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Skills > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are normal vital signs for an adult ?

A 
BP: >90/60 mm hgb - <120/80 mm hgb
Temp 96.8- 100.4
HR: 60-100 beats/min
Respiration’s: 12-20 breathes/min
O2: > or equal to 94
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2
Q

Guidelines for measuring VS

A 
Measuring VS is your responsibility 
Assess equipment is working right and appropriate equipment
What’s the usual VS range
Patient health history, therapies, meds
Control environmental factors
Organization
Verify/Commun. Significant finding 
Educate patient on findings
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3
Q

What are the 6 VS

A 
Temp
BP
SpO2
Respiration
Heart Rate
Pain
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4
Q

Normal Ranges for adults VS

A 
Temp: 96.8- 100.4
BP: >90/60 - <120/80 mm Hg
O2: > or equal to 94
Respiration: 12-20 breaths/min
Heart Rate: 60-100 beats/min
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5
Q

Alterations in VS

A 
Age
Exercise
Stress
Trauma
Illness
Infection
Disease
Medications
More
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6
Q

Body temp functions

A

Temp regulated by hypothalamus
Body keeps temp @ cool level
Core temp is temp of deep tissues that’s most constant and true

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7
Q

Factors determining temp

A

Site (oral, rectal, tympanic)
Time ( lowest temp 6:00 highest temp 1600)
Always use same instrument

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8
Q

Body temp regulation

A

Thermoregulation
-balance between heat production and heat loss
- for temp to stay at constant range and acceptable body must constantly produce and get rid of heat
Hypothalamus controls body temp
- like a thermostat

Heat conservation: vasoconstriction (narrowing) of vessels to reduce blood flow to the skin and extremities resulting in reduce heat loss
Heat loss: sweating, stopping heat production, vasodilation (widening) of blood vessels, which send blood to surface vessels to promote heat loss

Skin regulates temp through insulation w/ fat

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9
Q

Assessment of temp

1st 3

A

Site How to measure Pro Con

Oral- probe under tou he back corner, quick easy, comfy, inaccurate w/ foods and o2 cooperation

Temporal- on 4head move or rest on temporal artery, easy, rapid, comfy, sweating & hair

Tympanic- in ear pull ear up out and back, easy, rapid not influenced by food etc, injury

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10
Q

Assessment of temp

2nd 3

A

Rectal- lube probe insert in rectum no force and withdraw if resistance, more reliable if oral temp no good, painful, injury, invasive, cooperation

Axillary- place under arm in center of axilla,inexpensive, lengthy, probe in same position, sweat, not accurate

Infrared- place device few inches away from 4head get result, inexpensive safe noninvasive quick, sweat and environmental temp

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11
Q

Elevated and slow HR

A

Elevated: >100 beats/min tachycardia

Slow: <60 beats/min bradycardia

Irregular HR- dysrhythmia

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12
Q

Apical pulse

A

HR or heart rhythm irregular have to do apical pulse

  • can’t be delegated
  • also known as maximal impulse (PMI)
  • found at apex of heart (bottom)
To find: 
Sit or lay down
Sternal notch move right below 
Move hand to left and count in between ribs space (start at space 2) 
At 5 space move hand to mid clavicle
Stethoscope I’m replace 
Hear each lub dub 1 HR determine new HR
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13
Q

Pulse Deficit

A

Inefficient contraction of heart to send pulse to wrist

Asses apical and radial same time (partner needed)
Difference between 2 is pulse deficit

Often associated with abnormal heart rhythm

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14
Q

Respiration

A

Breathing controlled by medulla oblongata

Respiration involves: ventilation, diffusion, perfusion

Function control: regulated CO2 levels

Mechanics or breathing: inspiration: active process
Expiration: passive process

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15
Q

Respiration assessment

A

Respiratory rate:
Chest rise and fall don’t tell patient

Ventilators depth:
Unflavored or labored (working to breathe or normal)

Ventilatory depth:
Pattern even or uneven

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16
Q

SPO2 assessment

A

Measure arterial o2: measures % of hgb saturated w/ o2
No BP and o2 at same time
Include unit of measure and oxygen source

17
Q

SpO2 readings can be wrong

A

Tremors
Cold extremities
Dark nail polish

18
Q

Blood Pressure

A

Force exerted on wall as of artery by pulsing blood under pressure from heart

  • needs to remain under pressure to have the power to travel to tissue in body
  • less pressure tissues won’t receive blood
  • too much pressure small vessels in tissue may rupture
19
Q

BP function, factors and pulse pressure

A 
Function of arterial BP:
Cardiac output
Peripheral resistance 
Blood volume
Viscosity (thick)
Elasticity (recovery back to size)

Factors influencing BP:
Age, stress, ethnicity, genetics, gender, daily variation, medications, activity, weight, smoking

Pulse pressure:
Difference between systolic and diastolic pressure

20
Q

Hypertension VS hypotension

A 
Hyper- BP 130/80 or higher 
Asymptomatic 
Thickening of arterial walls
Loss of elasticity of arterial walls
Heart must exert more force to push blood out into system this increasing pressure

Hypo- BP < 90/60
Decrease blood flow to vital organs and tissues
Orthostatic/ postural changes ( BP drop when standing up)
Decrease in BP
Increase in HR
body unable to keep up with demands

21
Q

Meds for hypertension

A

Most likely on meds to control BP

job of meds to keep in normal range

If patient has high BP and you take it and it’s normal means they are adhering to med regimen

22
Q

BP assessment

A

Stethoscope
BP cuff

Correct size for patient
Cuff width be 40% of arm circumference
Inflatable bladder of cuff should encircle 80% of upper arm

Cuff too big - low readings
Cuff to small - high readings

23
Q

Precautions for BP readings

A

Avoid extremities with; dressing, cast, IV, and fistula

If lower extremity chosen the BP will be increased by 10 or more mm Hg

24
Q

Safety guidelines for nursing skills

A

Clean devices between each patient for decrease risk of infection

Rotate sites of repeated measurements of BP and pulse to decrease skin breakdown

Analyze trends for VS and report abnormal findings

Determine baseline for patients vital signs

Determine patient status before delegating

25
Q

Documenting vital signs

A

Document only your findings

If VS abnormal document in narrative charting along with additional assessment findings
- document condition, assessment findings, medications given, stress, pain, fever etc.

