Vital Signs Flashcards
why do vital signs need to be accurate
because therapeutic action could be taken from vital signs
what is the order to report vital signs
temp
pulse
respiration
BP + mean
pain
O2 (SpO2 & FiO2)
what is elder speak
infantilizing communication
ex: sweetie, dearie, honey
why do we not want to use elder speak
it conveys a message of incompetence of the receiver and dominance of the speaker over the elder
elder speak leads to what in patients with dementia
resistance to care which disrupts nursing care
when to assess vital signs in acute care settings
admission
institutional policy
change in a patents condition
before and after surgical or invasive diagnostic procedures
before and/or after certain medications
before and/or after activity in certain cases
why would it be important to assess vital signs before medication
some medication can lower or increase certain metabolic functions
EX: some medications lower heart rate and shouldn’t be given if heart rate is already low
why is it important for nurses to know textbook normal and patients normal
because somethings that are abnormal may be normal for the patient
EX: a runner could normally have a resting heart rate of 40, that is textbook very bradycardia but for this patient since he is a runner it explains he has a low resting heart rate
nursing process
ADPIE
assessment
diagnosis
planning
implementation
evaluation
assessment of VS requires you to make
judgments about the means of measurement, equipment, and frequency
you see a nursing student take a blood pressure with gloves on, why would this be wrong
unless there is a precaution or bodily fluids present we want to provide touch which shows care
normal oral temp
35.8-37.5
normal pulse rate
60-100
normal respirations
12-20
normal blood pressure
lower than 120/80
what are some factors that affect body temp
circadian rhythms (lower morning, higher afternoon)
Age (elderly will be less bc of hypothalamus and low amounts of sub)
Gender (men are lower)
physical activity (raises)
environmental temp
what is the primary source of heat production
metabolism
what is the primary source for heat loss
skin
what are some ways to take core temp
rectal
tympanic
temporal artery
pulmonary artery
bladder
esophagus
when you have a rectal temp should you add or subtract a degree
subtract
who do you not give a rectal temp to
heart problems (stimulates vagus nerve and drops HR)
kids
low WBC (neutropenic)
decrease platelets
surface temp sites
oral
axilla
skin surface chemical strips
when you have an axillary temp should you add or subtract a degree
add
when you add or subtract a degree do you chart it with that change
no chart the actual temp
what probe is for rectal temp
red
what do you apply to the thermometer before inserting the rectal thermometer
lubricant
what probe is for the oral/axillary
blue
afebrile
without fever
febrile
fever/temp
pyrexia
temp/fever
what are some physical effects of fever
decreased appetite
headache
hot skin
flushed face
thirst
muscle aches
fatigue
fever blisters
what should we note for fever in elderly
they may show signs of confusion before temp rises
what should we do for interventions for patients with a fever
MAXIMIZE HEAT LOSS
MINIMIZE HEAT PRODUCTION
how do we maximize heat loss
remove heavy blankets
keep clothing and linens dry (otherwise could lead to chills)
cool compresses
ice pack
cooling blanket
how do we minimize heat production
limit physical activity
what is radiation
energy that comes from a source and travels through space at the speed of light
what is convection
process by which heat is transferred by movement of a heated fluid such as air or water
what is evaporation
liquid into vapor
what is conduction
the process by which heat energy is transmitted through collisions between neighboring atoms or molecules
can we hear the peripheral artery
NO only palpate
what is the only place we can hear the heart
apical
lub/dub is a count of
1
what are the 3 characteristics of the peripheral pulse
rate
rhythm
amplitude
what is the amplitude 4 point scale
4+ bounding
3+ stong
2+ moderate
1+ weak
0 absent
what is the rhythm result
regular/irregular
where could you palpate a peripheral artery
temporal
carotid
brachial
radial
femoral
popliteal
posterior tibial
dorsalis pedis
where do you go to find to ausculate the apical pulse
5th intercostal space/ mid clavicular line
why do we not take pulse with thumb
thumb has a vein/artery in it so it has its own pulse
tachycardia
fast HR
over 100
bradycardia
slow HR
less 60
pulse deficit
difference between apical and peripheral
if we have a apical pulse of 88 and a peripheral of 88 what’s the pulse deficit
0/none
if we have a apical pulse of 88 and a peripheral of 80 what’s the pulse deficit
8
if we have a apical pulse of 85 and a peripheral pulse of 88, why does that not make sense?
