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Vital Signs > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Factors that affect VS

A

Medications
Illness/infection
Exercise/stresw
Age
Hypovolemia/dehydration
PO intake
Hormones
Circadian rhythm

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2
Q

Medications

A

Antipyretic such as acetaminophen decrease temp
Opioids such as morphine decrease resp rate
Antihypertensives such as atenolol decrease blood pressure and many decrease pulse
Cardiac glycosides such as digoxin can decrease pulse

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3
Q

Illness/infection

A

Can cause increased pulse, resp rate, bp
Infection causes increased pulse
Sepsis causes increased pulse and decreased bp

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4
Q

Exercise/stress

A

Increased metabolism temporarily increased temp,pulse,resp,bp
Postural changes can increase P and decrease BP

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5
Q

Age

A

Older adults and infants temp regulation is less effective

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6
Q

Hypovolemia/dehydration

A

Hemorrhage caused decreased bp and increased pulse same with dehydration

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7
Q

Environment

A

Visit to health care provider can increase BP, hot/cold environment can impact T

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8
Q

PO intake

A

Hot/cold beverages, smoking, etc can alter Temp, smoking, caffeine, heavy drinking can increase BP

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9
Q

Hormones

A

Ovulation can change T
Thyroid hormones cause increase in metabolic rate thus increase T and P

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10
Q

Circadian rhythm

A

T and BP can slightly fluctuate based on time of day

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11
Q

Why is it important to note VS

A

Important to note both negative and positive changes:
Can tell if a health status is declining or improving
Can tell if an intervention is working

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12
Q

Interpret

A

Assess in relation to other VS, clinical manifestations S&S, medical history, lab values

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13
Q

Temp average

A

36-38

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14
Q

Temp sites

A

Oral, axillary, temporal, tympanic, rectal
Skin tape, non contact
Core temp: pulmonary artery

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15
Q

Oral

A

Avg: 37
Most frequently taken
Easily accessible and comfortable
Must wait 20 minutes or chose another site if client has taken hit or cold foods/fluids, chewed gum, or smoked
Do not use on patient who have had oral surgery, facial trauma, very young, unconscious, confused, or uncooperative

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16
Q

Axillary

A

Avg: 36.5
Second most used
Takes longer to obtain reading
Often used in newborns and children
Accuracy effected by recent bathing, sepsis, surgery and sweating
If client is sweating wipe axilla prior to taking

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17
Q

Temporal

A

Avg: 37
Uses scanner probe to obtain infrared readings of temporal artery blood flow
Non-invasive and fast
Avoid any scar tissue, open abrasions or sores
Readings affected by diaphoresis and air flow across face

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18
Q

Tympanic

A

Avg: 37
Detects heat radiation from tympanic membrane using infrared sensor
Used less=prone to error such as incorrect straightening of ear canal, gettting a good seal, dirty lens
Affected by patients different sized and shaped ear canals, amount of cerumen as well as if they talk or yawn
Pull pinna down and back for ages 3 or less

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19
Q

Rectal

A

Avg: 37.5
Rarely used
Considered accurate but not convenient and uncomfortable/may be damaging to rectal tissue
Vagus nerve stimulation can cause bradycardia and synscope fainting
Need to be sure probe is not placed in feces
Contraindicated in infants and children, rectal surgery, disease, diarrhea, hemorrhoid, bleeding disorders, cardiac conditions, spinal injury, uncooperative clients

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20
Q

Skin tape or chemical disposable

A

Rarely used
Not very reliable
Contain liquid crystals that change colour according to temp

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21
Q

Non-contact

A

Newest
Used for covid 19

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22
Q

True core

A

Measures T of deep tissues
More closely represents T of internal organs
Is most accurate
Invasive, inconvenient, often unavailable
Used only in critical care and intraoperatively
Optimal core temp 36.5-37.5
Pulmonary artery catheter is best
T sensing foley in bladder and probe in esophagus are other methods

