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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
Signs and Symptoms of a heat stroke
Most important: dry, hot skin Confusion, excess thirst, muscle cramps Vital signs: Increased HR, decreased B/P No sweating
26
Temperature Alteration - Low Heat Exhaustion
Diaphoresis results in excess water and electrolyte loss Need to replace
27
Temperature Alteration - Low Hypothermia
Prolonged exposure to cold decreases body’s ability to produce heat Can be accidental or intentional Temps <86-96.8
28
How do we convert from Fahrenheit to Celsius?
C=(F - 32) x 5/9
29
How do we convert from Celsius to Fahrenheit?
F=(9/5 x C) + 32
30
Assessment of Temperature Oral Temperature
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
31
Assessment of Temperature Rectal Temperature
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
32
Assessment of Temperature Axillary Temperature
Considered safest Must be left in place 5-10 minutes Moisture in axillary area may reduce the temp
33
Assessment of Temperature Tympanic
One of the most rapid means of measurement Unaffected by PO intake Must remember to remove hearing aides before using
34
Assessment of Temperature Temporal Temperature
Most accurate compared to core temp Fast read: 2-3 seconds Ease of use Fewer errors that tympanic
35
What do you do for a fever?
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
What is pulse?
Palpable or audible bounding of blood flow noted at various points on the body An indirect measure of circulatory status
37
Assessment of Pulse - Sites Radial
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
Assessment of Pulse - Sites Apical
If pulse is abnormal If taking meds that affect HR If radial inaccessible
39
Assessment of Pulse - Sites Carotid
If patient condition suddenly worsens Need pulse quickly Do not measure bilateral at the same time
40
Assessment of Pulse - Sites Dorsalis Pedis
Top of foot Assesses status of circulation to foot Via Doppler if unable to palpate Assess bilaterally, at the same time
41
How do we assess our pulse?
Rate Rhythm - regular, irreg, dyrhytmia strength - 4+,3+,2+(normal),1+,0 Equality
42
Definition: Gas Exchange
THE PROCESS OF TRANSPORTING OXYGEN INTO CELLS TRANSPORT OF CARBON DIOXIDE OUT OF CELLS
43
Gas Exchange - Related Terms
Ventilation Respirations Ischemia Hypoxia Hypoxemia Respiratory Acidosis
44
Consequences: Impaired Gas Exchange
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
Ventilation (definition)
Movement of gases into and out of the lung
46
Diffusion (definition):
Movement of oxygen and carbon dioxide between alveoli and red blood cells
47
Perfusion (definition):
Distribution of red blood cells to and from the pulmonary capillaries
48
Assessment of Respiration
Rate How many breaths/minute Rhythm Regular/irregular Depth Deep, normal, shallow **Eupnea – Ventilation of normal rate and depth
49
Factors Influencing Respirations
Exercise Acute pain Anxiety Smoking Body Position Medications Neurological Injury Hemoglobin Function
50
Alterations in Breathing Pattern
Eupnea Bradypnea Apnea Cheyne-Stokes respiration Dyspnea Orthopnea
51
Eupnea:
Normal, breathing @ 12-18 breaths/min
52
Bradypnea:
Slower than normal rat (< 10 breaths/min), w/ normal depth & regular rhythm
53
Tachypnea:
Rapid, shallow breathing > 24 breaths/min
54
Apnea:
Period of cessation of breathing. Time duration varies
55
Cheyne-Stokes:
Regular cycle where the rate & depth of breathing increase, then decrease until apnea (usually 20 secs) occurs
56
Biot's respirations
Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 secs to 1 min
57
Assessment of Diffusion and Perfusion Pulse oximetry:
Indirect measurement of oxygen saturation Also light absorption w/ photo detector Pulse saturation (Sp02) estimates arterial saturation (Sa02)
58
Factors Affecting Pulse Ox Reading
Too loose/too tight Polish, artificial nails Temperature of extremity Movement Lighting Skin pigmentation Edema Peripheral Vascular Disease
59
What is bp?
Force exerted against the blood vessels by the blood
60
How is bp measured?
Measured in millimeters of mercury (mmHg)
61
There are two pressures, what are they?
Systolic pressure Diastolic pressure
62
What factors affect the arterial bp?
Cardiac Output Peripheral Resistance Blood Volume Viscosity Elasticity
63
Obtaining a Blood Pressure Reading Equipment needed?
Cuff Sphygmomanometer Stethoscope
64
What do we listen for in a bp reading?
Korotkoff sounds
65
How many phases do the Korotkoff sounds?
5
66
What is heard in the first phase?
a sharp thump
67
What is heard in the 2nd phase?
a blowing or whooshing sound
68
What is heard in the 3rd phase?
a crisp intense tapping
69
What is heard in phase 4?
a softer blowing sound that fades
70
What is heard in phase 5?
silence
71
How does the bp cuff need to be sized?
Cuff width needs to be 20% greater than arm diameter or 40% of circumference
72
Step by Step for bp
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
What is the ideal environment to check a bp?
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
Factors Influencing Blood Pressure
Age Stress Ethnicity Gender Daily Variation Medications Activity, weight Smoking
75
Blood Pressure Hypertension factors
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
Blood pressure Hypotension factors
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
Automatic Blood Pressure Machines Facts
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
Alternate Blood Pressure Sites Thigh
Supine position (not ideal) have pt bend knee Systolic pressure usually higher by 10 -40 mmHg Diastolic the same
79
Alternate Blood Pressure Sites Arterial line
Catheter inserted in an artery Reading monitored electronically
80
Pain PQRST Mnemonic
P – provokes/palliates Q – quality R – region /radiation S – severity and setting T – timing
81
When should we assess pain?
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
Things to Remember For VS
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
Safety Guidelines for Skills
Cleaning devices Rotating sites Analyze trends Determine the appropriate frequency based on the patient’s condition.

IM1 (18 decks)

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