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1080 Holistic Health Assessment > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Clinical Indicators for Vitals Assessment

A
  • Newly admitted (obtain baseline)
  • As per MD order or facility’s routine (no order needed as a nurse)
  • Pre- and post-surgery or certain procedures
  • Before, during, and after administration of specific drugs
  • As indicated by client condition/response: “I feel dizzy, weird, funny, different”
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2
Q

Pulse

A
  • Slow/fast heartbeat
  • Each ventricular contraction 60mL of blood (stroke volume)
  • Waves travel from aorta through distal artery ends
  • Accesses rate (bpm), rhythm, strength & symmetry
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3
Q

Bradycardia

A
  • heart rate below 60bpm
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4
Q

Tachycardia

A
  • Heart rate above 100bpm
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5
Q

Pulse Deficit Discrepancy

A
  • Difference of bpm in different pulse locations
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6
Q

Asystole

A
  • No heart contractions
  • Dead?
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7
Q

Arrhythmia

A
  • Heart rate outside regular range
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8
Q

LUB Heart Sound

A
  • signals beginning of systole contraction (blood pushed out of heart)
  • Loudest at apex or lower left sternal boarder
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9
Q

DUB Heart Sound

A
  • Signals beginning of diastole relaxation phase (heart fill with blood)
  • Loudest at base (top of heart)
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10
Q

Heart Sounds

A
  • Blood movement is silent
  • Listen to sounds of valve closing after blood passes
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11
Q

Palpation of Heart Rate

A
  • Best heard at 5th intercostal space at mid clavicular line
  • Below nipple (men) & above bra wire line (female)
  • Apex, point of maximum impulse (PMI)
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12
Q

Apical Pulse

A
  • above heart apex
  • Check if radial pulse is irregular, uncertainty or pulse deficit
  • Difficult to check in children
  • Always check in infants <2
  • Monitor during administration of drugs that alter heart rate (digoxin/lanoxin)
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13
Q

Auscultation of Heart Rate

A
  • Use diaphragm of stethoscope
  • Apex of heart 4/5th intercostal space
  • Listen for LUB & DUB
  • Count LUB sounds for 60 seconds
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14
Q

Distal Pulse Sites

A
  • Temporal
  • Carotid (side of neck)
  • Brachial (inner side of biceps)
  • Radial (inner wrist under thumb line)
  • Femoral (near pelvic bone)
  • Popliteal (behind knee)
  • Posterior tibial (lower limb calf)
  • Dorsalis pedis (over instep of food)
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15
Q

Radial Pulse

A
  • Take on adults & children 3+
  • Most accessible
  • Located inside wrist on thumb line
  • Excess pressure will obliterate pulse
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16
Q

Rhythm of Radial Pulse

A
  • Count for 30 seconds multiple by 2 for bpm
  • Unexpected finding at radial listen to apical site for 30 seconds
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17
Q

Newborn Pulse

A
  • 120bpm
  • Range 70-190
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18
Q

Toddler Pulse

A
  • 110bpm
  • Range 80-130
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19
Q

Child Pulse

A
  • 95bpm
  • Range 70-115
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20
Q

Preteen Pulse

A
  • 90bpm
  • Range 65-110
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21
Q

Teen Pulse

A
  • 80bpm
  • Range 55-105
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22
Q

Adult Pulse

A
  • 70-75bpm
  • Range 60-100
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23
Q

Elite Athlete Pulse

A
  • 50-60bpm
  • Range 50-100
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24
Q

Pulse Influencing Factors

A
  • Age, younger = faster
  • Gender, men faster
  • Exercise, increased oxygen needs = faster
  • Medications faster/slower
  • Fever, increased metabolic need = faster
  • Hemorrhage, loosing blood = faster
  • Stress, increased fight/flight = faster
  • Body position change, pump blood further = faster
  • Pain, SYN response = faster
  • Heart/respiratory contractions faster/slower
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25
Q

Pulse Documentation

A
  • Strength (amplitude) 0-4
  • 4 bounding, 3 full & increased, 2 normal, 1 diminished, 0 absent
  • Rhythm (different volumes)
  • Rate, bpm (2x30secs)
  • Symmetry/location
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26
Q

Blood Pressure

A
  • Pressure within arteries while pumping blood (how hard heart is working)
  • Forced exerted on walls of artery under pressure from heart
  • Indicator of cardiovascular health
  • Access same time as pulse
  • Measured in mmHg on sphygmomanometer
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27
Q

Systolic Blood Pressure

A
  • peak of maximum pressure with ejection/contraction
  • top number
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28
Q

Diastolic Blood Pressure

A
  • minimum pressure exerted with relaxation
  • bottom number
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29
Q

Contributing Factors of Blood Pressure

A
  • Cardiac output
  • Peripheral vascular resistance
  • Viscosity
  • Elasticity of vessel walls
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30
Q

Hypertension (HTN)

A
  • High blood pressure
  • 140+
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31
Q

Diurnal Rhythm

A
  • Varies throughout day
  • Higher in AM
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32
Q

Hypotension

A
  • Low blood pressure
  • Below 90/60
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33
Q

Orthostatic Postural Hypotension

A
  • Caused by change in body position
  • Sustained drop in blood pressure
34
Q

Pulse Pressure

A
  • Difference between systolic & diastolic pressure
35
Q

Shock

A
  • Heart failure
  • Decreased/narrow pulse pressure
36
Q

Assessment of Blood Pressure

A
  • Use cuff
  • 2/3 circumference of upper arm
  • Too tight, artificially increase reading
  • Too loose, artificially decrease reading
37
Q

