Vital Signs Flashcards
What is the range of normal temperatures?
96.8-100.4
What is the normal range of temperatures for an oral/tympanic/temporal thermometers?
97.6-99.6
What is the normal temperature range for a rectal thermometer?
98.6-100.4
What is the normal temperature range for a axillary thermometer?
96.6-98.6
What is the normal range for a pulse?
60-100 bpm (Lub-dub = 1 beat)
What are normal levels of O2 Saturation?
95-100%
What is a normal blood pressure?
120 / 80
What is prehypertension bp?
120-139 / 80-89
What is stage 1 hypertension bp?
greater than 140 / 90
What is hypotension?
less than 90 systolically with symptoms
Normal respiratory rate (Expiration and Inspiration =1)
12-20 breaths per minute
When do you measure Vital Signs? (6)
admission
pre physician orders
change in patient condition
before/after the procedure
during blood transfusions
after medications that affect VS
Where do you get the core temperature for a patient?
Bladder
Where is the regulation of temperature controlled?
Neural/Vascular Control : Hypothalamus
The anterior hypothalamus controls the heat _____ by causing the body to ____________.
lost; radiation, conduction, convection, evaporation, diaphoresis
The posterior hypothalamus controls the heat _____ by causing the body to ____________.
production; BMR and shivering
Radiation
transfer heat without direct contact
Conduction
transfer of heat with direct contact
Convection
transfer heat away by air movement
Evaporation
transfer of heat from liquid to gas
Diaphoresis
visible persperation
What factors that affect temperature?
age
hormonal levels
environment
excercise
circadian rhythm
medication alteration of temp
Pyrexia, Febrile
fever
To what degree does a fever turn harmful?
102.2
Fever Characteristics
defensive mechanism
taken several times a day
results from alter in hypothalamic set point
increase in metabolism and O2 consumption
increase in heart rate and respiratory rate
Hyperthermia
inability to promote heat loss or reduce production
Afebrile
no fever
FUO
Fever of unknown origin
Heatstroke
dangerous heat emergency with a high mortality rate
104 +
Heatstroke Signs and Symptoms
NO SWEATING
dry, hot skin
confusion, excess thirst, muscle cramps
VS: increase in heart rate with low bp
NO SWEATING
Heat exhaustion
diaphoresis = excess water and electrolyte loss
Replace fluids
Hypothermia
prolonged exposure to cold, decrease body’s ability of heat
Temperature lower than 86-96.8
Formula F to C
C = (F - 32) x 5/9
Formula C to F
F = (9/5 x C) + 32
Oral Thermometer
easily influenced by hot/cold food wait 30 minutes
most used
approximately one degree lower than core temperature
mercury, glass, or electronic
Rectal Thermometer
closest to the core temperature
How far should the nurse place the rectal thermometer into an adult, child, and infant?
Adult = 1 1/2 inches
Child = 1 inch
Infant = 1/2 inch
If the rectal thermometer is placed in feces, is it accurate temperature?
no, inaccurate
Axillary thermometer
safest and least accurate
moisture may reduce temperature
How long does the axillary thermometer need to be in place?
5-10 minutes
Tympanic thermometer
most rapid
unaffected by PO intake
remove hearing aides
Temporal thermometer
most accurate
fast, easy with few errors
What can a nurse do during vital signs
_______ culture
monitor ________ and _______________
conserve _____ and provide _______
bath water is ________
dry ______
________ meds (tylenol)
blood culture if ordered
monitor VS, skin color, temp., turgor, and lab work
reduce frequency activities to decrease oxygen
maximum heat loss
extra fluids
tepid bath water
oral hygiene
dry linens
antipyretic meds (tylenol)
What are the parts of a stethoscope called?
