Vital signs Flashcards
Body temperature is the
difference between the amount of heat produced by the body and the amount of heat lost to the environment.
Core body temperature is…(core middle)
(intracranial, intrathoracic, and intra-abdominal) is higher than surface body temperature
the nurse is expected to choose an…(for body temp)
an appropriate site, and the correct equipment, based on the patient’s condition, facility policy, and medical orders
If a temperature reading is obtained from a site other than the oral route
document the site used along with the measurement. I
peripheral pulse
palpated (felt) over a peripheral artery, such as the radial artery or the carotid artery
Characteristics of the peripheral pulse include (rrq)
rate, rhythm, and amplitude (quality; strong or weak)
Apical pulse measurement is the preferred method of pulse assessment for (2 apical)
infants and children less than 2 years of age
The normal pulse rate for adolescents and adults ranges from
60 to 100 beats per minute
Pulse rates are measured in
beats per minute
A difference between the apical and radial pulse rates is called
pulse deficit and indicates that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated. 2 nurses needed for this
Under normal conditions, healthy adults breathe about
12 to 20 times per minute
tachypnea (tacky at 24) (FEVER)
> 24 breaths/min; Shallow -
Fever, anxiety, exercise, respiratory disorders
Bradypnea and how many
<10 breaths/min; Regular - Depression of the respiratory center by medications, brain damage
Hyperventilation (not the number)
Increased rate and depth - Extreme exercise, fear, diabetic ketoacidosis (Kussmaul’s respirations), overdose of aspirin
Hypoventilation (just description, not number)
Decreased rate and depth; irregular - Overdose of narcotics or anesthetics
Cheyne–Stokes respirations
Alternating periods of deep, rapid breathing followed by periods of apnea; regular. Drug overdose, heart failure, increased intracranial pressure, renal failure
Biot’s respirations (don bot)
Varying depth and rate of breathing, followed by periods of apnea; irregular. Meningitis, severe brain damage
Assess patient for any signs of respiratory distress, which includes (RNG TO grunt)
retractions, nasal flaring, grunting, orthopnea (breathlessness), or tachypnea.
Systolic pressure is the
highest point of pressure on arterial walls when the ventricles contract and push blood through the arteries at the beginning of systole
When the heart rests between beats during diastole
the pressure drops. The lowest pressure present on arterial walls during diastole is the diastolic pressure
pulse pressure
the difference between systole and diastole
Prehypertension - ignore this
120–139
OR
80–89
High blood pressure (Ignore this card, powerpoint is different #s)
Stage 1
140–159
OR
90–99
Stage 2
≥160
OR
100 or higher
BP = The series of sounds for which to listen when assessing blood pressure are called
Korotkoff sounds
auscultation
listening to the heart
Diaphoresis
excessive, abnormal sweating in relation to your environment and activity level
Korotkoff sounds
The series of sounds for which to listen when assessing blood pressure
phase 1 bp
Characterized by the first appearance of faint, but clear tapping sounds that gradually increase in intensity
phase 2 bp
Characterized by muffled or swishing sounds; these sounds may temporarily disappear,
phase 3 bp
Characterized by distinct, loud sounds as the blood flows
phase 4 bp
Characterized by a distinct, abrupt, muffling sound with a soft, blowing quality
phase 5 bp (tap, whisper, yell, blow, silent)
The last sound heard before a period of continuous silence
hypotension signs (hypo pladd)
dizziness, lightheadedness, pallor, diaphoresis
when taking bp, assess for…(bp is an unstable CO falling)
Decreased cardiac output
Risk for falls
Risk for unstable blood pressure
dorsalis pedis
top of foot, use for bp in infants
fibula (small fib)
outside
Infants and children presenting with cardiac complaints may have blood pressures assessed in (not apical)
all four extremities. Large differences among blood pressure readings can indicate heart defects
The fifth Korotkoff sound corresponds to diastolic blood pressure in
children
oscillations (fluctuate my oscillate)
fluctuations
adult’s orthostatic blood pressure (lie, dangle, stand - 10,3,2)
1)Assist the client into a supine position.
2)Wait 3 to 10 minutes, then measure the client’s blood pressure.
3)Assist the client to the sitting position with legs dangling.
4)Wait 1 to 3 minutes, then measure the client’s blood pressure.
5)Assist the client to a standing position.
6)Wait 2 to 3 minutes, then measure the client’s blood pressure.
doppler - inflate until…
the sound disappears
What results would indicate to the nurse the client is experiencing orthostatic hypotension (the number)
A decrease in systolic pressure >20 mm Hg
if repeating doppler, wait until
the cuff is completely deflated before attempting another reading
What is most important for the nurse to do when using an automatic electronic device to obtain serial blood pressure readings
Check that the cuff is deflated completely after the reading.
orthostatic hypotension. The nurse explains that for each measurement, the client will have to remain in the position for approximately how long?
