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NURS2051L > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Vital Signs?

A

body temperature, pulse, respirations, blood pressure, and pain assessment

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2
Q

vital signs cont’d

A

Oxygen saturation is also commonly measured at
the same time as the traditional vital signs

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3
Q

Body temperature

A

reflects the balance between the heat produced
and the heat lost from the body, and is measured in heat units called
degrees

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4
Q

2 kind of body temp:

A

core & surface temp.

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5
Q

core temp.

A

is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity. It remains relatively constant. The normal core body temperature is a range of temperatures

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6
Q

surface temp,

A

is the temperature of the skin, the subcutaneous tissue, and fat. It, by contrast, rises and falls in response to the environment

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7
Q

The body continually produces heat as a by-product of

A

metabolism

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8
Q

When the amount of heat produced by the body equals the
amount of heat lost, the person is in

A

heat balance

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9
Q

factors that affect the body’s heat production

A
  1. Basal metabolic rate. The basal metabolic rate (BMR) is the
    rate of energy utilization in the body required to maintain essential activities such as breathing
  2. Muscle activity. Muscle activity, including shivering, increases
    the metabolic rate
  3. Thyroxine output. Increased thyroxine output increases the rate
    of cellular metabolism throughout the body.
  4. Epinephrine, norepinephrine, and sympathetic stimulation/
    stress response. These hormones immediately increase the rate
    of cellular metabolism in many body tissues.
  5. Fever. Fever increases the cellular metabolic rate and thus increases the body’s temperature further
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10
Q

Radiation

A

is the transfer of heat from
the surface of one object to the surface of another without contact between the two objects, mostly in the form of infrared rays

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11
Q

conduction

A

is the transfer of heat from one molecule to a molecule
of lower temperature

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12
Q

Convection

A

is the dispersion of heat by air currents

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13
Q

evaporation

A

n is continuous vaporization of moisture from the
respiratory tract and from the mucosa of the mouth and from the
skin. This continuous and unnoticed water loss is called insensible
water loss, and the accompanying heat loss is called insensible
heat loss. Insensible heat loss accounts for about 10% of basal heat
loss. When the body temperature increases, vaporization accounts
for greater heat loss.

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14
Q

The system that regulates body temperature has three main parts:

A

sensors in the periphery and in the core, an integrator in the hypothalamus, and an effector system that adjusts the production and loss
of heat.

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15
Q

3 physiological processes to increase the body temperature take place:

A
  1. Shivering increases heat production.
  2. Sweating is inhibited to decrease heat loss.
  3. Vasoconstriction decreases heat loss.
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16
Q

normal body temp.

A

The normal range for adults is considered to be between 36°C and
37.5°C (96.8°F to 99.5°F). T

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17
Q

PYREXIA

A

A body temperature above the usual range is called pyrexia,
hyperthermia, or (in lay terms) fever. A very high fever, such as 41°C
(105.8°F), is called hyperpyrexia

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18
Q

4 common types of fevers

A
  1. intermittent (the body temperature alternates at regular intervals between periods of time)
  2. remittent a wide range of temperature fluctuations (more than
    2°C [3.6°F]) occurs over a 24-hour period, all of which are above
    normal.)
  3. relapsing (short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature.)
  4. constant (the body temperature fluctuates minimally but always remains above normal)
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19
Q

A temperature that rises to fever level rapidly following a normal
temperature and then returns to normal within a few hours is called

A

fever spike

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20
Q

a result of excessive heat and dehydration

A

Heat exhaustion

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21
Q

Hypothermia

A

is a core body temperature below the lower limit of
normal

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22
Q

measuring temp.

A

oral, rectal, axillary, tympanic membrane, and skin/temporal artery

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23
Q

types of thermometer:

A

mercury-in-glass, Electronic thermometers. chemical disposable, temp. sensitive tape, infrared & temporal artery therm,

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24
Q

temp. scale conversion

A

C = (Fahrenheit temperature- 32) * 5/9
F = (Celsius temperature * 9/5) + 32

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25
Q

pulse

A

is a wave of blood created by contraction of the left ventricle of the heart
Generally, the pulse wave represents the stroke volume output or the amount of blood that enters the arteries with each
ventricular contraction.

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26
Q

Compliance

A

the arteries is their ability to
contract and expand. When a person’s arteries lose their distensibility, as can happen with age, greater pressure is required to pump the
blood into the arteries

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27
Q

Cardiac output

A

is the volume of blood pumped into the arteries by the heart and equals the result of the stroke volume (SV)
times the heart rate (HR) per minute.

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28
Q

peripheral pulse

A

is a pulse located away from the heart, for example, in the foot or wrist

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29
Q

apical pulse

A

is a central pulse; that is, it is located at the apex of the heart. It is also referred to as the point of maximal impulse (PMI).

