NUR 116 CL - TPR (Vitals) Flashcards
What are the 5 vital signs?
- Temperature
- Pulse
- Respirations
- Blood Pressure
- Pain
What is the purpose of Vital Signs?
-Reflect essential body functions
-Get a baseline of patient’s health
-Reflect changes in patient’s health (improvement of deterioration)
When do we take Vital signs?
- On admission
- Prior to administration of any medication that affects: heart rate, BP or respiration rate
- Anytime the client’s condition changes or they have a complaint
- At the beginning of your shift
- Whenever the client is leaving unit or returning to unit for testing (PT, OT, etc)
- According to agency policy
What are we measuring when we take a client’s temp?
The difference between the heat the body produced through metabolism and the heat lost to the environment
Areas to acquire temperature, and their effectiveness
Oral: common
Axillary: least accurate; 0.5 degrees lower than oral
Rectal: most accurate; sims position; 0.9 degrees higher than oral
Temporal
Tympanic: child, pull ear down and back; adult, pull ear up and back (inspect ear for cerumen/ear wax); 0.5 degrees lower than oral
Which temps sites give different readings compared to oral temp?
Rectal: 0.9 degrees higher than oral
Axillary & Tympanic: 0.5 degrees lower
What is the expected body temperature?
96.8 - 100.4 Fahrenheit
Average is 98.6
Older adults = lower end of normal
How far should the nurse insert the Rectal Thermometer for: adult, child, infant
Adult: 1-1.5 inches
Children: 0.5-1 inch
Babies: About 0.5 inches
When would you not take an oral temperature?
- Inaccurate if client ate/drank/smoked in past 30 minutes
- Safety concern for newborns, infants and young children
When would you not take a rectal temperature?
- Immune compromised
- Cardiac history (thermometer hits vagus nerve)
- Diarrhea, hemorrhoids
- Rectal surgery, coagulation disorders or
- If the patient has a sewn anus
Factors that affect temperature
Age, exercise, hydration levels, medications, daily fluctuations, health status
What is a normal pulse?
What are the names for low and high pulse rate?
Normal: 60-100 bpm
Bradycardia - Less than 60 bpm
Tachycardia - Greater than 100 bpm
Factors that affect pulse
Age, exercise, hydration levels, medication, temperature, position changes
What is the pulse deficit?
Difference between apical and radial pulse by more than 2 beats, when assessed by 2 nurses
What adjectives would you describe a pulse with?
Bounding +4
Strong +3
Weak +2
Thready +1
No pulse 0
List the landmark pulse sites
Temporal - temples; side of forehead
Carotid - Neck, under jaw
Apical - 5th intercostal space/mid clavicular line; PMI (point of maximum impact, apex of heart)
Brachial - “palm” side of elbow joint
Ulna - Pinky side wrist
Radial - Thumb side wrist
Femoral - Groin; upper thigh, where femur joints pelvis
Popliteal - Behind the knee
Posterior tibial - Lateral side of foot, behind ankle?
Dorsal pedal - Top of foot
What is the normal respiration rate for an adult?
What is the term for low and high respiration?
12-20 breaths (inhalation and exhalation)
Tachypnea - Greater than 20 resp
Bradypnea - Lower than 12 resp
What is eupnea vs apnea?
Eupnea - Normal respiration (Think eu = true)
Apnea - No respiration
What are dyspnea and orthopnea?
Dyspnea - Difficulty breathing
Orthopnea - Difficulty breathing when supine
Adjectives to describe respiration?
Pattern: regular or irregular
Shallow or deep
What is Systolic and Diastolic BP?
Systolic BP: The maximum amount of pressure exerted when the heart contracts and forces blood into the aorta
Diastolic BP: The minimum amount of pressure exerted when the heart is relaxed
What is hypertension?
Define Stage I and II Hypertension
Hypertension - blood pressure above the expected reference range
Stage I hypertension - systolic pressure is 130 to 139 mm Hg, or the
diastolic pressure is 80 to 89 mm Hg
Stage II hypertension - Systolic pressure is greater than 140 mm Hg or the diastolic pressure is greater than 90 mm Hg
What is a hypertensive crisis?
Hypertensive crisis - when the systolic pressure is greater than 180 mm Hg
and/or the diastolic pressure is greater than 120 mm Hg
How to estimate systolic pressure?
Palpate the brachial artery while inflating the cuff by increments of 10
- When pulse is lost add 20-30 mmHG then release feeling for return of brachial, which is estimate systolic
How to measure cuff?
40% arm circumference = cuff bladder width
80% arm circumference = cuff bladder length
- Too large will give false lower reading
- Too tight will give false higher reading
How to get systolic-diastolic
Pump up cuff to 20-30 mmHG above estimated systolic, release 2mmHG/sec
Initial sound is systolic
Last sound is diastolic
What is oxygenation saturation?
The estimated amount of oxygen bound to the hemoglobin
- It’s a direct reflection of client’s respiratory status
-Expected range is 95%-100%