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23
Q

Alterations in temp

A

Pyrexia
Hyperthermia
Fever
Hyperpyrexia
Febrile, afebrile
Hypothermia

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24
Q

Thermoregulation

A

Process that allows your body to maintain its internal core temp

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25
Q

Thermoreceptors

A

The body’s cold and warm temp receptors, send messages to hypothalamus

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26
Q

Hypothalamus

A

Part of brain responsible for thermoregulation, goal is to restore homeostasis

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27
Q

Homeostasis

A

Bringing internal T back to normal range

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28
Q

Too hot

A

Body increases capillary blood flow through vasodilation which allows blood closer to surface and results in sweating = decreased T
Sweating is body’s only mechanism to dissipate heat when environment warmer than core temp

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29
Q

Too cold

A

Body cells increase metabolic rate to increase heat production and blood vessels constrict to keep blood away from surface and core warm to conserve energy
Shivering (an involuntary contraction of muscles) occur to generate additional heat

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30
Q

Pyrexia

A

Fever
Occurs when the heat-loss mechanisms are unable to keep pace with excess heat production

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31
Q

Hyperthermia

A

T is elevated but it is a result of the body’s inability to promote heat loss or reduce heat production (an overload of the thermoregulatory mechanisms)

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32
Q

Febrile

A

If a client has elevated T they are febrile (above average temp is not called febrile, the client is called febrile
Increase T by heat exhaustion, heat stroke, virus, bacterial infection, sunburn
Treatment depends on cause and may include fluids, tepid bath, cooling blanket, anti-pyretics

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33
Q

Hypothermia

A

Occurs when core T is 36 or less
Can be mild or severe
Can be unintentional or medically induced (eg cooling protocol post MI)
Treatment can include warm IV, blanket warmer

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34
Q

Alterations In temp can indicate

A

Infection
Inflammatory response
Deteriorating client
Thermoregulatory disorders

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35
Q

Pulse

A

Radial
Apical
Brachial

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36
Q

Radial

A

Assessed by palpation
30 secs if normal, 60 if abnormal
Normal 60-100 per minute, regular rhythm, 2+ equal bilaterally

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37
Q

Pulse scale

A

0 (absent)
1+ (weak/thready)
2+ (strong)
3+ (full/increased)
4+ (bounding, difficult to obliterate)
If unequal bilaterally = impaired circulation to one side

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38
Q

Apical

A

Assessed by auscultation
Always needs to be assessed for full 60 secs
Needs to be assessed at PMI (Erbs points 3rd intercostal space L stern also boarder)

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39
Q

Brachial

A

Assessed by palpation but not usually counted for rate

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40
Q

Apical-radial pulse deficit

A

Difference between apical and radial pulse rates
Occurs when the pulse wave is not transmitted such as when someone has an arrhythmia

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41
Q

Respiration’s

A

Act of breathing addition of O2 and removal of CO2
Resp centre in brain stem driven primarily by CO2 levels
Ventilation, perfusion, diffusion
Mechanical ventilation sometimes used to assist
Perfusion involves cardio system ability to pump oxygenated blood to the body’s tissues and return unoxygenated blood to lungs
Diffusion responsible for the movement of molecules back and fourth

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42
Q

Inspiration

A

Active process with signals from brain causing diaphragm to contract and ribs to retract upward
Main muscles used are diaphragm and intercostal muscles

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43
Q

Exhalation

A

Passive
Expelling CO2
Diaphragm, lungs, chest wall return to their relaxed positions

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44
Q

Cardio output

A

HR x SV

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45
Q

Average pulse

A

60-100

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46
Q

Alterations in pulse

A

Tachycardia
Bradycardia
Arrhythmia/dysrhythmia
Pulse deficit

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47
Q

What causes pulse

A

When blood is pumped out of left ventricle that forceful contraction produces a pulse wave that is transmitted through the arteries to the periphery of the body
May be palpated where an artery is close to the surface of the skin, and over a bone or firm surface that supports the artery