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30
Q

factors affecting the pulse

A

age, sex, exercise, fever, medications, hypovolemia/dehydration, stress, position, pathology

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31
Q

Pulse sites

A

temporal, carotid, apical, femoral, brachial, radial, popliteal, posterior tibial, dorsalis pedis

32
Q

asessing the pulse

A

A pulse is commonly assessed by palpation (feeling) or auscultation (hearing). The middle three fingertips are used for palpating all pulse sites except the apex of the heart. A stethoscope is used for assessing apical pulses

33
Q

cont’d

A

When assessing the pulse, the nurse collects the following data:
the rate, rhythm, volume, arterial wall elasticity, and presence or
absence of bilateral equality

34
Q

An excessively fast heart rate (e.g., over 100 beats/min in an adult) is referred to as

A

tachycardia

35
Q

A heart rate in an adult of less than 60 beats/min is called

A

bradycardia

36
Q

pulse rhythm

A

is the pattern of the beats and the intervals
between the beats

37
Q

A pulse with an irregular rhythm is referred to as a

A

a dysrhythmia or arrhythmia

38
Q

Pulse volume

A

also called the pulse strength or amplitude, refers to the force of blood with each beat.
Usually, the pulse volume is
the same with each beat. It can range from absent to bounding. A normal pulse can be felt with moderate pressure of the fingers and can be obliterated with greater pressure. A forceful or full blood volume that
is obliterated only with difficulty is called a full or bounding pulse.
A pulse that is readily obliterated with pressure from the fingers is
referred to as weak, feeble, or thready

39
Q

apical-radial pulse assesment

A

An apical-radial pulse may need to be assessed for clients with
certain cardiovascular disorders
An apical pulse rate greater than a radial pulse rate can
indicate that the thrust of the blood from the heart is too weak for
the wave to be felt at the peripheral pulse site, or it can indicate that
vascular disease is preventing impulses from being transmitted.

40
Q

Any discrepancy between the two pulse rates is called a

A

pulse deficit

41
Q

Respiration

A

act of breathing

42
Q

Inhalation or inspiration

A

refers to the intake of air into the lungs

43
Q

Exhalation or expiration

A

refers to breathing out or the movement of gases from the lungs to the
atmosphere.

44
Q

. Ventilation

A

is also used to refer to the movement of air
in and out of the lungs

45
Q

2 types of breathing;

A

costal (thoracic) breathing - involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles

diaphragmatic (abdominal) breathing - involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the
abdomen, which occurs as a result of the diaphragm’s contraction and
downward movement.

46
Q

Mechanics and Regulation of Breathing

A

During inhalation, the following processes normally occur
(Figure 29–16 •): The diaphragm contracts (flattens), the ribs move
upward and outward, and the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation
(Figure 29–17 •), the diaphragm relaxes, the ribs move downward
and inward, and the sternum moves inward, thus decreasing the size
of the thorax as the lungs are compressed. Normal breathing is automatic and effortless. A normal adult inspiration lasts 1 to 1.5 seconds,
and an expiration lasts 2 to 3 seconds.

47
Q

Respiration is controlled by

A

(a) respiratory centers in the medulla oblongata and the pons of the brain and
(b) chemoreceptors located centrally in the medulla and peripherally in the carotid and aortic bodies. These centers and receptors respond to changes in the
concentrations of oxygen (O2), carbon dioxide (CO2), and hydrogen
(H+) in the arterial blood.

48
Q

Abnormally slow respirations are referred to as

A

bradypnea

49
Q

abnormally fast respirations are called

A

tachypnea or polypnea

50
Q

Apnea

A

is the absence of breathing

51
Q

Factors Affecting Respirations

A

Several factors influence respiratory rate. Those that increase the rate
include exercise (increases metabolism), stress (readies the body for
“fight or flight”), increased environmental temperature, and lowered
oxygen concentration at increased altitudes. Factors that may decrease
the respiratory rate include decreased environmental temperature, certain medications (e.g., narcotics), and increased intracranial pressure.

52
Q

during a normal inspiration and expiration, an adult takes in about 500 mL of air. This
volume is

A

tidal volume

53
Q

Hyperventilation

A

refers to very deep, rapid respirations

54
Q

hypoventilation

A

refers to very shallow respirations.

55
Q

Respiratory rhythm

A

refers to the regularity of the expirations and the inspirations. Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular or irregular. An infant’s respiratory rhythm may be less regular than an adult’s

56
Q

Respiratory quality or character

A

refers to those aspects of breathing that are different from normal, effortless breathing

57
Q

Arterial blood pressure

A

is a measure of the pressure exerted by
the blood as it flows through the arteries

58
Q

2 blood pressure measurements

A

The systolic pressure is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave.

The diastolic pressure is the pressure when the ventricles are at
rest. Diastolic pressure, then, is the lower pressure, present at all
times within the arteries.

The difference between the diastolic and
the systolic pressures is called the pulse pressure. A normal pulse
pressure is about 40 mmHg but can be as high as 100 mmHg during
exercise

59
Q

A typical blood pressure for a healthy adult is

A

120/80 mmHg

60
Q

PUMPING ACTION OF THE HEART

A

When the pumping action of the heart is weak, less blood is pumped
into arteries (lower cardiac output), and the blood pressure decreases.
When the heart’s pumping action is strong and the volume of blood
pumped into the circulation increases (higher cardiac output), the
blood pressure increases.

