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Nursing Assessment > Vital Signs > Flashcards

Vital Signs Flashcards

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1
Q

afebrile

A

The state of normal body temperature.

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2
Q

Normal oral temp

A

Oral: 97.6-99.6

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3
Q

Factors Affecting Body Temperature

A

Age, Environment, Time of Day

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4
Q

Factors Affecting Pulse Rate

A

Age: generally decreases
ANS: Sympathetic increases, Parasympathetic decreases

Medications

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5
Q

Tachycardia

A

Pulse >100bpm

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6
Q

Bradycardia

A

Pulse <60bpm

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7
Q

Normal Pulse Rate

A

60-100 bpm

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8
Q

Regularly Irregular Pulse

A

Irregular but consistent pulse rhythm.

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9
Q

Irregularly Irregular Pulse

A

Irregular and inconsistent rhythm

Ex: atrial fibrillation

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10
Q

Factors Affecting respiration

A 
Age - Child to adult decreases, increases with aging
Medications
Stress
Exercise
Altitude (faster)
Gender
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11
Q

Tachypnea

A

> 20 breaths per minute

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12
Q

Bradypnea

A

<12 breaths per minute

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13
Q

Apnea

A

Absence of breathing

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14
Q

Eupenea

A

Normal breathing rhythm

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15
Q

Biot Respirations

A

Regular deep respirations interspersed with periods of apnea caused by damage to the pons due to stroke, trauma, or uncal herniation

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16
Q

Cheyne-Stoke Respirations

A

A period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all.

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17
Q

Kussmaul Respirations

A

A deep, rapid breathing pattern associated with metabolic acidosis.

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18
Q

Stridor

A

Harsh inspiratory that could be compared to crowing.

Think children with croup or aspiration of a foreign object.

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19
Q

Wheezing

A

A continuous high-pitched musical sound

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20
Q

Rhonchi

A

A continuous low-pitched snoring sound

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21
Q

Crackles

A

discontinuous popping or clicking sounds heard in cases of pneumonia or pulmonary edema.

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22
Q

Sighs

A

breaths of deep inspiration and prolonged expiration.

Occasional can be normal

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23
Q

Systolic Blood Pressure

A

Pressure in veins during heart ejection

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24
Q

Diastolic Blood Pressure

A

Pressure in arteries when heart is filling

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25
Q

Pulse Pressure

A

Difference between systolic and diastolic pressures

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26
Q

Orthostatic Hypotension

A

Drop of 20 mmHg systolic or 10 mmHg diastolic AND increase of heart rate by 10 bpm when moving from lying to sitting or sitting to standing

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27
Q

Orthostatic Hypotension Causes

A

Hypovolemia or failure of autonomic nervous system

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28
Q

Normal BP

A

systolic <120, diastolic < 80

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29
Q

Hypertension

A

> = 140/90 (either)

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30
Q

Normal O2 saturation

A

> 90% and note whether pt is on O2)

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31
Q

Normal axillary temp

A

Axillary: 96.6-98.6

32
Q

Normal rectal temp

A

Rectal: 98.6-100.6

33
Q

Normal respiratory rate

A

12-20 respirations per minute

34
Q

When do we take vital signs

A
  • at presentation
  • set frequency (provider orders)
  • change in status
35
Q

Factors affecting temperature

A

age, diurnal variations, exercise, hormones, stress, environment

36
Q

List temperature sites from most to least accurate

A 
rectal
oral
axillary
tympanic
temporal
37
Q

tympanic temp

A

ear

38
Q

Where is oral thermometer placed

A

sublingual posterior pocket (needs to be supported)

39
Q

temporal temp

A

forehead

40
Q

fever s/s

A 
> 100.4
photosensitivity/glassy eyes
increased HR RR thirst
drowsiness, malaise, weakness
decreased appetite
warm skin, sweating
shivering, cold, clammy skin
41
Q

what to monitor with fever

A

vital signs
i/o
WBC values

42
Q

comfort interventions for fever

A

blankets, fluids, nutrition, oral hygiene, tepid sponge bath, dry clothes

43
Q

hypothermia

A

<95

44
Q

clinical signs shared by fever and hypothermia

A

shivering, drowsiness

45
Q

temperature considerations

A

is this route appropriate (medically and developmentally)
are there environmental considerations
is there user error/equipment issues

46
Q

with age, do pulses go up or down?

