Vital Sign material Flashcards
True or False: We should always obtain a baseline of vitals on patient admission to the hospital or a new area.
True
A physician has requested that the patient you are caring for have his vital checked Q4h. What does this mean?
Check vitals every 4 hours
True or False: Your patient’s condition has started to worsen. It is okay not to check vitals since you obtained them 30 mins ago.
False
True or false: it is important to obtain vitals signs before and after any major surgery
True
Why is it important that we obtain vitals during a blood transfussion?
One of the first signs of a reaction during a blood transfusion is a change in the patients pulse rate and temp.
Why is it important that we obtain vitals after medications or interventions that affect vitals signs.
Helps us assess the effect of the medications or interventions. It will tell us if the patient is reacting positively or negative to our desired outcome.
What is the normal temp range for adults
96.8- 100.4
What is considered a normal oral, tympanic or temporal temp in an adult?
97.6-99.6
What is considered a normal rectal temp in an adult?
98.6-100.4
What is considered a normal axilla temp in an adult?
96.6-98.6
What is considered a normal pulse in an adult?
60-100bpm
What is considered a normal respiration rate in an adult?
12-20 breaths per min
What is considered a normal adult blood pressure?
less than 120/80 mm Hg
What is considered a pre-hypertensive adult blood pressure?
systolic of 120-139
diastolic of 80-89
What is considered a hypertensive adult blood pressure?
Systolic greater than 140
Diastolic greater than 90
What is considered a hypotensive adult blood pressure?
Systolic lower than 90 and symptomatic
True or false: For an adult patient to be considered hypotensive they must have a systolic lower than 90 and be symptomatic
True
Why does a patient have to be symptomatic to be considered hypotensive when they have BP reading of a systolic lower than 90?
Some athletes will actually read below 90 but are not hypotensive.
Name different temperature sites you can obtain a temp read from.
Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery, urinary bladder
When is a esophageal temp usually taken?
During and esophageal procedure
What part of your brain regulates our temp?
Hypothalamus
True or False: The anterior hypothalamus is in control of heat loss.
True
True or false: The posterior hypothalamus controls heat production?
True
True or false: Your metabolism does not contribute to the production of heat?
False
True or false: Shivering is a form of heat production?
True
What are ways we can lose heat?
Radiation, Conduction, convection, evaporation, diaphoresis
True or false: Your skin contributes to heat production/heat loss?
True
True or false: Your skin acts as insulation
True
True or false: Vasoconstriction causes shivering
True
What is radiation?
Transfer of heat from surface of one object to surface of another without direct contact between the two
What is conduction?
Transfer of heat from one object to another with direct contact
What is convection?
Transfer of heat away by air movement
What is evaporation?
Transfer of heat energy when a liquid is changed to a gas
Diaphoresis is defined as
Visable perspiration
Diaphoresis is defined as
Visible perspiration
What are some factors that affect body temp?
Age–> babies are susceptible to body temp factors since they are unable to regulate their own temp
Hormonal level–>menopause
Environment
Excercise
Circadian rhythm
temp alterations–> pyrexia -“temp”
Why do we run fevers (pyrexia)
Our bodys response to fighting infection
How often should you take a patients temp who is running a temp?
several times a day
True or False: Your brain can have alterations in the hypothalamic set points if fever is uncontrolled?
True
True or false: Your heart rate and respiratory rate decreases when you run a fever?
False
What is hyperthermia?
Inability to promote heat loss or reduce production of heat
What are some signs of heatstroke
Body temp of 104F or more
MOST IMPORTANT: dry, hot skin, not sweating
Confusion, excess thirst, muscle cramps,
How might a heatstroke affect your vital signs?
Increased HR– Decreased B/P
What is febrile?
Fever present
What is afebrile?
absent fever
What is FUO
Fever of Unkown orgin
What is heat exhustion?
Diaphoresis results in excess water and electrolyte loss
What is hypothermia?
Prolonged exposure to cold which decreases the body’s ability to produce heat
What is temp range of a patient experiencing hypothermia?
86-96.8
True or false: A patient can have accidental or intentional hypothermia?
True
How can you convert Fahrenheit to Celsius?
(F-32) divided by 1.8
How can you convert Celsius to Fahrenheit?
(1.8 X C)+32
True or false: The oral temp is approximately 2 degrees lower than core temp?
False- it is approximately 1 degrees lower
True or false: Chewing gum can affect an oral temp read?
True
Why would chewing gun affect a patients oral temp?
Because chewing activates metabolism which is heat producing
How far should you place a rectal thermometer in an adult patient?
1 1/2 inches
How far should you place a rectal thermometer in a child patient
1in
How far should you place a rectal thermometers in an infant?
1/2 in
True or false: Rectal temp will give us the closest and most accurate core temp? (non-invasive)
True
True or false: feces present on rectal thermometer may indicate an inaccurate read?
True
What site is considered the safest way to take a patients temp?