Document interventions initiated on basis of VS measurement

Document plan of action

Document follow up/ reassessment of vitals with appropriate assessment

26
Q

Pain

A

Considered 6th vital sign

Often under recognized, misunderstood, and inadequately treated

Subjective finding

Nurses legally and ethically responsible for assessing and managing pain

Pain management should be patient centered

27
Q

Scientific knowledge of pain

A

Pain stimulus is sent to cerebral cortex then interpreted by brain

Brain interprets the quality of pain and also process info from past experiences, knowledge and cultural associations in perception of pain

Person becomes aware of pain and reacts

Person can react physiological or behavioral responses

28
Q

Physiological response with pain

A

Body’s stress response from pain stimulates autonomic nervous system

Low to moderate intensity and superficial pain will elicit SNS (increased HR, BP, respitory rate)

Continuous, severe, or deep pain (organs ex. Kidney stones) elicit the PNS

All patients respond differently to pain VS may or may not change with pain

29
Q

Acute/Transient pain

A

Protective
Identifiable cause
Short duration
Limited tissue damage and emotional response
Common after acute injury, disease, surgery
Acute pain treated aggressively (with interventions) bc of predictable ending by managing pain successfully patient becomes involved in self care, increases mobility, promotes healthy sleep habits, and reduces pulmonary complications

Unrelieved acute pain can go to chronic

30
Q

Chronic pain

A

Affects more than 50 million American adults

Serves no purpose

Frantic effect on a persons quality of life

3 to 6 months

Can impact psychological and physical ability

Symptoms: fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, depression anger

31
Q

Factors influencing pain

A

Physiological:
Age, fatigue, genes, neurological function

Social:
Previous experience, family and social network,
Spiritual factors

Psychological:
Attention, anxiety and fear, coping style

Cultural:
Meaning of pain, ethnicity

Impacted by pain
Quality of life, self care, work, social support

32
Q

Health promotion

A

Maintaining use of different types of pain relief measures

Be willing to use more than one type of pain relief
Use measurements patient believes are effective
Keep open mind about ways to relieve pain
Don’t give up on relieving pain
May not be totally eliminated but can be improved for function

33
Q

Non pharmacological pain relief interventions

A 
Relaxation and guided imagery
Distraction
Music
Repositioning
Cutaneous stimulation 
-heat/cold
Massage
Breathing techniques 
Reducing noise dimming lights
34
Q

Pharmacological pain therapies

A

Need order from provider
Analgesics most common and effective for pain relief can use this and non pharmacological interventions to reduce pain

Must know medication ordered, indication of use, effects and addiction risk

Route of med determine onset and duration

Analgesic med for around clock or schedule time is better than prn help maximize pain relief

May need less meds bc body at constant therapeutic level

Response to it is highly individualized

35
Q

Analgesics: non opioids

A

Acetaminophen (Tylenol)
Safe
Action of med is to inhibit enzyme required to make prostaglandins ; they are responsible for causing pain
Can be combined with narcs
Max 24 hours 4g for healthy adult 3g for older adult or patient with liver disease
cause hepatotoxicity if more than that (liver disease)

NSAIDS ( non steroidal anti-inflammatory drug)
Aspirin, ibuprofen, naproxen
Aspirin higher doses of 325 mg is for pain relief 81 mg for cardiac related purposes
Reduce inflammation
Increase gastrointestinal irritation
Can reduce blood flow to kidneys and have kidney problems avoid giving to older adults

36
Q

Analgesics : opioids

A

Moderate to severe pain
Reduction of pain intensity to a level of acceptable comfort
Tramadol, oxycodone, hydrocodone, morphine, fetanyl
Labeled based on potential of abuse
Some in long acting for (8-12 hours)
Given during episodes of acute pain for short durations to aggressively treat issue
Longer than a week stay on longer
Manage chronic pain
Depress CNS
Must assess the patient thoroughly before and after administering opioid med
-VS before and after HR, BP, RR, O2, pain level, mental status
Many common and dangerous side effects
When given older adults special considerations must be taken due to age

37
Q

Barriers to effective pain management

A

Physical dependence:
Body becomes physical dependent drug bc has adapted to
Withdraw syndrome when drug is abruptly decreased
Physical dependency does not mean addiction
Drug be tapered

Drug tolerance:
Increased dose for pain control
Rotate drug type if tolerance develops as increasing dose can contribute to hyperalgesia (extreme response to pain, increase sensitivity to feeling pain)

Addiction:
Behavior from a drive to obtain and take substances for reasons other than the prescribed therapeutic value

38
Q

Documentation of pain

A

Details of the pain, ask appropriate and detailed questions
Location
Severity
Quality
Duration
Offer interventions (30 min to hour for reassess)
Follow up on pain at least every 2 hours if not sooner

39
Q

Reminders

A

Assess previously used for pain remedies
Invasive therapies first
Actions and side effects of meds
Monitor for and respond to adverse responses
Lack of pain expression don’t mean they don’t have it
Pain is subjective

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