathing for several seconds
what is hypoventilation?
low rate and shallow
what is the normal range for BP?
135/80
what is orthostatic hypotension?
If systolic drops 20 or more mmHg and HR goes up by 20 beats or more when position is changing
What are the three portions of a general survey?
- Physical appearance
- Mobility
- Behaviour
What 6 components are part of the physical appearance portion of a general survey?
- Age (appears vs. actual)
- sex
- LOC X3 or X4 (place, person, time) & (know the situation)
- skin colour and lesions
- facial features (symmetry)
- body structure
what component is part of mobility in the general survey?
Gait - coordinated or uncoordinated, ROM
what 5 parts are part of the behaviour component of general survey?
- facial expressions
- mode & affect
- speech
- dress
- personal hygiene
what is the gate control theory?
closing the ‘gate’ of sensations from entering the brain to provide a perception of pain
Includes the notion that the perception of pain may be altered by stimulating other sensory pathways that interefere with the transmission of pain messages to the brain
what are the 4 sources of pain?
- somatic - damage to the tissue that creates pain
- visceral - anything relating to the internal organs
- neuropathic - relating to the nerves
- referred - pain that originates from another area and shows in a separate area (i.e., appendicitis, myocardial infarction)
What does OPQRSTUV stand for? explain each one
o Onset – when did it start?
o Provocative and palliative – what makes it better, what makes it worse?
o Quality – what kind of pain? Can you describe it for me?
o Region/radiation – show me where the pain is
o Severity – pain scale 0-10
o Treatment and timing – what have you done to help it? Does it happen at a certain time of day?
o Understanding – do you think this could be caused by anything?
o Values – how is this pain impacting your life and ADLs? Any limitations due to pain?
What is considered as the fifth vital sign?
Pain
How would you assess pain in an unconscious individual?
Individuals will exhibit grimacing, wincing, rigidity, or shaking
