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Module 1 (Intro To Basics) > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What is the range of normal temperatures?

A

96.8-100.4

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2
Q

What is the normal range of temperatures for an oral/tympanic/temporal thermometers?

A

97.6-99.6

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3
Q

What is the normal temperature range for a rectal thermometer?

A

98.6-100.4

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4
Q

What is the normal temperature range for a axillary thermometer?

A

96.6-98.6

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5
Q

What is the normal range for a pulse?

A

60-100 bpm (Lub-dub = 1 beat)

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6
Q

What are normal levels of O2 Saturation?

A

95-100%

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7
Q

What is a normal blood pressure?

A

120 / 80

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8
Q

What is prehypertension bp?

A

120-139 / 80-89

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9
Q

What is stage 1 hypertension bp?

A

greater than 140 / 90

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10
Q

What is hypotension?

A

less than 90 systolically with symptoms

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11
Q

Normal respiratory rate (Expiration and Inspiration =1)

A

12-20 breaths per minute

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12
Q

When do you measure Vital Signs? (6)

A

admission
pre physician orders
change in patient condition
before/after the procedure
during blood transfusions
after medications that affect VS

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13
Q

Where do you get the core temperature for a patient?

A

Bladder

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14
Q

Where is the regulation of temperature controlled?

A

Neural/Vascular Control : Hypothalamus

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15
Q

The anterior hypothalamus controls the heat _____ by causing the body to ____________.

A

lost; radiation, conduction, convection, evaporation, diaphoresis

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16
Q

The posterior hypothalamus controls the heat _____ by causing the body to ____________.

A

production; BMR and shivering

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17
Q

Radiation

A

transfer heat without direct contact

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18
Q

Conduction

A

transfer of heat with direct contact

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19
Q

Convection

A

transfer heat away by air movement

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20
Q

Evaporation

A

transfer of heat from liquid to gas

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21
Q

Diaphoresis

A

visible persperation

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22
Q

What factors that affect temperature?

A

age
hormonal levels
environment
excercise
circadian rhythm
medication alteration of temp

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23
Q

Pyrexia, Febrile

A

fever

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24
Q

To what degree does a fever turn harmful?

A

102.2

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25
Q

Fever Characteristics

A

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

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26
Q

Hyperthermia

A

inability to promote heat loss or reduce production

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27
Q

Afebrile

A

no fever

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28
Q

FUO

A

Fever of unknown origin

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29
Q

Heatstroke

A

dangerous heat emergency with a high mortality rate
104 +

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30
Q

Heatstroke Signs and Symptoms

A

NO SWEATING
dry, hot skin
confusion, excess thirst, muscle cramps
VS: increase in heart rate with low bp
NO SWEATING

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31
Q

Heat exhaustion

A

diaphoresis = excess water and electrolyte loss
Replace fluids

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32
Q

Hypothermia

A

prolonged exposure to cold, decrease body’s ability of heat
Temperature lower than 86-96.8

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33
Q

Formula F to C

A

C = (F - 32) x 5/9

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34
Q

Formula C to F

A

F = (9/5 x C) + 32

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35
Q

Oral Thermometer

A

easily influenced by hot/cold food wait 30 minutes
most used
approximately one degree lower than core temperature
mercury, glass, or electronic

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36
Q

Rectal Thermometer

A

closest to the core temperature

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37
Q

How far should the nurse place the rectal thermometer into an adult, child, and infant?

A

Adult = 1 1/2 inches
Child = 1 inch
Infant = 1/2 inch

38
Q

If the rectal thermometer is placed in feces, is it accurate temperature?

A

no, inaccurate

39
Q

Axillary thermometer

A

safest and least accurate
moisture may reduce temperature

40
Q

How long does the axillary thermometer need to be in place?

A

5-10 minutes

41
Q

Tympanic thermometer

A

most rapid
unaffected by PO intake
remove hearing aides

42
Q

Temporal thermometer

A

most accurate
fast, easy with few errors

43
Q

What can a nurse do during vital signs
_______ culture
monitor ________ and _______________
conserve _____ and provide _______
bath water is ________
dry ______
________ meds (tylenol)

A

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)

44
Q

What are the parts of a stethoscope called?

