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IM1 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are the measurements for vitals?

A

Temp
Pulse
RR
BP
O2

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2
Q

When do we measure VS?

A

On admission
Per orders
Any change in pt’s condition
Before & after a major procedure
During blood transfusion
After meds or interventions that affect VS

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3
Q

What is the normal temp range for rectal temp>

A

Rectal (98.6-100.4)

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4
Q

What is normal range for axilla temp?

A

-Axilla (96.6-98.6

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5
Q

What is the normal range for oral/tympanic/temporal temp?

A

Oral/tympanic/temporal (97.6-99.6)

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6
Q

What is the normal VS ranges for Adults

A

Temp (96.8 - 100.4)
-Oral/tympanic/temporal (97.6-99.6)
-Rectal (98.6-100.4)
-Axilla (96.6-98.6
Pulse: 60-100 bpm
RR: 12-20 RR
BP: less than 120/80 mmHg

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7
Q

What is the Pre-hypertensive range for BP?

A

Systolic: 120-139
Diastolic: 80-89

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8
Q

What is the Hypertensive range for BP?

A

Systolic >140
Diastolic >90

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9
Q

What is the Hypotensive range for BP?

A

Systolic < than 90 & symptomatic

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10
Q

What does temp measure?

A

heat produced & heat lost

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11
Q

What are temp sites?

A

Oral, rectal, axially, tympanic membrane, temporal artery, esophageal, pulmonary artery, urinary bladder

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12
Q

What regulates temp via neural & vascular control?

A

anterior/posterior hypothalmus

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13
Q

What regulates temp for heat production?

A

BMR
Shivering

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14
Q

What regulates temp for heat loss?

A

Radiation
Conduction
Convection
Evaporation
Diaphoresis

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15
Q

What regulates temp for skin?

A

Insulation
Vasoconstriction
Sensation

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16
Q

What does radiation mean?

A

Radiation - transfer of heat from surface of one object to surface of another without direct contact between the two

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17
Q

What is conduction?

A

Conduction - transfer of heat from one object to another with direct contact

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18
Q

What is convection?

A

Convection - transfer of heat away by air movement

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19
Q

What is evaporation?

A

Evaporation - transfer of heat energy when a liquid is changed to a gas

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20
Q

What is diaphoresis?

A

Diaphoresis - visible perspiration

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21
Q

What are factors that affect body temp?

A

Age
Hormonal Level
Environment
Exercise
Circadian Rhythm
Temperature Alterations

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22
Q

Alterations in Temperature: Fever (Pyrexia)

A

Usually not harmful if below 102.2°F
Important defense mechanism
Temp should be taken several times throughout day
Results from an alteration in the hypothalamic set point.
Causes increase in metabolism and oxygen consumption
Increased heart rate and respiratory rate

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23
Q

Temperature Alteration - High:
Hyperthermia

A

Inability to promote heat loss or reduce production

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24
Q

Temperature Alteration - High
Heatstroke

A

Dangerous heat emergency/high mortality rate
Body temp 104°F or more

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25
Q

Signs and Symptoms of a heat stroke

A

Most important: dry, hot skin
Confusion, excess thirst, muscle cramps
Vital signs: Increased HR, decreased B/P
No sweating

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26
Q

Temperature Alteration - Low
Heat Exhaustion

A

Diaphoresis results in excess water and electrolyte loss
Need to replace

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27
Q

Temperature Alteration - Low
Hypothermia

A

Prolonged exposure to cold decreases body’s ability to produce heat
Can be accidental or intentional
Temps <86-96.8

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28
Q

How do we convert from Fahrenheit to Celsius?

A

C=(F - 32) x 5/9

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29
Q

How do we convert from Celsius to Fahrenheit?

