Nursing Techniques - Vital Signs Flashcards
what is the checklist for techniques
- perform, greet, introduce, verify, explain, raise, position, maintain, assess, use, provide, leave, clean, document
what do vital signs tell us?
this assessment provides us with a picture of the clients thermoregulatory, respiratory, and cardiovascular status
what are some things that can affect vital signs?
- medications = antipyretics (acetaminophen) - decrease temp (masking fever), opioids (morphine) - decrease respiratory rate, antihypertensives (atenolol) - decreased BP and many decrease pulse, cardiac glycosides (digoxin)
- illness/infection = fever increases P, RR, BP, infection increases P, sepsis increases P + decreases BP
- exercise/infection = increased metabolism temporarily increases T, P, RR, BP, postural changes increase P + decrease BP
- age = T regulation is less effective
- hypovolema/dehydration = hemorrhage causes decreased BP + increased P
- environment = visiting doctor can increase BP
- PO intake: hot/cold v=beverages, smoking, can alter T, smoking, caffeine, heavy alcohol consumption can increase BP
- hormones = ovulation changes T, thyroid hormone causes increase in basal metabolic rate + increases T+P
- circadian rhythm = T + B can fluctuate based on time of day
describe temperature measurements
- average T is 36-38 degrees
- oral = avg. 37 degrees, must wait 20 minutes or choose another site, if client has taken hot/cold bereaves, chewed gum, or smoked
- axillary = avg 36.5 - often used in newborns + children
- temporal = avg 37 degrees - scanner probe that is noninvasive + fast
- tympanic = avg 37 degree - easily accessible + fast - pull pinna up + back for people over 3 + under 3 is down and back
- rectal = avg 37.5 - rarely used, risks damaging rectal tissue so never use on a newborn
what are some alterations in temperature
thermoregulation = process that allows the body to maintain its internal core temperature
- thermoreceptors are hot + cold receptors + sends messages to hypothalamus (restore homeostasis)
- pyrexia, hyperthermia, fever, hyperpyrexia, febrile, afebrile, hypothermia
define pyrexia
aka a fever = occurs when the heat loss mechanisms are unable to keep pace with excess heat production
define hyperthermia
T is elevated but it is as a result of the body’s inability to promote heat loss or reduce heat production
define hyperpyrexia
very high fever (over 41 degrees)
define febrile / afebrile
febrile = elevated temperature
afebrile = normal temperature
define hypothermia
occurs when the core body is less than 36 degrees
define pulse
when blood is pumped out of the left ventricle the forceful contraction produces a pulse
- pulse is a significant indicator of cardiac function
define cardiac output
volume of blood pumped in one minute
- generally heart beats both faster + stronger to increase cardiac output
what is the average persons HR?
60-100 bpm
define stroke volume
amount of blood that enters the aorta with each ventricular contraction
- on average persons stroke volume is 60-70mL
alterations in pulse:
- tachycardia = abnormally fast HR, greater than 100bpm
- caused by: exercise, fever, anxiety, stress, acute pain, meds (epinephrine), hemorrhage, postural changes from standing to sitting, diseases (asthma, COPD, CHF) - bradycardia = abnormally slow HR, less than 60bpm
- caused by: long term exercise, hypothermia, relaxation, medications (digoxin), lying down, hypothyroidism, cardiac conduction block - arrhythmia/dysrhythmia = irregular heart rhythm
- pulse deficit = difference between the apical and radial pulse rate
describe the radial pulse
assessed by palpation for 30 sec (x2 to get bpm) if normal
- count for 60 seconds if abnormal
- normal is between 60-100bpm
- description = regular rhythm, 2+ strong strength and equal bilaterally
what is the pulse strength scale?
0 = absent
1+ = weak / thready
2+ = strong
3+ = full / increased
4+ = bounding / difficult to obliterate
describe apical pulse
assessed by auscultation, needs to be assessed for a full 60 seconds
describe brachial pulse
assessed by pupation, but not normally counted for rate
describe apical radial pulse deficit
same as pulse deficit - difference between the apical + radial pulse
define respirations
effort it takes to expand and contract the lungs
define inspiration
taking in oxygen, considered an active process with signals from your brain causing your diaphragm to contract the ribs and retract upward
define exhalation
expelling CO2, which is a passive process where the diaphragm, lung, + chest wall return to their relaxed positions
assessment of respirations
- rate is regular if counted for 30 seconds + x2, 60 sec if irregular
- depth is normal, deep, shallow
- rhythm is regular or irregular
- quality = effortless/silent, dyspnea/orthopnea, easy
what is normal respiration rate?
12-20 respirations / min in adults
30-60 respirations / min in newborns
alterations in breathing
- tachypnea = fast breathing (more than 20 R/min)
- bradypnea = slow breathing (less than 12 R/min)
- hyperventilation = rapid + deep respirations may result in hypocarbia (decreased CO2)
- hypoventilation = slow + shallow breathing which may result in hypercarbia (increase CO2)
- dyspnea = difficult/laboured breathing - unsatisfied need for air, clinical manifestation of hypoxia
- orthopnea = ability to breath only in an upright/standing/tripod position
describe oxygen saturation
normal adult oxygen saturation = 95-100%
- people with COPD may have less than 70% which is life threatening
alterations in oxygen saturation
- hypoxia = inadequate tissue oxygenation at cellular level
- caused by conditions like anemia - hypoxemia = below normal level of oxygen in your blood
- conditions like COPD
describe blood pressure
pressure exerted on arterial walls by the force of hearts contraction
- pressure rises and falls during the cardiac cycle: systole, diastole, use pressure
describe the vascular system
a closed system with a central pump which is the heart, the pressure of the system is highest in the ventricles + decreases as the distance from the heart increases
what is the difference between systole and diastole?
- systole/systolic blood pressure is the top/bigger number, this BP reading is the highest pressure on the arterial walls + occurs during heart contraction
- diastole/diastolic blood pressure is the lower/smaller of the two numbers, this BP reading is the lowest pressure in the arteries during a brief rest period
describe pulse pressure
the difference between systole + diastole which is normally somewhere between 30mmHg
what is phase 5 of BP?
phase 5 is the diastolic value - the absence of sound
you should not use the arm for BP when…
- client has had a mastectomy on the same side (may cause lymphedema)
- if it has a dialysis fistula, IV infusion, if the arm is swollen or painful, or if there is a cast or injury
what are the values of BP
- optimal = <120/80
- normal = <130/85
- hypertension = >135/85
- hypertension systolic = <90mmHg
*needs to be several BP to diagnose someone
hypertension is also known as what
a silent killer
hypertension can be caused by what?
hemorrhage
describe orthostatic hypotension
aka postural hypertension
- is it a drop of 20mmHg or more is systolic or 10mmHg or more in diastolic within 3 minutes of the patient standing up from a lying or sitting position
*orthostatic hypotension is when you stand up and get real dizzy (BP drops)