3 min
A nurse is measuring a client’s blood pressure using an electronic device. What is important for the nurse to do to ensure accurate results? (learn this)
Check to make sure the client’s heart rate is regular.
The nurse estimates a client’s systolic pressure to be 150 mm Hg. When obtaining the client’s blood pressure measurement with a sphygmomanometer, the nurse would inflate the cuff to which pressure?
180 - 30 above
Estimating Systolic Pressure (palp, tight, inflate, deflate a minute)
Palpate the pulse at the brachial or radial artery
Tighten the screw valve on the air pump.
inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears.
Deflate the cuff and wait 1 minute.
Obtaining Blood Pressure Measurement
no more than 3 ft away
Place the stethoscope earpieces in your ears.
bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery
tighten screw valve
Pump the pressure 30 mm Hg above the point at which the systolic pressure was palpated and estimated.
Open the valve on the manometer and allow air to escape slowly
Note the point on the gauge at which the first faint, but clear, sound appears - this is systolic pressure
do not reinflate
Note the point at which the sound completely disappears. Note this number as the diastolic pressure
Allow the remaining air to escape quickly.
When measurement is completed, remove the cuff.
Clean the bell or diaphragm of the stethoscope with the alcohol wipe
remove ppe
when to assess vital signs
When it is ordered (minimum requirement) - very minimum
may be pre-op and post-op, or every 30 min - you can use judgement to assess
you may need to document vital signs before giving meds. meds for heart rate, etc. you want to see how the medication is working.
if patient is on bedrest, you may need to assess vital signs, possibly orthostatis (lying, sitting, standing)
or might want to assess after (tachycardia)
• On Admission to hospital or at office visit
• When coming on to shift
Policy Guidelines
• Before during or after surgery or certain procedures
• To monitor effect of medications or interventions
Nurses Judgment
• Before activity
• To monitor effect of activity
• Change in behavior or assessment
surface temp is based on (the environment is on the surface)
changes in the environment
temp is controlled by
hypothalamus - think of it as a thermostat. it has a set point.
When hypothalamus senses body temp lower
than set point
Impulses sent to increase body temp, ex. shiver, piloerection, veins aren’t visible anymore
When hypothalamus senses heat beyond (more) the set point
Impulses sent out to reduce body temp - vessels closer to skin, diaphorisis,
who can’t regulate temp?
elderly (facilities don’t have air conditioning in bay area) - mobility issues, someone in shock, newborns (can’t even shiver)
what things affect heat production? - what makes heat go up? (heat B basal SF)
Basal Metabolic Rate (BMR) thyroid
Shivering - produces heat
Fever - change in set point
Influences of Heat Loss - radiation
• Radiation: (hat or blanket)
Surface to surface without
contact
Transfer through
electromagnetic waves
ex. removing a hat or blanket
• Factors Affecting Heat Loss
• Conduction: (conductor - mozart)
•
• Transfer of heat from one
molecule to another with
contact
•
ex - ice pack, tempid bath, cooling blanket
• Factors Affecting Heat Loss
• Convection:
• Dispersion of heat away
from body by air currents next
to body
ex - fan
• Factors Affecting Heat Loss
• Evaporation: via how???
• Via skin and lungs resulting in
heat and water loss
• Insensible water loss (loss can’t be measured)
infants only have…
brown fat stores, can’t regulate temp
Factors Affecting Temperature (SHAD from the temp) S - what you’re always under
• Age
• Hormones - temp, ovulation, hot flashes
• Stress
• Environment
oral temp is surface or core? (oral on the surface)
surface temperature - is fine to establish trends***
axillary temp is surface or core temp?
surface temp, but not as accurate
temporal temp is measuring..
core temp
rectal temp is
core temp (appropriate choice for ppl w/ unstable temp) only if necessary
rectal temp is
core temp (appropriate choice for ppl w/ unstable temp) only if necessary. Is most reliable measurement of core temp, better than temporal
rectal temp is
core temp (appropriate choice for ppl w/ unstable temp) only if necessary - don’t use for cardiac and bleeding problems. only use for good core temp (better than temporal) - don’t use for young children
which location is best temp for kids…
usually axillary
Other Sites used to measure core temperature
Pulmonary Artery -Esophagus - Bladder
Pyrexia/Fever
alteration in set point (does not happen w/ hypothermia)
P A T T E R N S O F F E V E R (SRR - Sr, your fever is relapsing)
pylonepheritis - peaks and valleys.
really need to wait 24 hrs to see if fever is gone - and infection is resolving
Sustained
Remittent
Relapsing
temperature types (the 3 Hs)
• Hyperthermia
• Heatstroke
• Hypothermia
we will almost always refer to temp in…
celcius
T E M P E R A T U R E
Temperature Scales
Know how to convert between
Celsius and Fahrenheit
• Celsius 36 -38
• Fahrenheit 96.8 - 100.4
USE these values for clinicals
normal celcius range - know this!