because the heart is the source of pumping so we have to have apical higher or equal to the peripheral
how many people do you need to complete a pulse deficit
2
when we are inspecting respirations what are we looking for
rate
depth
rhythm
work of breathing
symmetry
hypoventilation
low rate and shallow depth
hyperventilation
fast rate and increase depth
dyspnea
difficulty breathing
what does DYS mean
difficulty
tachypnea
fast
orthopnea
difficulty breathing when laying flat
apnea
no breathing
what does ‘a’ mean
without
blood pressure systolic is the
highest pressure on arterial walls
contraction of the ventricles
blood pressure diastolic is the
lowest pressure on arterial walls
ventricles at rest
what numbers are classified as elevated blood pressure
systolic between 120-129
AND
diastolic between 80-89
what numbers are classified as stage 1 blood pressure
systolic 130-139
OR
diastolic 80-89
what would be told if you have stage 1 blood pressure
lifestyle changes should begin at 130/80
medication if patient is at risk for CV event
what numbers are classified as stage 2 blood pressure
systolic at least 140
OR
diastolic at least 90
what numbers are classified as hypertensive crisis
systolic over 180
AND/OR
diastolic over 120
factors that are affecting blood pressure
age (older stiffness of vessel increases BP)
race (AA have increased chance of hypertensive)
circadian rhythm (lower in morning, higher afternoon)
exercise
weight
emotional state (increase BP)
body position (lowest BP: supine flat)
drug medications (all ready hypertensive and take cold medication will increase pressure)
disease processes
cigarette smoking (CO2 causes vasoconstriction)
how much should people reduce salt intake to
less than 2300
if people reduce salt intake to less than 2300 this could reduce cases of high blood pressure by _____ million and save _____ billion health care dollars every year
11, $18
why do we do the 2 step method of blood pressure
so we do not miss the auscultatory gap
what is the first korotkoff sound
systolic
what is the 5th korotkoff sound
diastolic
how do we know where the diastolic sound is at
the point at which all sounds disappear
what artery is the most commonly used for the blood pressure
Brachial
what arm do we not take a blood pressure in
mastectomy, fistula, lymphedema, amputee, IV
what do you do if you take a mobile BP into a isolation room
clean cart
what do you do if the reading indicates hypertension or hypotension
take it again in different arm
what is the pulse of the fistula called
thrill
what is the sound of the fistula called
bruit
a bruit sounds like
whoosing
a bruit is normal in a fistula because it indicates there is blood flow, where is a bruit abnormal
heart
hypotension is classified as
less than 90/60 WITH symptoms
orthostatic hypotension is a decrease of how much
20 systolic
10 diastolic
what is the proper way to check for orthostatic hypotension
lay down for 5 mins BP and pulse
sit for 3-5 mins recheck
stand for 3 mins recheck
what is primary hypertension
cause is unknown
what is secondary hypertension
cause is known, normally secondary to a medical condition
what are all of the numbers in when we take blood pressure
2
what is one advantage to take an automatic blood pressure
do not need a stethoscope
what are the limitations to automatic blood pressure
vulnerable to error in
- arrhythmias
- older adults
- obese extremity
may not work with hypotensive
you need a MAP of ___ or greater to perfuse vital organs
60
what is the normal MAP
70-100
how do you find map
2xdiastolic + systolic divided by 3
pain is ALWAYS
what the patient says
what numbers on numerical scale are mild
1-3
what numbers on the numerical scale are moderate
4-6
what numbers on the numerical scale are severe
7-10
FLACC is used for patients who
cannot communicate
what does FLACC stand for
face
legs
activity
cry
consolability
PAINAD is used for patients with
advanced dementia
if the patient has pain what do we ask if the patient if they say they have pain
onset
location
functional limitations
pain interventions
patients functional goal
how often do you reassess pain
4 hours or sooner
why might someone ask for more pain meds
because they have built up a tolerance
(EX: someone with sickle cell might have built up a tolerance and will need more when in sickle crisis)
SPO2 measures the
amount of hemoglobin saturated with oxygen in arterial blood
SPO2 measures NOT ventilation but
oxygenation
what does FIO2 stand for
fraction of inspired air
why is FIO2 important
because an individual at 88% on oxygen is at more of an emergency than an individual at 88% on room air
what percent of SPO2 is abnormal in everyone
less than 85
HYPOXEMIA
KILLS
if we have a patient who has low SPO2 what is one nursing intervention we can do
raise head of bed which helps lungs expand
what are some factors that interfere with light transmission
outside light sources
carbon monoxide
patient motion
jaundice
dark skin pigmentation may result in signal loss or over estimation of saturation (false high)
why is SPO2 a rough measurement
you could have a 100% SPO2 but only have 6 hemoglobin
what are some factors interfere with arterial pulsations
peripheral vascular disease
hypothermia at assessment site
low cardiac output
hypotension
perisperhal edema
tight probe
arrthythmias
edema
what is the heart rate criteria for rapid response team
over 140/min or less than 40/min
what is the respiratory rate criteria for rapid response team
28/min or less than 8/min
what is the blood pressure criteria for rapid response team
systolic greater than 180 or less than 90
what is the oxygen saturation criteria for the rapid response team
less than 90% despite supplementation
what is another reason to call a rapid response team that is not related to vitals
acute change in mental status
