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)