Axillary
What is one of the disadvantages of taking an axillary temp?
Takes 5-10mins
What are some benefits of taking a patients temp on the tympanic membrane?
Unaffected by PO intake
Rapid
What is something you have to remove before taking a tympanic read?
hearing aides
True or False: The Tympanic temp read is the most accurate?
False
How do you take a temporal temp?
Remove glasses
start in middle of forehead move down the face and then behind the ear
When using a no touch thermometer where should take the patients temp?
temporal artery
What nursing interventions would you take for a patient running a fever?
Obtain blood cultures if ordered
monitor VS,
assess skin color, temp, turgor and lab work,
reduce frequency of activites to decrease o2 demand
maximize heat loss
extra fluid
tepid water bath
oral hygiene –> bacteria growns everywhere
dry linen –> common for patients to sweat when running a temp if left damp could cause patient to shiver which is heat production
antipyretic meds as ordered
Define pulse
-palpable or audible bounding of blood flow noted at various points of the body– it is an indirect measure of circulatory status
The diaphragm of your stethoscope hears what pitch
high pitch
What site is most commonly used for pulse in routine vital signs?
Radial
Where would a nurse teach a patient to feel for a pulse?
Radial
What can palpating the radial pulse also tell us?
Assesses circulation status to the hand
Where can you locate the apical pulse?
located in the 5th mid clavicular intercostal space
If you have to take a patients apical pulse how long should you listen for the pulse?
1 min
True or False: Some medications will require you to assess the apical pulse when taking VS?
True
True or false: you should only check a patient carotid pulse if a patients conditions suddenly worsens?
True
True or false: It is okay to measure bilateral carotid sites at the same time
False
Where is the dorsalis pedis pulse site at?
Top of foot.
If you are unable to assess the dorsalis pedis what would your next step be?
Check pulse with doppler
Can you assess dorsalis pedis bilaterally together?
YEs
What can you describe the rhythm of a HR as?
Regular
Irregular
dysrhythmia
When you have a pulse that is a 4+ in strength it means?
Heavy pounding
When you have a pulse that is a 3+ in strength it means?
Beating more strong
When you have a pulse that is 1+ in strength it means?
1 weak and thready
When you have a pulse that is a 0 in strength it mean?
you can not feel it
What are some consequences of impaired gas exchange
-ineffective ventilation
-reduced capacity for gas transportation (reduced hemoglobin and / or red blood cells)
-inadequate perfusion
What is ventilation?
Movement of gasses into and out of the lung
What is diffusion?
Movement of oxygen and carbon dioxide between alveoli and red blood cells
What is perfusion?
Distribution of red blood cells to and from the pulmonary capillaries
What is Eupena
Ventilation of normal rate and depth
How can you describe the depth of breathing?
Deep, shallow, normal
What are some factors that influence respirations?
Exercise
Acute pain–> breathing is most likely shallow because you do not want to move
Anxiety- rapid or more often
Smoking–> narrow airway and build up happens
Body position– orthopneic position–> sitting up expands the lungs
medications–>albutarol speeds up, opids slow down
neurological injury–> C spine injurys trach or vent patients
Hemoglobin functions
What is Eupena
Normal breathing 12-18 breaths per min
What is bradypnea
Slow than normal rate less than 10 breaths/min with normal depth and regular rhythm
Apnea
Absent breathing– time duration varies. may occur briefly during other breathing disorders such as sleep apnea
orthopnea
Discomfort when breathing lying down flat
What is cheyne strokes breathing
specific form of periodic breathing— regular cycle where the rate of depth of breathing increases then decreases until apnea usually about 20 sec
What is dyspnea?
Difficult breathing
What is biot’s respiration?
Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 sec to one min)
How can you assess diffusion and perfusion?
Pulse oximetry
What is an acceptable range for pulse ox readings?
95%-100%
What factors can affect pulse ox readings?
Fitting
nail polish
temp of extremity
movement
lighting
skin pigmentation
edema
PVD
What is blood pressure?
Force exerted against the blood vessels by blood
How is blood pressure meassured?
Millimeters of mercury mmHg
What is systolic pressure
Max pressure of bp that occurs
What is diastolic pressure
min point of pressure that bp occurs
What is cardiac output
volume of blood that we eject out from our heart. The higher volume of blood the higher the BP
What is peripheral resistance?
Like plaque– in the blood vessel will create resistance and causes bp to increase since the blood is having to be pushed harder to past the resistance
What is viscosity?
Thickness of blood.
What is elasticity?
How flexible blood vessels are
What is the step by step process of taking a patients blood pressure?
Determine proper cuff size and site
Position arm at heart level, palm up
Wrap cuff around upper arm
Place stethoscope in ears and close valve
Inflate cuff to 30 mmHg above baseline
Slowly release pressure bulb
Note first clear sound
Note when sound disappears
Record reading
What is the ideal environment for taking a patients bp?
quiet room, comfortable temp
sitting is preferred position
avoid sites with iv or other devices
What factors can influence blood pressure
age
stress
ethnicity
gender
daily variation
medication
activity,weight
smoking
True or false: A patient experiencing hypertension will start having thickening of walls, loss of elasticity?
true
What are some alternate blood pressure sites?