A

F=(9/5 x C) + 32

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30
Q

Assessment of Temperature
Oral Temperature

A

Temperature easily influenced by hot or cold foods
One of the most frequently used methods of attaining temperature
Approximately one degree lower than core temp.
May be glass (mercury) or electronic

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31
Q

Assessment of Temperature
Rectal Temperature

A

Placement of thermometer:
Adult- insert 1 ½ inches
Child- insert 1 inch
Infant-insert ½ inch
Placement of thermometer into feces may give inaccurate readings

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32
Q

Assessment of Temperature
Axillary Temperature

A

Considered safest
Must be left in place 5-10 minutes
Moisture in axillary area may reduce the temp

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33
Q

Assessment of Temperature
Tympanic

A

One of the most rapid means of measurement
Unaffected by PO intake
Must remember to remove
hearing aides before using

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34
Q

Assessment of Temperature
Temporal Temperature

A

Most accurate compared to core temp
Fast read: 2-3 seconds
Ease of use
Fewer errors that tympanic

35
Q

What do you do for a fever?

A

Obtain blood cultures if ordered
Monitor VS, assess skin color, temperature, turgor and lab work
Reduce frequency of activities to ↓ 02 demand
Maximize heat loss
Extra fluids
Tepid water bath
Oral hygiene
Dry bed linens
Antipyretic meds as ordered

36
Q

What is pulse?

A

Palpable or audible bounding of blood flow noted at various points on the body

An indirect measure of circulatory status

37
Q

Assessment of Pulse - Sites
Radial

A

Most common for routine vital signs
Used for patient teaching
Assesses circulation status to the hand
Should be assessed together as well as once for pulse

38
Q

Assessment of Pulse - Sites
Apical

A

If pulse is abnormal
If taking meds that affect HR
If radial inaccessible

39
Q

Assessment of Pulse - Sites
Carotid

A

If patient condition suddenly worsens
Need pulse quickly
Do not measure bilateral at the same time

40
Q

Assessment of Pulse - Sites
Dorsalis Pedis

A

Top of foot
Assesses status of circulation to foot
Via Doppler if unable to palpate
Assess bilaterally, at the same time

41
Q

How do we assess our pulse?

A

Rate
Rhythm - regular, irreg, dyrhytmia
strength - 4+,3+,2+(normal),1+,0
Equality

42
Q

Definition: Gas Exchange

A

THE PROCESS OF TRANSPORTING OXYGEN INTO CELLS
TRANSPORT OF CARBON DIOXIDE OUT OF CELLS

43
Q

Gas Exchange - Related Terms

A

Ventilation
Respirations
Ischemia
Hypoxia
Hypoxemia
Respiratory Acidosis

44
Q

Consequences: Impaired Gas Exchange

A

Impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) becomes impaired because of:
Ineffective ventilation
Reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)
Inadequate perfusion

45
Q

Ventilation (definition)

A

Movement of gases into and out of the lung

46
Q

Diffusion (definition):

A

Movement of oxygen and carbon dioxide between alveoli and red blood cells

47
Q

Perfusion (definition):

A

Distribution of red blood cells to and from the pulmonary capillaries

48
Q

Assessment of Respiration

A

Rate
How many breaths/minute

Rhythm
Regular/irregular

Depth
Deep, normal, shallow

**Eupnea – Ventilation of normal rate and depth

49
Q

Factors Influencing Respirations

A

Exercise
Acute pain
Anxiety
Smoking
Body Position
Medications
Neurological Injury
Hemoglobin Function

50
Q

Alterations in Breathing Pattern

A

Eupnea
Bradypnea
Apnea
Cheyne-Stokes respiration
Dyspnea
Orthopnea

51
Q

Eupnea:

A

Normal, breathing @ 12-18 breaths/min

52
Q

Bradypnea:

A

Slower than normal rat (< 10 breaths/min), w/ normal depth & regular rhythm

53
Q

Tachypnea:

A

Rapid, shallow breathing > 24 breaths/min

54
Q

Apnea:

A

Period of cessation of breathing. Time duration varies

55
Q

Cheyne-Stokes:

A

Regular cycle where the rate & depth of breathing increase, then decrease until apnea (usually 20 secs) occurs

56
Q

Biot’s respirations

A

Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 secs to 1 min

57
Q

Assessment of Diffusion and Perfusion
Pulse oximetry:

A

Indirect measurement of oxygen saturation
Also light absorption w/ photo detector
Pulse saturation (Sp02) estimates arterial saturation (Sa02)

58
Q

Factors Affecting Pulse Ox Reading

A

Too loose/too tight
Polish, artificial nails
Temperature of extremity
Movement
Lighting
Skin pigmentation
Edema
Peripheral Vascular Disease

59
Q

What is bp?

