Vital Sign Self-Study Flashcards
What are vital signs (V/S)?
Indicators of physiologic functioning that reflect a persons health status (T,P,R,BP)
What is the normal range of BP?
120/80
What is the normal range of P?
60-100
What is the normal range of R?
12-20
What is the normal range of T?
96.4 - 99.5
What is the normal range of O2?
> 95%
How factors affect V/S?
AGE Biological Sex Food Exercise Weight Emotional state Body Position Race Drugs/ Medications
What is orthostatic blood pressure (BP)?
Results from an inadequate physiologic response to postural changes
-Orthostatic hypotension/postural hypotension is a temporary fall in BP associated with assuming an upright position.
What are nursing interventions for patients who have orthostatic BP?
- Rising and moving slowly especially after long periods of bed rest
- First raise the head of the patients bed, than assist to sitting position, on the side of the bed or dangling.
- If pt becomes dizzy or faint, return to sitting position in bed.
What is hypertension (HTN)?
Hypertension is one of the most common health problems and is when a persons BP is above normal for a sustained period.
- Systolic is greater than 130 and the diastolic is above 80.
What ethnicity is high risk for HTN?
Hypertension is more prevalent in African American and Hispanic adults.
What is the physiology of BP in elderly?
Hypertension is more prevalent in African American and Hispanic adults.
When there is a consistent inter-arm difference, which arm should be used to measure BP?
the arm with the higher pressure should be used.
When is it contraindicated to take BP?
BP assessment should not be taken on arms with intravenous line or with an arteriovenous line or shunt. BP should also be avoided on the side of an axillary node dissection or mastectomy since it can increase the risk of lymphedema developing in the affected area.
What are Korotkoff sounds?
Series of sounds for which the nurse listens when assessing the blood pressure
Korotkoff sounds
PHASE 1
- first appearance of faint but clear tapping
- the first tapping sound is the Systolic pressure
Korotkoff sounds
PHASE 2
- muffled or swishing sounds
- after after the auscultatory gap
Korotkoff sounds
PHASE 3
- distinct, LOUD sounds as the blood flows freely through an increasingly open artery
Korotkoff sounds
PHASE 4
- distinct, ABRUPT, muffling sound with soft blowing quality
Korotkoff sounds
PHASE 5
- The last sound heard
- Diastolic pressure
How many routes can you assess patient’s temp?
5 Routes to access temp • Oral • Tympanic membrane- ear • Temporal Artery- Right or left side of the forehead • Axillary- under the armpit • Rectal
Which one is the most accurate
route?
Rectal Temp- Core body temp and is most accurate
Are there any contraindications for assessing temp?
👷♂️🚧
Why do you, as a nurse, need to assess patient’s V/S?
Nurses assess vital signs and compare findings with accepted normal values. Vital signs have been identified as the best indicator of cardiopulmonary arrest, unplanned ICU admission, and unexpected death.
When do you check a patient’s V/S?
As often as patient’s condition requires. Frequency of Assessment is based on patient’s medical diagnosis, comorbidities, types of treatments received, and the patient’s level of acuity.
What are your responsibilities to a patient’s V/S?
It’s the nurses responsibility to ensure the accuracy of the data, interpret vita sign findings, and report abnormal findings.