Technique of Blood Pressure Assessment

A
  • calmly seated for 5 minutes
  • Back supported with chair
  • Bare arm/thing clothing
  • Arm supported at level of heart
  • Feet on floor
  • Uncrossed legs
  • No talking prior to or during procedure
38
Q

Measurement of Blood Pressure

A
  • Palpitate brachial artery
  • Systolic over diastolic
  • Inflated cuff stops arterial blood flow
  • Silent blood flow when artery no longer compressed
  • 1st beat systolic
  • Last beat diastolic
39
Q

Newborn Blood Pressure

40
Q

Infant Blood Pressure

41
Q

Toddler Blood Pressure

42
Q

Child Blood Pressure

43
Q

Preteen Blood Pressure

A
  • 102/61mmHg
44
Q

Teen Blood Pressure

A
  • 112/64mmHg
45
Q

Adult & Elite Athletes

A
  • <120/80mmHg
46
Q

Risk Assessment for Blood Pressure

A
  • Low risk 120/80
  • Medium risk 121-139/80-89
  • High risk 140+/90+
  • Hypotension <90/<60
47
Q

Influencing Factors of Blood Pressure

A
  • Age up/down
  • Stress up
  • Medications up/down
  • Ethnicity (up for Asian, indigenous & black)
  • Gender up men after puberty & women in menopause
  • Diurnal variations (daily fluctuations, higher in morning)
48
Q

Temperature

A
  • Result of difference between heat produced by metabolism & lost through skin
  • Normal body temp 37C
49
Q

Rectal Temperature

A
  • Core temperature
  • Red probe
  • 37-37.5C
  • Under 6 months
50
Q

Tympanic (ear)

A
  • Core temperature
  • 36-37.5C
51
Q

Temporal (forehead)

A
  • Surface temperature
  • 36.5-37.5C
52
Q

Oral Temperature

A
  • Surface temperature
  • Blue probe
  • 36.5-37.5
53
Q

Axilla (armpit)

A
  • Surface temperature
  • 35.9-37.2
54
Q

Temperature Accuracy

A
  • Hot/cold drink in last 30 mins
  • Chewing gum or smoking in last 30 mins
  • Wait 10-15 minutes for accurate reading
  • Posterior mouth, under tongue near back molars
55
Q

Influencing Factors of Temperature

A
  • Age
  • Exercise
  • Hormone levels
  • Circadian rhythm
  • Environment
  • Stress
56
Q

Temperature of Fever

57
Q

Febrile

58
Q

Afebrile

A
  • absence of fever
59
Q

Pyrogen

A
  • bacteria/virus causing fever
60
Q

Antipyretic

A
  • fever treatment medication
61
Q

Diaphoresis

A
  • Movement of air between lung passages
  • Access rate, rhythm, depth & effort
62
Q

Diffusion

A
  • gas exchange in body
63
Q

Perfusion

A
  • flow of air in & out of bronchi
64
Q

Assessment of Respirations

A
  • Rate, # of inspirations/expirations per 30 seconds
  • Rhythm, regularity of inspirations/expirations
  • Depth/effort, degree of movement of chest wall
  • Count ins/exps for 30 secs multiple by 2 (60 secs for children/abnormal)
65
Q

Tachypnea

A
  • Faster than 20 breaths per minute
66
Q

Bradypnea

A
  • Slower than 12 breaths per minutes
67
Q

Dyspnea

A
  • Difficulty breathing
  • No pain
68
Q

Apnea

A
  • Lack of breathing
  • Irregular rhythm
69
Q

Newborn Respirations

A
  • 30-40 per minute
70
Q

Infant Respirations

A
  • 20-40 per minute
71
Q

Toddler Respirations

A
  • 25-32 per minute
72
Q

Child Respirations

A
  • 20-26 per minute
73
Q

Preteen Respirations

A
  • 18-26 per minute
74
Q

Teen Respirations

A
  • 12-22 per minute
75
Q

Adult Respirations

A
  • 12-20 per minute
76
Q

Elite Athlete Respirations

A
  • 10-20 per minute
77
Q

Influencing Factors of Respirations

A
  • Young age, up
  • Exercise, up
  • Hypothermia, down
  • Anxiety, up
  • Smoking, up
  • Upright body position, down
  • Opioid/narcotic use, down
  • Medical conditions (anemia), up
78
Q

Oxygen Saturation (SpO2)

A
  • Indirect measurement of O2 in blood
  • Infrared light passes through tissues to read blood cells
  • Determines amount of red blood cells stock with O2 in %
  • Reveals oxygenation issues
  • Also measures pulse (inaccurate)
79
Q

Regular Oxygen Saturation

80
Q

Underlying Lung Disease Oxygen Saturation

81
Q

Measuring Oxygen Saturation

A
  • Finger fully in probe
  • Light against nail bed
  • Hand steady (hold if shakey)
82
Q

Influencing Factors of Oxygen Saturation

A
  • Carbon monoxide poisoning
  • Smoke inhalation
  • Restless, agitated, moving
  • Nail polish/artificial nails
  • External light sources
  • Intravascular imaging dyes
  • Jaundice
  • Peripheral edema (fluid swelling in hands/fingers)

1080 Holistic Health Assessment (5 decks)

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