61
Q

PERIPHERAL VASCULAR RESISTANCE

A

Peripheral resistance can increase blood pressure.

62
Q

arteriosclerosis.

A

If the elastic and muscular tissues of the arteries are replaced
with fibrous tissue, the arteries lose much of their ability to constrict
and dilate

63
Q

BLOOD VOLUME

A

When the blood volume decreases (for example, as a result of a hemorrhage or dehydration), the blood pressure decreases because of decreased fluid in the arteries. Conversely, when the volume increases
(for example, as a result of a rapid intravenous infusion), the blood
pressure increases because of the greater fluid volume within the circulatory system.

64
Q

BLOOD VISCOSITY

A

Blood pressure is higher when the blood is highly viscous (thick),
that is, when the proportion of red blood cells to the blood plasma is
high. This proportion is referred to as the hematocrit. The viscosity
increases markedly when the hematocrit is more than 60% to 65%.

65
Q

factors affecting b.p

A

age, exercise, stress, race, sex, medications, obesity, diurnal variations, medical conditions, temp.

66
Q

hypertension

A

A blood pressure that is persistently above normal

An elevated blood pressure of unknown cause is called primary hypertension. An elevated blood pressure of known cause is called secondary hypertension.

Individuals with diastolic blood pressures of 80 to 89 mmHg or systolic blood pressures of 120 to 139 mmHg should be considered prehypertensive and,
without intervention, may develop cardiac disease. Hypertension is
when either the systolic BP is higher than 140 mmHg or when the
diastolic blood pressure (BP) is 90 mmHg or higher

67
Q

hypotension

A

is a blood pressure that is below normal, that is, a systolic reading consistently between 85 and 110 mmHg in an adult whose normal pressure is higher than this.

Orthostatic hypotension is a blood pressure that decreases when the client sits
or stands

68
Q

Assessing Blood Pressure

A

Blood pressure is measured with a blood pressure cuff, a sphygmomanometer, and a stethoscope. The blood pressure cuff consists of a
bag, called a bladder, that can be inflated with air (Figure 29–18 •). It
is covered with cloth and has two tubes attached to it. One tube connects to a bulb that inflates the bladder. A small valve on the side of
this bulb traps and releases the air in the bladder.
The other tube is attached to a sphygmomanometer. The
sphygmomanometer indicates the pressure of the air within the
bladder. There are two types of sphygmomanometers: aneroid and
digital. The aneroid sphygmomanometer has a calibrated dial with a
needle that points to the calibrations (Figure 29–19 •).

69
Q

BLOOD PRESSURE ASSESSMENT SITES

A

The blood pressure is usually assessed in the client’s upper arm using
the brachial artery and a standard stethoscope. Assessing the blood
pressure on a client’s thigh is indicated in these situations:
• The blood pressure cannot be measured on either arm (e.g., because of burns or other trauma).
• The blood pressure in one thigh is to be compared with the blood
pressure in the other thigh.
Blood pressure is not measured on a particular client’s limb in the following situations:
• The shoulder, arm, or hand (or the hip, knee, or ankle) is injured
or diseased.
• A cast or bulky bandage is on any part of the limb.
• The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on that side.
• The client has an intravenous infusion or blood transfusion in
that limb.
• The client has an arteriovenous fistula (e.g., for renal dialysis) in
that limb.

70
Q

When taking a blood pressure using a stethoscope, the nurse
identifies phases in the series of sounds called

A

Korotkoff’s sounds

71
Q

auscultatory gap

A

occurs particularly in hypertensive clients, is the temporary disappearance
of sounds normally heard over the brachial artery when the cuff pressure is high followed by the reappearance of the sounds at a lower
level

72
Q

pulse oximeter

A

is a noninvasive device that estimates a client’s
arterial blood oxygen saturation (SaO2) by means of a sensor
attached to the client’s finger, toe, nose, earlobe,
or forehead (or around the hand or foot of a neonate). The oxygen
saturation value is the percent of all hemoglobin binding sites that
are occupied by oxygen. The pulse oximeter can detect hypoxemia
(low oxygen saturation) before clinical signs and symptoms, such as a
dusky color to skin and nail beds, develop.

73
Q

e pulse oximeter’s sensor has two parts:

A

(a) two light-emitting
diodes (LEDs)—one red, the other infrared—that transmit light
through nails, tissue, venous blood, and arterial blood; and
(b) a photodetector placed directly opposite the LEDs (e.g., the other side
of the finger, toe, or nose)

74
Q

Normal oxygen saturation

A

is 95% to 100%, and below 70% is
life threatening.

75
Q

Factors Affecting Oxygen
Saturation Readings

A

hemoglobin, circulation, activity, carbon monoxide poisoning,

NURS2051L (3 decks)

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