Thigh and arterial line
To take a patients bp using their thigh what position should they be in?
supine position with knee flexed
The systolic pressure runs higher by how much when taking bp by thigh?
10-40 mmHG
What is the mnemonic used to assess pain?
PQRST
In the mnemonic for pain what does the P stand for and what questions should be asked?
P-Provokes/palliates– What makes your pain worse or better?
In the mnemonic for pain what does the Q stand for and what questions should be asked?
Q-quality– what type of pain? dull? stabbing? burning?
In the mnemonic for pain what does the R stand for and what questions should be asked?
R- region/radiation— where is it located and is where is it moving? radiating?
In the mnemonic for pain what does the S stand for and what questions should be asked?
S- Severity and setting— how bad is the pain and is a place or setting causing it to be worse?
In the mnemonic for pain what does the T stand for and what questions should be asked?
T-Timing– is it worse in the morning or afternoon
True or false: you should assess pain often
True
True or false: You should assess the pain of a patient before procedures, activity and medications?
True
True or false: It is okay to assume the patients pain level?
False
How long after you give pain meds should you reassess the patient?
30 mins
A nurse assesses an oral temperature for an adult patient. The patient’s temperature is 37.5°C (99.5°F). What term would the nurse use to report this temperature?
a. Febrile
b. Hypothermia
c. Hypertension
d. Afebrile
D. Afebrile
A nurse is assessing the vital signs of patients who presented at the emergency department. Based on the knowledge of age-related variations in normal vital signs, which patients would the nurse document as having a normal vital sign? Select all that apply.
a. A 4-month old infant whose temperature is 38.1°C (100.5°F)
b. A 3-year old whose blood pressure is 118/80
c. A 9-year old whose temperature is 39°C (102.2°F)
d. An adolescent whose pulse rate is 70 bpm
e. An adult whose respiratory rate is 20 bpm
f. A 72-year old whose pulse rate is 42 bpm
D. An adolescent whose pulse rate is 70bpm
E. An adult whose respiratory rate is 20 breaths per mins
F. A 72 year old whose pulse rate is 42 bpm
- A patient who is febrile may lose body heat through perspiration. The nurse recognizes that this is an example of what mechanism of heat loss?
a. Evaporation
b. Convection
c. Radiation
d. Conduction
C. Evaporation
- While taking an adult patient’s pulse, a nurse finds the rate to be 140 beats/min. What should the nurse do next?
a. Check the pulse again in 2 hours.
b. Check the blood pressure.
c. Record the information.
d. Report the rate to the primary care provider.
D. Report the rate to the primary care provider
A patient complains of severe abdominal pain. When assessing the vital signs, the nurse would not be surprised to find what assessments? Select all that apply.
a. An increase in the pulse rate
b. A decrease in body temperature
c. A decrease in blood pressure
d. An increase in respiratory depth
e. An increase in respiratory rate
f. An increase in body temperature
A. An increase in the pulse rate
E. An increase in respiratory rate
- The nurse instructor is teaching student nurses about the factors that may affect a patient’s blood pressure. Which statements accurately describe these factors? Select all that apply.
a. Blood pressure decreases with age.
b. Blood pressure is usually lowest on arising in the morning.
c. Women usually have lower blood pressure than men until menopause.
d. Blood pressure decreases after eating food.
e. Blood pressure tends to be lower in the prone or supine position.
f. Increased blood pressure is more prevalent in African Americans.
b. Blood pressure is usually lowest on arising in the morning.
c. Women usually have lower blood pressure than men until menopause.
e. Blood pressure tends to be lower in the prone or supine position.
f. Increased blood pressure is more prevalent in African Americans.
A patient is having dyspnea. What would the nurse do first?
a. Remove pillows from under the head
b. Elevate the head of the bed
c. Elevate the foot of the bed
d. Take the blood pressure
B. Elevate the head of the bed
Prioritization: Place the following descriptions of the phases of Korotkoff sounds in order from Phase I - Phase V.
a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap
b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
c. The last sound heard before a period of continuous silence, known as the second diastolic pressure
d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure
e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure
d. Characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; known as the systolic pressure
a. Characterized by muffled or swishing sounds that may temporarily disappear; also known as the auscultatory gap
b. Characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery
e. Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality; considered to be the first diastolic pressure
c. The last sound heard before a period of continuous silence, known as the second diastolic pressure
- A patient has a blood pressure reading of 130/90 mm Hg when visiting a clinic. What would the nurse recommend to the patient?
a. Follow-up measurements of blood pressure
b. Immediate treatment by a physician
c. No action, because the nurse considers this reading is due to anxiety
d. A change in dietary intake
A. Follow- up measurement of blood pressure