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48
Q

CO

A

Volume of blood pumped in one minute
Approx 5L of blood a minute is pumped

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49
Q

HR

A

Number of beats per minute

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50
Q

Stroke volume

A

Amount of blood that enters the aorta with each ventricular contraction
Avg: 60-70ml

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51
Q

If pulse significantly increases, decreases or becomes irregular

A

Alters cardiac output
Increasing HR or pulse is the first compensatory mechanism the body used to maintain adequate CO
Body can increase SV by pumping more forcefully or increasing amount of blood that fills the left ventricle before it pumps

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52
Q

Tachycardia

A

Abnormally fast HR
Greater than 100 bpm
Increased pulse can be caused by exercise, fever and heat, anxiety, stress, acute pain, meds such as epinephrine, hemorrhage, postural changes, diseases such as asthma, COPD, CHF

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53
Q

Bradycardia

A

Slow HR less than 60bpm
Can be caused by long term exercise, hypothermia, relaxation, medications such as digoxin, lying down , hypothyroidism, cardiac conduction block

54
Q

Arrhythmia/dysrhythmia

A

Irregular heart rhythm
Places individuals at risk as it may cause an inadequate cardiac output

55
Q

Pulse deficit can be caused by

A

Cardiovascular disease
Atrial fibrillation
Aflutter
Heart block
Premature ventricular contractions

56
Q

Assessment of resps include

A

Rate: if regular count 30 secs 12-20
Depth: normal deep or shallow
Rhythm: regular or irregular
Quality: effortless/silent, or dyspnea/orthopnea

57
Q

Eupnea

A

Normal breathing
12-20, effortless, automatic, quiet and regular
Resp rate strong predictor of adverse events

58
Q

Newborn resp

A

30-60
RR gradually slows fill the normal adult rate

59
Q

Factors affecting resp

A

Exercise, age, acute pain, anxiety, smoking, body position, meds, neurological injury, hemoglobin function, fever

60
Q

Tachypnea

A

Fast rate of breathing over 20 breaths per minute

61
Q

Bradypnea

A

Slow rate of breathing under 12 breaths per minute

62
Q

Hyperventilation

A

Rapid and deep respiration’s which may result in hypocarbia (decreased CO2)

63
Q

Hypoventilation

A

Slow and usually shallow breathing which may result in hypercarbia (increased CO2)

64
Q

Dyspnea

A

Difficult/laboured breathing, breathlessness, an unsatisfied need for air. Clinical manifestation of hypoxia

65
Q

Orthopnea

A

Ability to breath only upright, standing or in tripod position, need serval pillows to sleep at night or need head of bed to be elevated

66
Q

Oxygen saturation

A

Avg adult 95-100%
Under 70% life threatening
Sensor placed on finger, toe, nose, earlobe

67
Q

Pulse oximetry

A

Measures the ratio of oxygen in the blood combined with hemoglobin to the total amount of oxygen that the hemoglobin molecule can carry

68
Q

Things that affect o2 measurement

A

Nail polish
Impaired circulation
Movement such as shivering
Severe anemia (may have good readings however as their amount of hgb is inadequate they are still hypoxia)
Carbon monoxide can trick into providing a good reading because co attached to Hgb in oxygens spots and the oximeter is unable to differentiate between the two molecules

69
Q

Hypoxia

A

Inadequate tissue oxygenation at the cellular level
Can be caused by anemia

70
Q

Hypoxemia

A

Below normal level of oxygen in your blood, specifically in your arteries
From COPD

71
Q

What is bp

A

Pressure exerted on arterial walls by the force of the hearts contraction
Pressure rises and falls during the cardiac cycle