A

Earpieces, binaural, tubes, chest piece with bell and diaphragm

45
Q

Pulse definition

A

palpable/audible bounding of blood flow at various points in the body
indirect measure of circulatory status

46
Q

Radial pulse

A

most common routine
used for pt teaching
circulation to hand
assessed with VS pulse

47
Q

Apical pulse

A

located 5th intercostal and mid clavicle
if abnormal radial pulse, check meds and radial inaccessible

48
Q

Carotid pulse

A

only if patient suddenly worsens
pulse quickly
do not measure bilaterally at same time

49
Q

Doralis Pedis

A

top of foot between 1st and 2nd toes or ankle
circulation to foot
via doppler if no palpation
do both at the same time

50
Q

Pulse Characteristics

A

Rate (baseline, if abnormal try apical)
Rhythm (regular, irregular, dysrhythmia)
Strength (4,3,2 (normal), 1, 0)
Equality

51
Q

What pulse strength is normal?

A

2

52
Q

Gas Exchange

A

moving air in or out (inspiration and expiration)

53
Q

Where is gas exchanged?

A

Alveoli

54
Q

Ischemia

A

insufficient oxygen supply leads to cell injury/death

55
Q

Hypoxia

A

cells don’t have enough oxygen

56
Q

Hypoxemia

A

arterial blood does not have enough oxygen

57
Q

Respiratory Acidosis

A

carbon dioxide stays and causes no oxygen to enter

58
Q

Perfusion

A

swapping of gases at alveoli

59
Q

What do you assess during pulse?

A

rate, rhythm, and depth

60
Q

Eupnea

A

ventilation of normal rate and depth

61
Q

Factors influencing pulse

A

exercise, acute pain, anxiety, smoking, body positions, meds, neuro injury, hemoglobin functions

62
Q

Possible Alterations of Respiration Patterns (-pnea(s))

A

tachypnea
bradypnea
apnea
cheyne-strokes respirations
dyspnea
orthopnea
biot’s respiration

63
Q

Tachypnea (bpm rate)

A

24 bpm or higher

64
Q

Bradypnea (bpm rate)

A

less than 10

65
Q

Apnea

A

life-threatening with no breathing for a period of time

66
Q

Cheyne-strokes Respirations

A

rate and depth increase then apnea

67
Q

Dyspnea

A

difficult breathing or shortness of breath

68
Q

Orthopnea

A

positional breathing laying down

69
Q

Biot’s respiration

A

normal 3-4 breaths with apnea

70
Q

What method is an indirect oxygen saturation?

A

pulse oximetry

71
Q

Pulse Oximetry

A

light absorption with photodetector
SpO2 = SaO2

72
Q

Factors Affecting Pulse Oxygenation

A

too loose/tight device
polished artificial nails
temperature of extremities
movement
lighting
skin pigmentation
edema
peripheral vascular disease

73
Q

Blood Pressure definition

A

force exerted against blood vessels by blood
measured in mmHg

74
Q

Systolic

A

maximum pulse pressure

75
Q

Diastolic

A

minimum pulse pressure

76
Q

Physiology Factors of BP

A

cardiac output (volume of blood)
peripheral resistance (plague)
blood volume
viscosity
elasticity

77
Q

Korotkoff Sounds in Phases

A

1- sharp thump (systolic)
2- blow/whooshing
3-crisp, intense tap
4-soft blowing fades (diastolic)
5-silence

78
Q

Steps of BP

A

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

79
Q

Ideal Environment for BP

A

quiet sitting
record both arms initially
same arm everytime
avoid IVs
rest 5 minutes before assessment
ask not to speak

80
Q

Factors Affecting BP

A

age, stress, ethnicity, gender, daily variation, meds, activity, weight, smoking
White Coat Syndrome

81
Q

Hypertension effects

A

major factor in underlying stroke
contributes to heart attacks
No symptoms

82
Q

Hypotension symptoms

A

skin molting, clammy, confusion, increase heart rate, decrease in urine output

83
Q

Automatic BP machines

A

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%

84
Q

Hypertension signs

A

thicken of walls
loss of elasticity
family history
risk factors

85
Q

Hypotension signs

A

systolic less than 90
dilation of arteries
loss of blood volume
decrease in blood flow to organs
orthostatic/postural

86
Q

Alternative BP sites

A

thigh (systolic raises by 10-40, but diastolic is same)
Arterial line

87
Q

Pain Mnemonic
PQRST

A

Provokes/palliative: worst or better
Quality: type
Region/radiation: where
Severity/Setting
Timing: time of day

88
Q

Pain Severity Scale 0-10
None =
Mild =
Moderate =
Bad to Worst =

A

0
1-3
4-6
7-10

89
Q

When do you assess pain?

A

Before procedures, activity, and medication
30 minutes after pain meds
After procedures, activity

90
Q

T/F:
Always assume what the patient says and don’t assume their pain levels.

A

True

91
Q

When do you assess pain?

A

Before procedures, activity, and medication
30 minutes after pain meds
After procedures, the activity

Module 1 (Intro To Basics) (32 decks)

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