A

down (slower)

47
Q

You should not take bilateral pulse in which site?

A

carotid

48
Q

pulse assessment components

A

rate 60-100
rhythm regular/irregular
bilateral equality same on both sides
quality 0-4+ (2+ normal)

49
Q

quality measures of pulse

A 
absent 0
weak, easily obliterated 1+
Normal 2+
Increased full volume 3+
Bounding 4+
50
Q

When you find an irregular pulse, what immediate assessment steps do you take?

A

apical pulse, full minute assessment

51
Q

Assessment technique pulse

A

2 fingertips (index and middle)
light pressure
count for 60 seconds (or 30x2)
Assess same site other side for comparison

52
Q

How long to assess an apical pulse

A

60 seconds

53
Q

location of apical pulse

A

5th intercostal space, mid clavicular line

54
Q

when to use apical pulse

A

weak radial, irregular, brady/tachy, cardiac meds, pulse deficit, infants/children

55
Q

pulse deficit

A

variation between apical and distal pulse

56
Q

movement of gases in and out of lungs

A

ventilation

57
Q

intake of air into lungs

A

inspiration (inhalation)

58
Q

movement of gases from lungs to atmosphere

A

expiration (exhalation)

59
Q

movement of O2 and CO2 between alveoli and red blood cells

A

diffusion

60
Q

movement of RBCs in pulmonary capillaries

A

perfusion

61
Q

type of normal breathing

A

diaphragmatic and costal/thoracic (up and down movement of diaphragm or ribs)

62
Q

normal stimulus to breathe

A

CO2 ↑

63
Q

apnea

A

absence of respirations for at least 10-15 seconds

64
Q

respiration assessment elements

A

rate, rhythm, depth, quality (automatic, quiet, effortless vs. dyspnea)

65
Q

dyspnea

A

difficulty breathing

66
Q

systole

A

ventricular contraction

67
Q

diastole

A

ventricular rest

68
Q

determinants of blood pressure

A

cardiac output
peripheral vascular resistance
blood volume
vessel elasticity

69
Q

inverse or direct relationship between blood pressure and heart rate in hypovolemia

A

inverse

70
Q

symptoms of shock

A

cool, clammy skin
fast thready pulse
↓ urine output
confusion

71
Q

preparation for blood pressure reading

A
  • no caffeine or nicotine for 30”
  • sit at rest for 5”
  • select correct cuff size
  • sitting, both feet on floor
  • no talking
  • place cuff correctly and snugly
  • support client arm at heart level
72
Q

misc causes of erroneous BP readings

A

unidentified auscultatory gap
failure to use same arm consistently
white coat syndrome

73
Q

cuff causes of erroneous BP readings

A

cuff size
cuff deflation rate
insufficient inflation

74
Q

client prep causes of erroneous BP readings

A

arm not supported or at heart level

client has just eaten, smoked, exercised, emotional upset

75
Q

sudden ↓ in BP when client moves from lying to sitting or sitting to standing

A

orthostatic (or postural) hypotension
- drop of 20 in systolic or 10 in diastolic
- increase of 10 bp with postural change
wait 2 minutes in between before BP and HR measures

76
Q

how to palpate blood pressure

A
  • without auscultation
  • inflate cuff and record pressure when first pulsation is felt (systolic).
  • Record as xx mmHg palpated
  • can’t assess diastolic

Nursing Assessment (13 decks)

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