72
Q

Where is pressure highest

A

In the ventricles and decreased as the distance from the heart increases

73
Q

Why is adequate bp required

A

For perfusion of all the body tissues with oxygenated blood, transportation of essential nutrients, and removal of waste materials by the liver, kidneys, and lungs

74
Q

Systole/systolic bp

A

Top or bigger number, highest pressure on the arterial walls and occurs during heart contraction

75
Q

Diastole/diastolic

A

Lower or smaller of the two numbers, the lowest pressure in the arteries during the brief rest period

76
Q

Pulse pressure

A

Difference between systole and diastole and is normally 30-50mmHg

77
Q

Consistently high/wide pulse pressure

A

Can be a result of arteriosclerosis, increased ICP, fever, pregnancy, anxiety, endocarditis, heart block, anemia

78
Q

Consistently low/narrow pulse pressure

A

Can result from blood loss, low stroke volume, heart failure, shock

79
Q

Procedure of measuring BP

A
  1. Position client
  2. Find brachial artery
  3. Measure bp cuff and apply
  4. Preform palpatory
  5. Place stethoscope over brachial
  6. Obtain reading
  7. Document and inform client
80
Q

Cuff is inflated

A

To a pressure greater than the arterial blood flow, blood returns to brachial artery and produces sounds

81
Q

Bp sounds

A

Korotkoff sounds

82
Q

Phase 5

A

Diastolic value
Absence of sound

83
Q

Position

A

In order to determine future treatment in relation to BP important to compare values in a consistent position and on the same arm

84
Q

Apply bp cuff

A

2.5-3cm above antecubital fossa 40/80 rule

85
Q

Auscultatory gap

A

Temporary disappearance of sound often between first and second phase, can occur and may last up to 40mmHg may cause systolic reading to be underestimated
Why we do palpatory
Often occurs with hypertensive clients as a result of arteriosclerosis and can lead to a missed diagnosis of hypertension

86
Q

Last sound

A

Take last sound heard and subtract 2mmHg

87
Q

Why not use arm in bp

A

If client has had a mastectomy on same side may cause lymphedema leading to aching, discomfort
Also cannot use are that has a dialysis fistula or graft, an iv infusion, if arm is painful or swollen and if there is a cast or injury

88
Q

Alternative sites for bp

A

Radial artery
Posterior tibial artery
Popliteal artery

89
Q

Bladder length

A

Covers 80%-100%

90
Q

Bladder width

A

40%

91
Q

Cuff too small

A

False high

92
Q

Cuff too big

A

False low

93
Q

Optimal bp

A

120/80

94
Q

Normal bp

A

Less than 130/85

95
Q

Hypertension

A

135/85

96
Q

Hypotension

A

Systolic less than 90

97
Q

Bp value

A

One bp alone does not give enough data , needs to be several bp’s to diagnose something like hypertension

98
Q

Factors that affect bp

A

Age
Sex
Stress
Ethnicity
Daily variations
Medications
Activity
Weight
Smoking
Pyrexia
Diabetes
White coat syndrome

99
Q

Hypertension

A

Significant risk factor for CVA, CAD, CHF, PVD, renal failure

100
Q

Clinical manifestations HTN

A

Often silent killer
May get headache, ringing in ears, flushed face, nosebleeds, fatigue

101
Q

Hypotension

A

May occur due to hemorrhage, MI

102
Q

Clinical manifestations hypotension

A

Pallor, mottling, clamminess, confusion, increase hr, decreased urine output

103
Q

Orthostatic hypotension

A

Postural hypotension
Important to assess as it leads to falls
Drop of 20mmHg or more in systolic or 10mmHg or more in diastolic within 3 mins of the client rising

104
Q

Direct vs indirect bp

A

Indirect = non invasive sphygmomanometer or automated bp machine
Direct = invasive obtained by using an arterial line needle or catheter into brachial, radial, or femoral artery and the reading is displayed on a monitor
Only in ICU