36 - 38
T E M P E R A T U R E
Nursing Interventions - what we do to adjust temps
• Depends on cause, adverse effects, intensity and duration
• May need to provide culture specimens (Before antibiotics are initiated!)
• Maintain I & O, encourage fluid intake - everything they drink and put out
• Administer antipyretics as ordered - ex. acetomen and tylenol
• Increase heat loss by evaporation, convection radiation
• Avoid stimulation of shivering (can deplete energy stores) tepid cloth is fine or cooling blanket
have a general understanding of
abbreviations - don’t need to memorize
AFib causes an…(just what it is)
increase in irregular heart rate
If temp isn’t normal, what other info?
look at trend - is this normal for her? there are variations. other vital signs, has she had a cold drink or eaten anything. medications she’s on. she had a night of confusion - can’t follow direction and keep her mouth closed.
1st - look at trend
2nd - advise instructor if it’s high or low
3rd - also might be technique error
pulse (normal range)
Normal range is
60-100
beats/min Stroke Volume
Cardiac Output
pulse sites - NEED TO MEMORIZE these
Count pulse rate, count the beats. pulse usually at the radial.
if patient has perfusion (blood flow at capillary level) check pulse at what sites?
posterior tibial and dorsal pedis (pedal pulse)
popliteal
need to assess bp in lower extremity
Factors affecting pulse rate (SHAM F and P) think stress…
• Age
• Fever
• Medications (tribunalin - increases, beta blockers, digoxin - decrease)
• Hemorrhage
• Stress
• Position changes
P U L S E assessment (RRQ)
• Rate - counting beat
• Rhythm - is it regular
• Quality - fullness of pulse
fluid volume overload - will be a fuller pulse
palpate radial
use 2 fingers, count for 60 seconds
A S S E S S M E N T
M E T H O D S :
A U S C U L T A T I O N
• Apical Pulse
• Apex of the heart
• Not a wave, but two heart valve sounds heard
listening to the heart sounds
skin evaluations - use gloves or not?
yes
apical heart rate
place stethascope at PMI (point of maximal impulse - the best sound) count down from clavical - 5 intercostal
D I F F I C U L T Y P A L P A T I N G A P U L S E
W A V E - use a…
doppler
C A R D I A C M O N I T O R - another way to assess
in simulation - youll get to practice
Tachycardia
more than 100
Bradycardia
less than 60
Pulse deficit
different pulse at different sites, difference of more than + or - 2, then the patient has a pulse deficit
Arrhythmia
irregular
if patient has irregular rate, you must do
apical for one full minute.
if patient has afib,
do apical pulse
if heart rate is irregular, first you must
check the chart - see if this is the patient’s trend. Check purfusion - check if there’s a pulse deficit. If irregular, document and monitor
Respiration - Normal Adult rate
Normal Adult rate 12 - 20/ min
Control of Respirations -
• Respiratory Center in brain
• Chemoreceptors in coratid and aorta
morphine - monitor more closely to make sure rate doesn’t go below 10. notify nurse or instructor.
kussmal respirations (sp)
increase in rate and depth of respirations - to blow off CO2 - seen in diabetic acid kedosis to raise pH
dysnea (dys - ex)
difficulty breathing
orthopnea (ortho feet up)
difficultly breathing when lying flat - first thing raise head of bed
Assessment respiration
Rate: Count for 30-60 secs.
Observe full inspiration and expiration
Depth
Rhythm
pulse oximeter
saturation of oxygen - make sure finger is clean
Factors Affecting Respirations (breathe STEAM F at the mountain top)
these will all increase respiration to decrease except meds - usually opioids
• Stress
• Increased Altitude
• Increased Room temp
• Medications
• Fever
lying flat - breathing rate 26 bmp
cause - lying flat
actions - put bed up and assess pulse oximeter
then you reassess and check for trends
Terms relating to blood pressure:Systolic pressure****
• Systolic pressure
First sound heard
Blood pressure during contraction
of ventricles
Normally is 90-119mmHg
Terms Relating to Blood Pressure (con’t)
• Diastolic Pressure:*******
• Diastolic Pressure:
When sound is inaudible
Blood pressure when ventricles of heart are refilling
with blood
Normally is 60-79 mmHg
Pulse Pressure
Pulse Pressure
Difference between systolic and diastolic
40mmHg is ave
narrowing pulse pressure (less than 40) - quadrapalegics, shock
New blood pressure guidelines: YOU NEED TO KNOW THIS
• Normal: Less than 120/80 mm Hg;
• Elevated: Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
Hypotension: (under what systolic?)