A

Force exerted against the blood vessels by the blood

60
Q

How is bp measured?

A

Measured in millimeters of mercury (mmHg)

61
Q

There are two pressures, what are they?

A

Systolic pressure
Diastolic pressure

62
Q

What factors affect the arterial bp?

A

Cardiac Output
Peripheral Resistance
Blood Volume
Viscosity
Elasticity

63
Q

Obtaining a Blood Pressure Reading
Equipment needed?

A

Cuff
Sphygmomanometer
Stethoscope

64
Q

What do we listen for in a bp reading?

A

Korotkoff sounds

65
Q

How many phases do the Korotkoff sounds?

A

5

66
Q

What is heard in the first phase?

A

a sharp thump

67
Q

What is heard in the 2nd phase?

A

a blowing or whooshing sound

68
Q

What is heard in the 3rd phase?

A

a crisp intense tapping

69
Q

What is heard in phase 4?

A

a softer blowing sound that fades

70
Q

What is heard in phase 5?

A

silence

71
Q

How does the bp cuff need to be sized?

A

Cuff width needs to be 20% greater than arm diameter or 40% of circumference

72
Q

Step by Step for bp

A

Determine proper cuff size and site
Position arm at heart level, palm up
Wrap cuff around upper arm
Place stethoscope in ears and close valve
Inflate cuff to 30 mmHg above baseline
Slowly release pressure bulb
Note first clear sound
Note when sound disappears
Record reading

73
Q

What is the ideal environment to check a bp?

A

Quiet room, comfortable temperature
Sitting is preferred position
Record in both arms initially
Same arm every reading if possible
Avoid sites with IV fluids
Rest at least 5 minutes before assessing
Ask patient not to speak

74
Q

Factors Influencing Blood Pressure

A

Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity, weight
Smoking

75
Q

Blood Pressure
Hypertension factors

A

Major factor underlying stroke
Contributing factor to heart attacks
Frequently no symptoms
More common than hypotension
Thickening of walls
Loss of elasticity
Family History
Risk factors

76
Q

Blood pressure
Hypotension factors

A

Symptoms include skin mottling, clamminess, confusion, increased heart rate, or decreased urine output
SBP <90mmHg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs
Orthostatic/postural

77
Q

Automatic Blood Pressure Machines
Facts

A

Used when frequent assessment needed
Baseline BP manually first
More susceptible to error
Unable to accurately detect low BP
Do not talk with patient during reading
Can cause increase in BP by 10% - 40%

78
Q

Alternate Blood Pressure Sites
Thigh

A

Supine position (not ideal) have pt bend knee
Systolic pressure usually higher by 10 -40 mmHg
Diastolic the same

79
Q

Alternate Blood Pressure Sites
Arterial line

A

Catheter inserted in an artery
Reading monitored electronically

80
Q

Pain PQRST Mnemonic

A

P – provokes/palliates
Q – quality
R – region /radiation
S – severity and setting
T – timing

81
Q

When should we assess pain?

A

Often
Always assess pain before procedures, activity and medicate if available
Always re assess pain at least 30 minutes after pain medication has been given
Do not assume to know what your patient’s pain level is….it is what your patient says it is

82
Q

Things to Remember
For VS

A

Nurse is responsible for measurement
Know baseline
Assure equipment is functional
Know history, therapies and medications
Obtain vital signs in a systematic, organized way
Vital signs should be taken at same time every day

83
Q

Safety Guidelines for Skills

A

Cleaning devices
Rotating sites
Analyze trends
Determine the appropriate frequency based on the patient’s condition.

IM1 (18 decks)

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