RLE: Vital Signs Flashcards
1
Q
health indication/help determine patient’s health
A
vital signs
2
Q
vital signs is done simultaneously with
A
interview
3
Q
6 vital signs
A
- body temperature
- pulse rate
- respiratory rate
- blood pressure
- o2
- pain
4
Q
Nx consideration: frequency of getting VS
A
- stable pt: q4
- unstable pt: q1
procedure (ex. blood trans/dialysis) - 1st hour: q15
- 2nd hour: q30
- 3rd & 4th hour: q1
5
Q
2 types of body temperature
A
core
surface
6
Q
body temperatures from core
A
oral and rectal
7
Q
body temperatures from surface
A
axillary and tympanic
8
Q
general normal temperature
A
36.5-37.5 C
9
Q
fever temperature
A
> 37.8 C
10
Q
high temperature than normal
A
fever/hyperpyrexia/hyperthermia
11
Q
TSB
A
tepid sponge bath
12
Q
lower temp than normal
A
hypothermia
13
Q
factors that affect body temp:
A
age
stress
exercise
hormones
environment
14
Q
types of fever (5)
A
intermittent
remittent
relapsing
constant fever
fever spite (staircase)
15
Q
fever: alternating temps
A
intermittent
16
Q
fever: alternating, prolonged
A
remittent
17
Q
fever: short period of time
A
relapsing
18
Q
fever: temperature rises (dengue’s unique symptom/sign)
A
fever spite (staircase)
19
Q
normal oral temp
A
36.5-37.5
20
Q
normal axillary temp
A
35.8-37
21
Q
normal rectal temp
A
37-38.1
22
Q
normal tympanic temp
A
36.8-37.9
23
Q
heat production (4)
A
radiation
conduction
convection
evaporation
24
Q
transfer of heat from surface to another surface without contact
A
radiation
25
transfer of heat from surface to another surface with contact
conduction
26
dispersion of heat by air current
convection
27
most accessible temperature site
oral temp
28
which clients are not applicable for oral temperature
young children/infant
unconscious
seizure-prone
N/V
w/ mouth ulcer
29
most accurate temperature site
rectal
30
contraindication for rectal temp
diarrhea
rectal surgery
heart attack
31
safest and non-invasive site for temp
axillary
32
after use, clean thermometer from ??? to ???
body to tip
33
farenheit to celsius
(F-32) (5/9)
34
celsius to farenheit
(C x 9/5)+32
35
⬆️RR
tachypnea
36
⬇️RR
bradypnea
37
no RR
apnea
38
normal cpm
12-20 cpm
39
characteristics of respiratory rate (4)
rate
depth
rhythm
quality/character
40
depth (RR)
shallow & deep breathing
41
rhythm (RR)
intervals/patterns
42
RR: slow to deep to stop
cheyne stoke respiration
43
RR: shallow (heart failure)
Kussmaul respiration
44
RR: atelectasis
Biot's respiration
45
quality/character (RR)
nose flaring, mouth breathing, use of accessory muscles
46
normal breath sounds (3)
bronchovesicular
vesicular
bronchial
47
abnormal breath sounds
wheezing
stridor
bubbling
48
normal cpm for infant/newborn
30-60
49
normal pulse rate
adult: 60-100
newborn: 80-180
50
⬆️PR
tachycardia
51
⬇️PR
bradycardia
52
pulse site: readily accessible
radial
53
pulse site: used when radial is unavailable
temporal
54
pulse site: determine circulation to brain
carotid
55
pulse site: for BP
brachial
56
pulse site: children and infant
femoral
57
pulse site: circulation to lower leg
popliteal
58
pulse site: circulation to feet, BP on foot
posterior tibial & doralis pedis
59
pulse site: most accurate
apical
60
pulse assessment: absence/cannot be felt
0
61
pulse assessment: weak
1+
62
pulse assessment: 2+
normal
63
pulse assessment: 3+
bounding
64
mmHg
mm per mercury
65
normal blood pressure
<120/<80
66
elevated BP
120-129/<80
67
HPN 1
130-139/80-89
68
HPN2
>140/>90
69
HPN3
>180/>120
70
O2 sat normal
95-100%
71
Newborns (0-1 month): BP
Systolic pressure of 67-84 mm Hg, Diastolic pressure of 35-53 mm Hg.
72
Infants (1-12 months): BP
Systolic pressure of 72-104 mm Hg, Diastolic pressure of 37-56 mm Hg.
73
when is 76% normal SpO2
patients with tetralogy of fallot
74
NRS
numerical pain scale
75
how can pain be measured/assessed
NRS
COLDSPA
PQRST
Wong Baker Scale
76
Pain scale (pedia)
Wong Baker Scale
77
can happen with prolonged exposure to cold temperatures
Hypothermia
78
can happen with prolonged exposure to hot temperatures.
hyperthermia
79
is an elevation of body temperature above the normal variation, which is induced by cytokine activation.