Earpieces, binaural, tubes, chest piece with bell and diaphragm
Pulse definition
palpable/audible bounding of blood flow at various points in the body
indirect measure of circulatory status
Radial pulse
most common routine
used for pt teaching
circulation to hand
assessed with VS pulse
Apical pulse
located 5th intercostal and mid clavicle
if abnormal radial pulse, check meds and radial inaccessible
Carotid pulse
only if patient suddenly worsens
pulse quickly
do not measure bilaterally at same time
Doralis Pedis
top of foot between 1st and 2nd toes or ankle
circulation to foot
via doppler if no palpation
do both at the same time
Pulse Characteristics
Rate (baseline, if abnormal try apical)
Rhythm (regular, irregular, dysrhythmia)
Strength (4,3,2 (normal), 1, 0)
Equality
What pulse strength is normal?
2
Gas Exchange
moving air in or out (inspiration and expiration)
Where is gas exchanged?
Alveoli
Ischemia
insufficient oxygen supply leads to cell injury/death
Hypoxia
cells don’t have enough oxygen
Hypoxemia
arterial blood does not have enough oxygen
Respiratory Acidosis
carbon dioxide stays and causes no oxygen to enter
Perfusion
swapping of gases at alveoli
What do you assess during pulse?
rate, rhythm, and depth
Eupnea
ventilation of normal rate and depth
Factors influencing pulse
exercise, acute pain, anxiety, smoking, body positions, meds, neuro injury, hemoglobin functions
Possible Alterations of Respiration Patterns (-pnea(s))
tachypnea
bradypnea
apnea
cheyne-strokes respirations
dyspnea
orthopnea
biot’s respiration
Tachypnea (bpm rate)
24 bpm or higher
Bradypnea (bpm rate)
less than 10
Apnea
life-threatening with no breathing for a period of time
Cheyne-strokes Respirations
rate and depth increase then apnea
Dyspnea
difficult breathing or shortness of breath
Orthopnea
positional breathing laying down
Biot’s respiration
normal 3-4 breaths with apnea
What method is an indirect oxygen saturation?
pulse oximetry
Pulse Oximetry
light absorption with photodetector
SpO2 = SaO2
Factors Affecting Pulse Oxygenation
too loose/tight device
polished artificial nails
temperature of extremities
movement
lighting
skin pigmentation
edema
peripheral vascular disease
Blood Pressure definition
force exerted against blood vessels by blood
measured in mmHg
Systolic
maximum pulse pressure
Diastolic
minimum pulse pressure
Physiology Factors of BP
cardiac output (volume of blood)
peripheral resistance (plague)
blood volume
viscosity
elasticity
Korotkoff Sounds in Phases
1- sharp thump (systolic)
2- blow/whooshing
3-crisp, intense tap
4-soft blowing fades (diastolic)
5-silence
Steps of BP
proper cuff size and site
position at heart level with palm up
wrap cuff around
place stethoscope and close valves
inflate to 30 mmHg above baseline
document
Ideal Environment for BP
quiet sitting
record both arms initially
same arm everytime
avoid IVs
rest 5 minutes before assessment
ask not to speak
Factors Affecting BP
age, stress, ethnicity, gender, daily variation, meds, activity, weight, smoking
White Coat Syndrome
Hypertension effects
major factor in underlying stroke
contributes to heart attacks
No symptoms
Hypotension symptoms
skin molting, clammy, confusion, increase heart rate, decrease in urine output
Automatic BP machines
frequent assessment needed
baseline BP is manually 1st
more susceptible to error
unable to accurately detect low BP
talking during BP will rise by 10-40%
Hypertension signs
thicken of walls
loss of elasticity
family history
risk factors
Hypotension signs
systolic less than 90
dilation of arteries
loss of blood volume
decrease in blood flow to organs
orthostatic/postural
Alternative BP sites
thigh (systolic raises by 10-40, but diastolic is same)
Arterial line
Pain Mnemonic
PQRST
Provokes/palliative: worst or better
Quality: type
Region/radiation: where
Severity/Setting
Timing: time of day
Pain Severity Scale 0-10
None =
Mild =
Moderate =
Bad to Worst =
0
1-3
4-6
7-10
When do you assess pain?
Before procedures, activity, and medication
30 minutes after pain meds
After procedures, activity
T/F:
Always assume what the patient says and don’t assume their pain levels.
True
When do you assess pain?
Before procedures, activity, and medication
30 minutes after pain meds
After procedures, the activity
