Vital Signs Flashcards
What is the purpose of taking vital signs?
To monitor a change in a person condition
What do you do when the vital sign is abnormal?
Try to take it twice and switch arms & if still abnormal report to nurse
When do you asses vital signs?
-On admission
-Discharge
-Pre and Post-opt
-Change in condition
-Loss of consciousness
-When medications are given that affect cardiac rate and rhythm
-Per MD order or hospital policy
What are the physiological responses for temperature?
-disease or trauma of the hypothalamus or spinal cord will alter temperature
-hypothalamus also receives messages from cold and warm thermal receptors located throughout body
What is the most common way to take temp in a hospital?
Orally
What temp sites are considered core temp?
Tympanic, rectal, and temporal artery
What are surface temp measurement sites?
Skin, mouth, and axiallae
How do you take tympanic temp?
Pull up and back (ear)
What temp is more accurate?
Core temperature
What are the four mechanisms of heat transfer?
Radiation, Convection, Evaporation, and Conduction
What is radiation (mechanism of heat transfer)?
Diffusion or dissemination of heat by electromagnetic waves (ex. Gives of heat from uncovered areas)
What is convection (mechanism of heat transfer)?
Dissemination of heat by motion between areas of density (ex. Fan blows cool air across warm)
What is Evaporation (mechanism of heat transfer)?
Conversion of liquid to vapor (ex. Sweating)
What is conduction (mechanism of heat transfer)?
Transfer of heat to another object during contact (ex. Ice pack)
What is the primary source for body heat?
Metabolism
What other two mechanisms play a role in generation of body heat?
Hormones and exercise
What factors affect variations in temperature?
Circadian Rhythms, gender/age, illness, environment
What does pyrexia mean?
Has fever (febrile)
What does a febrile mean?
No fever
What is hyperpyrexia?
Condition where the body temp goes above 106.7 (life-threatening issue)
What is hypothermia?
Condition where the body temp drops really low, commonly caused by prolonged exposure to cold
What are the expected ranges in oral temp?
96.8 to 100.4 (average is 98.6)
What are expected ranges of rectal temp?
Usually 0.9 degrees higher than oral and tympanic
What is expected ranges of axillary temp?
Usually 0.9 degrees lower than oral and tympanic temp
What are expected temporal temp ranges?
Are close to rectal, but they are nearly 1 degree higher than oral and 2 degree higher than axillary
What are the fever signs/symptoms?
Hot, dry skin, flush, general malaise, and increased heart rate
What is intermittent fever?
Body temp comes back to normal in 24 hours
What is remittent fever?
Does not come back to normal but does fluctuate
What is relapsing fever?
Returns back to normal then fluctuates
What are some nursing interventions for fever?
VS, I&O, fluids (IV or oral), Meds, Tepid bath, cooling blanket, oral hygiene, dry clothing and linen
Before taking an oral temp what should you ask the patient?
If they have had anything cold or hot within the last 20 minutes
What are the pulse physiological responses?
- Autonomic system
- Parasympathetic nervous system
- Sympathetic nervous system
What is the autonomic nervous system
Controls heart rate
What is the parasympathetic nervous system?
Lowers heart rate “rest & relax”
What is the sympathetic nervous system?
Raises the heart rate “Fight or Flight”
Where is the apical point?
In the 5th intercostal space
What does the acronym APETM stand for?
Aortic area
Pulmonic area
Erb’s point
Tricuspid area
Mitral area
What factors affect the pulse rate?
Age: lowers it
Exercise: raises it
Pain: raises it
Hemorrhage: raises it
Fever: raises it
Stress: raises it
Illness: raises it
Where is the carotid artery?
On both sides of the neck; never squeeze both at same time
Where is the brachial artery?
In the inner elbow lines up with the pinky
Where is the radial pulse?
On the wrist below the thumb
Where is the femoral pulse?
On the inner thigh by pubis region
Where is the popliteal pulse?
Behind the knee
Where is the dorsalis pedis?
On the foot right above the big toe and 2nd toe
How do you assess the pulse?
Rate, Rhythm, Quality/Strength, Equal Bilaterally
What is a pulse deficit?
Difference between apical rate and radial rate
What is pulmonary ventilation?
Movement of air in and out of lungs
What is diffusion?
Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood
What is perfusion?
The exchange of oxygen and carbon dioxide between circulating blood and tissue cells
What factors influence respiratory rate?
-Age
-Acid-base balance
-C-V disease
-Pain
-Emotions
-Opiod-narcotics
-Anesthesia
-CNS injury
What do you assess during respirations?
-Rate
-Depth
-Rhythm(pattern)
-Quality
-Procedure
What is Eupnea?
Normal breathing
What is apnea?
Absence breathing
What is orthopnea?
Difficulty breathing when laying down
What is blood pressure?
Force of moving blood against the atrial walls
What is orthostatic hypotension?
BP drops when patient stands (within 3 minutes takes the BP again)
What is pulse pressure?
Difference between systolic & diastolic
What is the range for a normal pulse pressure?
40-60mmHg
What factors affect BP?
-Age
-Circadian Rhythm
-Gender
-Eating food
-Weight
-Emotions
-Body Position
-Race
-Medications
When taking someone blood pressure what should you ask beforehand?
-Have you had an recent surgeries on either arms they would not let me use the arm for BP?
-Any extremity with IV or AV shunt
What is the 1st phase of Korotkoff Sounds?
Systolic
What is the 5th phase of Korotkoff Sounds?
Diastolic
How should you measure what size BP cuff you should use?
Width 40% of arm circumference
Why is BP often higher in older adults?
Decreased elasticity in arterial walls
What is considered the 5th vital sign?
Pain (Scale 0-10)
What is the 6th vital sign?
Pulse oximetry
What is the normal range for pulse ox?
95%-100%
How can you maintain adequate oxygenation?
-Positioning
-Promoting proper breathing
-Turn, Cough and Deep Breathe
-Providing supplemental oxygen
Why is documentation important for vital signs?
You note significant changes and report, and compare/trend
