Vital Signs 1 Flashcards
what are the factors that affect VS?
medication, illness/infection, exercise/stress, age, hypolemia/dehydration, environment, PO (oral) intake, hormones, circadian rhythm
how do medications affect VS?
antipyretics - reduce temperature and hide fever
opioids - decrease RR and can take away the drive to breathe
antihypertensives - decrease BP and P
how does illness and infection affect VS?
fever - cause an increase in BP, P, RR
infection - increase P… sepsis causes increase P and decrease BP
how does exercise and stress affect VS?
increased metabolism temporarily increases T, P, BP, and RR
how does age affect VS?
older adults and infants have a harder time regulating their T
how does hypovolemia and dehydration affect VS?
haemorrhage causes decreased BP and increased P… dehydration can do the same
how does the environment affect VS?
visiting a healthcare provider can be anxiety ridden and cause increase BP
how does PO (oral) intake affect VS?
hot/cold beverages and smoking can increase or decrease T
smoking, caffiene, lots of alcohol can increase BP
how do hormones affect VS?
ovulation can change T
the thyroid hormone can cause an increase in T and P
how does the circadian rhythm affect VS?
T and BP can fluctuate throughout the day
what changes do you note when taking VS?
positive and negative changes
ANY CHANGE
what do you do if there is a change in VS?
inform clinical instructor and buddy nurse
take the VS again
what is the average T?
36-38 C
what are the 7 ways to take T? What are the average T taken for each type?
oral - 37
axillary - 36.5
temporal - 37
tympanic -37
rectal - 37.5
skin tape
non contact
how do you check someones core T? what is the average core T?
through the pulmonary artery
36.5-37.5
when is oral T an appropriate route?
haven’t eaten, drank, smoked in 30 mins
not after oral surgery
not if PT is uncooperative/unconscious
when is it axillary T an appropriate route?
children, newborns
not after bathing
not if septic
not if sweating excessively
not after surgery
when is temporal T an appropriate route?
when you need something fast and noninvasive
not if theres excessive scar tissue or abrasions
when is tympanic T an appropriate route?
most prone to inaccurate readings and most room for error
very fast
when is rectal T an appropriate route?
rarely used
accurate but inconvenient
not with children as rectal tissue is soft
when is non contact T an appropriate route?
quick and contactless
good for COVID-19 screening
when is the true core T an appropriate route?
the T of the vital organs
most accurate but the most invasive and inconvenient
only used for critical care
what is pyrexia?
fever
when heat-loss mechanisms can’t keep up and produces excess heat
what is thermoregulation?
process that allows body to maintain its internal core T
what is the hypothalamus’s goal?
maintain homeostasis
where does the temperature receptors send their information?
to the hypothalamus
what is hyperthermia?
the body’s inability to lose heat fast enough, heatstroke
what is hyperplexia?
a fever greater than or equal 41 C
what does it mean when someone is febrile?
when a client has an elevated T
what does it mean when someone is afebrile?
a client with a normal T range
what is hypothermia?
the body’s T is 36 C or less
classified as mild to severe
can be medically induced or unintentional
what can a change in T alter?
urine output
skin
consciousness
what can T indicate?
presence of infection/disease
inflammation
deteriorating client status
thermoregulatory disorders
what is P a significant indicator of?
cardiac function
what is the volume of blood pumped per minute
CO
what is the number of BPM?
HR
what is the amount of blood pumped into the aorta per contraction?
SV
what is the average SV?
60-70mL
how do you calculate CO?
HR x SV
what are 3 alterations to pulse?
tachycardia, bradycardia, and pulse deficit
what is tachycardia?
abnormally fast HR
greater than 100 BPM
what is bradycardia
abnormally slow HR
less than 60 BPM
what are some causes of tachycardia?
fever, exercise, anxiety, stress, acute pain, medication (epinephrine), hemorrhage, postural changes (sitting to standing), diseases like asthma and COPD
what are some causes of bradycardia?
long term exercise (elite athletes), hypothermia, relaxation, medication (digoxin), lying down, hypothyroidism
what is a pulse deficit?
a differences between the radial and apical pulse
what are some causes of a pulse deficit?
cardiovascular disease, atrial fibrillation, aflutter, heart block, premature ventricular contractions (PVC)
what’s the scale for rating pulse strength?
0 (absent), +1 (weak/thready), +2 (strong), +3 (full/increased), +4 (difficult to obliterate)
what is arrhythmia/dysrhythmia?
irregular heart rhythm
what can arrhythmia/dysrhythmia cause?
inadequate CO
where is the radial P? how do you take a radial P?
on the thumb side of the wrist, count bests for 30 seconds and multiply by 2
what is a normal radial P?
60-100 BPM
what is the apical P? how do you take apical P?
we will use Erb’s point, and auscultation for a full 60 seconds
what is the brachial P? do you take a brachial P, what is it used for?
on the pinky side of the forearm near the elbow, isn’t usually used for P but to find the brachial artery for taking BP
what is an apical-radial P deficit?
when there is an inconsistency of P at the radial artery and at Erb’s point
how can you check to see if there’s a pulse deficit?
the 2 nurse technique
what is RR?
respiration rate (breathing)
process of moving gas into and out of the lungs
the work that is taken to breathe is referred to as what?
effort
what is diffusion?
the movement of particles back and forth
what is the difference between thoracic/costal breathing, and abdominal/diaphragmatic breathing?
thoracic/costal - breathing from the chest, chest moves upward and outward
diaphragmatic/abdominal - the diaphragm contracts downwards
what are the accessory muscles used in assisting breathing?
sternocleidomastoid, traps/scalene
what is a normal RR?
12-20 R/min
what are the 4 things to note when taking RR?
rhythm
rate
effort/quality
depth
what is eupnea?
normal breathing (12-20 R/min)
what is tachypnea?
fast RR, greater than 20 R/min
what is bradypnea?
slow RR, less than 12 R/min
what is hyperventilation? what can it result in?
rapid and deep R, can result in decreased CO2 (hypocarbia)
what is hypoventilation?
slow and shallow R, can result in increased CO2 (hypercarbia)
what is hypocarbia?
decrease of CO2
what is hypercarbia?
increase of CO2
what is dyspnea?
difficult and laboured breathing
what is orthopnea?
breathing only in the upright or tripod position
what does the pulse oximetry measure?
percentage of O2 in the blood combined with hemiglobin
what are normal O2 stats?
95-100%
how does being anemic alter O2 results?
anemic people have less hemoglobin so it shows within normal range
what affects O2 stats?
nail polish, impaired circulation, movement like shivering
how does carbon monoxide trick the oximeter?
the carbon monoxide attaches to the hemoglobin in replace of O2
what is hypoxia?
inadequate tissue oxygenation
what is hypoxemia?
below average level of O2
