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Fundamentals Of Nursing > Vital Signs > Flashcards

Vital Signs Flashcards

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1
Q

What is the purpose of taking vital signs?

A

To monitor a change in a person condition

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2
Q

What do you do when the vital sign is abnormal?

A

Try to take it twice and switch arms & if still abnormal report to nurse

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3
Q

When do you asses vital signs?

A

-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

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4
Q

What are the physiological responses for temperature?

A

-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

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5
Q

What is the most common way to take temp in a hospital?

A

Orally

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6
Q

What temp sites are considered core temp?

A

Tympanic, rectal, and temporal artery

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7
Q

What are surface temp measurement sites?

A

Skin, mouth, and axiallae

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8
Q

How do you take tympanic temp?

A

Pull up and back (ear)

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9
Q

What temp is more accurate?

A

Core temperature

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10
Q

What are the four mechanisms of heat transfer?

A

Radiation, Convection, Evaporation, and Conduction

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11
Q

What is radiation (mechanism of heat transfer)?

A

Diffusion or dissemination of heat by electromagnetic waves (ex. Gives of heat from uncovered areas)

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12
Q

What is convection (mechanism of heat transfer)?

A

Dissemination of heat by motion between areas of density (ex. Fan blows cool air across warm)

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13
Q

What is Evaporation (mechanism of heat transfer)?

A

Conversion of liquid to vapor (ex. Sweating)

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14
Q

What is conduction (mechanism of heat transfer)?

A

Transfer of heat to another object during contact (ex. Ice pack)

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15
Q

What is the primary source for body heat?

A

Metabolism

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16
Q

What other two mechanisms play a role in generation of body heat?

A

Hormones and exercise

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17
Q

What factors affect variations in temperature?

A

Circadian Rhythms, gender/age, illness, environment

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18
Q

What does pyrexia mean?

A

Has fever (febrile)

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19
Q

What does a febrile mean?

A

No fever

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20
Q

What is hyperpyrexia?

A

Condition where the body temp goes above 106.7 (life-threatening issue)

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21
Q

What is hypothermia?

A

Condition where the body temp drops really low, commonly caused by prolonged exposure to cold

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22
Q

What are the expected ranges in oral temp?

A

96.8 to 100.4 (average is 98.6)

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23
Q

What are expected ranges of rectal temp?

A

Usually 0.9 degrees higher than oral and tympanic

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24
Q

What is expected ranges of axillary temp?

A

Usually 0.9 degrees lower than oral and tympanic temp

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25
Q

What are expected temporal temp ranges?

A

Are close to rectal, but they are nearly 1 degree higher than oral and 2 degree higher than axillary

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26
Q

What are the fever signs/symptoms?

A

Hot, dry skin, flush, general malaise, and increased heart rate

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27
Q

What is intermittent fever?

A

Body temp comes back to normal in 24 hours

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28
Q

What is remittent fever?

A

Does not come back to normal but does fluctuate

29
Q

What is relapsing fever?

A

Returns back to normal then fluctuates

30
Q

What are some nursing interventions for fever?

A

VS, I&O, fluids (IV or oral), Meds, Tepid bath, cooling blanket, oral hygiene, dry clothing and linen

31
Q

Before taking an oral temp what should you ask the patient?

A

If they have had anything cold or hot within the last 20 minutes

32
Q

What are the pulse physiological responses?

A
  1. Autonomic system
  2. Parasympathetic nervous system
  3. Sympathetic nervous system
33
Q

What is the autonomic nervous system

A

Controls heart rate

34
Q

What is the parasympathetic nervous system?

A

Lowers heart rate “rest & relax”

35
Q

What is the sympathetic nervous system?

A

Raises the heart rate “Fight or Flight”

36
Q

Where is the apical point?

A

In the 5th intercostal space

37
Q

What does the acronym APETM stand for?

A

Aortic area
Pulmonic area
Erb’s point
Tricuspid area
Mitral area

38
Q

What factors affect the pulse rate?

A

Age: lowers it
Exercise: raises it
Pain: raises it
Hemorrhage: raises it
Fever: raises it
Stress: raises it
Illness: raises it

39
Q

Where is the carotid artery?

A

On both sides of the neck; never squeeze both at same time

40
Q

Where is the brachial artery?

A

In the inner elbow lines up with the pinky

41
Q

Where is the radial pulse?

A

On the wrist below the thumb

42
Q

Where is the femoral pulse?

A

On the inner thigh by pubis region

43
Q

Where is the popliteal pulse?

A

Behind the knee

44
Q

Where is the dorsalis pedis?

A

On the foot right above the big toe and 2nd toe

45
Q

How do you assess the pulse?

A

Rate, Rhythm, Quality/Strength, Equal Bilaterally

46
Q

What is a pulse deficit?

A

Difference between apical rate and radial rate

47
Q

What is pulmonary ventilation?

A

Movement of air in and out of lungs

48
Q

What is diffusion?

A

Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood

49
Q

What is perfusion?

A

The exchange of oxygen and carbon dioxide between circulating blood and tissue cells

50
Q

What factors influence respiratory rate?

A

-Age
-Acid-base balance
-C-V disease
-Pain
-Emotions
-Opiod-narcotics
-Anesthesia
-CNS injury

51
Q

What do you assess during respirations?

A

-Rate
-Depth
-Rhythm(pattern)
-Quality
-Procedure

52
Q

What is Eupnea?

A

Normal breathing

53
Q

What is apnea?

A

Absence breathing

54
Q

What is orthopnea?

A

Difficulty breathing when laying down

55
Q

What is blood pressure?

A

Force of moving blood against the atrial walls

56
Q

What is orthostatic hypotension?

A

BP drops when patient stands (within 3 minutes takes the BP again)

57
Q

What is pulse pressure?

A

Difference between systolic & diastolic

58
Q

What is the range for a normal pulse pressure?

A

40-60mmHg

59
Q

What factors affect BP?

A

-Age
-Circadian Rhythm
-Gender
-Eating food
-Weight
-Emotions
-Body Position
-Race
-Medications

60
Q

When taking someone blood pressure what should you ask beforehand?

A

-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

61
Q

What is the 1st phase of Korotkoff Sounds?

A

Systolic

62
Q

What is the 5th phase of Korotkoff Sounds?

A

Diastolic

63
Q

How should you measure what size BP cuff you should use?

A

Width 40% of arm circumference

64
Q

Why is BP often higher in older adults?

A

Decreased elasticity in arterial walls

65
Q

What is considered the 5th vital sign?

A

Pain (Scale 0-10)

66
Q

What is the 6th vital sign?

A

Pulse oximetry

67
Q

What is the normal range for pulse ox?

A

95%-100%

68
Q

How can you maintain adequate oxygenation?

A

-Positioning
-Promoting proper breathing
-Turn, Cough and Deep Breathe
-Providing supplemental oxygen

69
Q

Why is documentation important for vital signs?

A

You note significant changes and report, and compare/trend

Fundamentals Of Nursing (9 decks)

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