105
Q

Shivering

A

Monitor when reducing heat not to cause shivering as it increased core temp

106
Q

Hyperthermia symptoms

A

Decreased skin turgor
Dry mucous membranes
Tachycardia
Hypotension
Decreased venous filing
Concentrated urine

107
Q

Heatstroke symptoms

A

Body temp of 40 or more
Hot
Dry skin
Tachycardia
Hypotension
Excessive thirst
Muscle cramps
Visual disturbances
Confusion
Delirium

108
Q

Hypothermia symptoms

A

Pale skin
Skin cool or cold
Bradycardia
Dysrhythmias
Shallow respiration’s

109
Q

Older person temp

A

At lower end 36
Temps considered within normal range often reflect fever in an older person

110
Q

Pulse sites

A

Temporal (above and lateral to eyebrow)
Carotid ( along medial edge of sternocleidomastoid in neck)
Apical
Brachial
Radial
Ulnar
Femoral
Popliteal
Posterior tibial
Dorsalis pedis

111
Q

Risk factors for pulse alterations

A

History of heart disease
Cardiac dysrhythmia
Onset of sudden chest pain or acute pain
Invasive cardiovascular diagnostic tests
Surgery
Sudden infusion of a large volume of iv
Internal or external hemorrhage
Meds

112
Q

Signs and symptoms of altered cardiac function

A

Dyspnea
Fatigue
Chest pain
Orthopnea
Syncope
Palpitations
Edema
Cyanosis
Pallor

113
Q

Symptoms of peripheral vascular disease

A

Pale
Cool extremities
Thin shiny skin
Decreased hair growth
Thickened nails

114
Q

If pulse count differs by more than 2

A

A deficit exists

115
Q

S1 S2

A

S1 is sound of tricuspid and mitral valves closing at the end of ventricular filling S2 is sound of pulmonic and aortic valves closing at end of systolic contractions

116
Q

Diffusion

A

Movement of o2 and CO2 between alveoli and rbc

117
Q

Risk factors for resp alterations

A

Fever
Pain
Anxiety
Diseases of lungs or chest wall
Constructive dressings
Abdominal incisions
Gastric distension
Chronic pulmonary disease
Traumatic injury to chest
Presence of chest tube
Resp infection
Pulmonary edema and emboli
Head injury
Anemia

118
Q

Symptoms of resp alterations

A

Cyanosis of skin nail beds lips mucous membrane
Restlessness
Irritability
Reduced levels of consciousness
Pain during inspiration
Laboured breathing
Orthopnea
Use of accessory muscles
Adventitious breath sounds
Inability to breath spontaneously
Thick frothy blood tinged or copious sputum

119
Q

Apnea

A

Resps cease for several seconds, resistant cessation results in resp arrest

120
Q

Biots respiration

A

Irregular resps varying in depth followed by periods of apnea (associated with CNS disorders)

121
Q

Bradypnea

A

Rate of breathing is regular but abnormally slow (less than 12)

122
Q

Cheyne-stokes resps

A

Rate and depth irregular characterized by alternating periods of apnea and hyperventilating

123
Q

Hyperpnea

A

Resps increase in depth and rate over 20 (occurs during exercise)

124
Q

Hyperventilation

A

Resp increase
Hypocarbia may occur

125
Q

Hypoventilation

A

Rate is abnormally low
Hypercarbia may occur

126
Q

Priority abc

A

Airway, breathing, circulation

127
Q

Radiation

A

Transfer of heat from the surface of one object to the surface of another without direct contact

128
Q

Conduction

A

Transfer of heat from one object to another through direct contact

129
Q

Convection

A

Transfer of heat away from the body by air movement

130
Q

Diaphoresis

A

Visible perspiration

131
Q

Pyrogens

A

Such as bacteria and viruses can rise temp

132
Q

Fever causes

A

Cellular metabolism to increase and oxygen consumption to rise
HR and resp rate increase

Vital Signs (1 decks)

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