Fever
80
is the term for exceptionally high fever (greater than ?? C), which can occur in patients with severe infections.
hyperpyrexia;
41
81
It is a time in a day where Body Temp varies. It is lower in the morning rather than the evening.
circadian rhythm
82
infants and children usually have a higher temperature compared to adults due to ???.
immature heat regulation
83
women may experience a slight increase in body temperature during ???
ovulation
84
[physical activity] releases body heat which increases body temperature.
muscle contraction
85
such as crying and anger can increase body temp
emotion
86
Number of pulses for a minute
Rate of pulse
87
Refer to the strength of the pulse when the heart contracts
Volume/Force
88
It can be a bounding pulse(full) or a thready pulse ( weak).
Intensity
89
Refers to the regularity or equal spacing of all the beats of the pulse.
Rhythm
90
A pulse with an irregular rhythm is known as
dysrhythmia or arrhythmia
91
An ??? occurs when the heart occasionally skips a beat.
intermittent pulse
92
as age increases pulse rate ???
decreases
93
Female pulse rate is about ??? bpm greater among male around their age
10
94
heat loss is greater in a ??? body, resulting in heart pumping faster to compensate
small
95
is an indicator of how well oxygen is being provided by the tissues of the body by watching, listening or feeling the movement of inspiration (inhalation) and expiration (exhalation) on the patient's back, stomach and chest.
Respiratory rate
96
Regular and equal spacing of breathing.
respiratory rhythm
97
The volume of air that is inhaled or exhaled. It is described as either shallow or deep.
Respiratory Depth
98
refers to deep and rapid respiration
Hyperventilation
99
refers to shallow and slow breathing.
Hypoventilation
100
Refer to breathing patterns both normal and abnormal
Respiratory Quality
101
low pitched breath sounds that are similar to snoring
Rhonchi
102
high pitched breath sounds that are similar to popping or snapping
Crackles
103
a high pitched whistling sound that occurs due to the narrowing of the bronchial tubes
Wheezing
104
a harsh, vibratory sound that occurs due to the narrowing of the upper airway, heard most prominently when inhaling.
Stridor
105
The membranes that cover the walls of your chest cavity and the outer surface of your lungs are called pleura. If they get inflamed and rub together, they can make this rough, scratchy sound.
Pleural Friction Rub
106
This high-pitched gasp typically follows a long bout of coughing. If you hear a whoop when you breathe in, it may be a symptom of whooping cough (pertussis), a contagious infection in your respiratory system.
whooping
107
pertussis
whooping cough
108
Absence of breathing.
Apnea
109
Normal breathing.
Eupnea
110
Difficulty or unable to breath while lying down.
Orthopnea
111
subjective sensation related by patient as breathing difficulty.
Dyspnea
112
attacks of severe shortness of breath that wakes a person from sleep
Paroxysmal Nocturnal Dyspnea
113
Increased depth of breathing
Hyperpnea
114
Increased rate or depth or combination of both.
Hyperventilation
115
Decreased rate or depth or combination of both.
Hypoventilation
116
Deep and labored breathing pattern often associated with severe metabolic acidosis, particularly Diabetic Ketoacidosis (DKA) but also Kidney Failure.
Kussmaul's Respiration
117
It is defined as the amount of force exerted on arterial walls while the heart is pumping blood. Specifically, when the ventricle contracts.
blood pressure
118
The highest pressure that occurs on the left ventricles of the heart when contracting
systolic BP
119
Is the lowest pressure level that occurs when the heart is relaxed and the ventricle is at rest and refilling with blood.
Diastolic Blood Pressure
120
Is the difference between Systolic reading and Diastolic reading when you subtracted it.
pulse pressure
121
A pulse pressure greater than 40 mmHg is considered ???, and less than 30 mmHg is considered as ???.
widened; narrowed
122
These are the rhythmic, tapping sound that you will hear while getting the blood pressure as the arterial wall distends under the compression of the cuff. It will appear and disappear as cuff is inflated and deflated.
Korotkoff sound
123
Typically referred as the fifth vital sign.
pain
124
is short-term pain that comes on suddenly and has a specific cause, usually tissue injury.
Acute pain
125
Pain that lasts for more than six months, even after the original injury has healed, is considered chronic.
Chronic Pain
126
Is the most common type of pain. Its caused by stimulation of nociceptors, which are pain receptors for tissue injury.
Nociceptive pain
127
Results from injuries or damage to your internal organs. You can feel it in the trunk area of your body, which includes your chest, abdomen, and pelvis. Its often hard to pinpoint the exact location
Visceral pain
128
Results from stimulation of the pain receptors in your tissues, rather than your internal organs. This includes your skin, muscles, joints, connective tissues, and bones. Its often easier to pinpoint the location of this rather than visceral pain.
Somatic pain
129
Results from damage to or dysfunction of your nervous system. This results in damaged or dysfunctional nerves misfiring pain signals. This pain seems to come out of nowhere, rather than in response to any specific injury.
Neuropathic pain
130
Pain that is no known cause or origin.
Idiopathic pain
131
Refers to ongoing sensation of pain from a body part that is no longer there
Phantom pain