Under 90mmHg systolic
Orthostatic Hypotension (use to see if patient can tolerate ambulating or low hematocrites) have patient lie down, assess HR and BP, go to sitting - if they’re ortho while sitting, don’t ask patient to stand, then standing.
Drop of 20mmHg in systolic pressure
and/or drop of 10mmHg in diastolic within 3 minutes of standing from sitting or lying
position
Increase in HR by 20 bpm
Conditions Influencing Blood Pressure (think about arteries and blood - all physiological stuff) (start w/ PVD) (PHHAV law - my bp is high)
• Peripheral vascular resistance - increase in BP
• Compliance (elasticity) - hardening of arteries
• Arteriosclerosis - plaque
• Viscosity: - thickness increase
• Hematocrit
F A C T O R S A F F E C T I N G B L O O D
P R E S S U R E (men over women)
Age Exercise Stress
Race Obesity
men higher, but women after meno
what factors can influence bp? (white coat) (MW in the bp)
Medications
Disease White coat
syndrome
P A T I E N T C O N D I T I O N S
T HA T M A Y N O T
B E A P P R O P R I A T E F O R
E L E C T R O N I C
B L O O D P R E S S U R E
M E A S U R E M E N T (IPV L) (don’t forget low…) this is just jittery, not medical.
• Peripheral vascular obstruction (e.g., clots, narrowed vessels)
• Shivering
• Seizures
• Excessive tremors
• Inability to cooperate
BP sites (just arm and leg)
• Arm over brachial artery
• Leg: Popliteal artery
(don’t do bp if someone has fistula, lymph node stuff)
BP methods - direct and indirect
if in bed, need quiet
if in office, feet on floor, bp at heart level, don’t talk to patient
• Direct: invasive catheter into artery
• Indirect: Noninvasive includes auscultatory and palpatory
• Korotkoff sounds: sounds heard in auscultation of blood pressure
• Position limb: Take at heart level
do this during assessments (vital signs are during the assessment)
• Cleaning devices between patients decreases the risk for infection.
• Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown.
• Analyze trends for vital signs, and report abnormal findings.
• Determine the appropriate frequency of measuring vital signs based on the patient’s
condition.
patterns of fever - intermittent
Fever spikes interspersed with usual temperature levels
patterns of fever remittent (the readmitt is not normal)
Fever spikes and falls without
a return to normal temperature levels
patterns of fever - relapsing
Periods of febrile episodes and periods with acceptable temperature values
vital signs are a good way to…
establish a baseline and monitor trends - if patient has low blood volume, signs of shock, signs of infection, vitals are helpful.
assess vitals signs if there isn’t an order…
if it’s hospital policy, ie during surgery
when you have a fever (pyrexia) alteration in set point - this is what happens
body raises set point (say 103), then body does what it needs to to produce heat to reach the set point - chills, vasoconstriction, piloerection, epinephrine secretion, shivering. When you reach the set point, these symptoms stop. Then you take tylenol, and you sweat, vasodilation, etc.
patterns of fever - sustained (and at what temp)
Constant above 38° C (100.4° F)
with little fluctuation
pulse sites help the nurse determine…
count heartbeat, perfusion, fluid volume (fullness of pulse)
if someone has afib, check…
perfusion by checking pulse deficit (difference of + or - 2 in two different pulse sites)
digit preference
respiration has been 20, so I’m just going to write 20 without taking it.
• Hyperthermia
high temp, but doesn’t alter set point. can lead to heatstroke.
Heatstroke (and symptoms…)
Person has exhausted all of their temperature decreasing abilities. cant sweat, electrolyte imbalances. hot, dry skin and giddiness,
Hypothermia (you don’t have this number here)
low temp, different pop at risk - young, old, alcoholics, sometimes medically induced during surgery for example
is pulse rate in neonates higher or lower than adults?
higher
what diseases influence blood pressure?
diabetes, cardiovascular disease
diurnal affects what?
blood pressure and also temp
exercise affects what?
temp, blood pressure, heat production, respiration, and pulse rate. All of them.
if someone has an irregular heart rate, or Blood pressure less than 90 mm Hg systolics, DO NOT
use electronic BP device
does a fever affect respiration?
yes
does increased room temp affect respiration?
yes
