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Vital Signs > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Types of vital signs

A

temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain

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2
Q

when to measure vital signs

A

on admission
per physicians order
any change in patients condition
before and after any major procedure
during blood transfusion
after medications or interventions that affect vital signs

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3
Q

temperature ranges

A

96.8-100.4

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4
Q

oral/tympanic/temporal

A

97.6-99.6

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5
Q

rectal

A

98.6-100.4

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6
Q

axilla

A

96.6-98.6

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7
Q

pulse: average adults

A

60-100 beats per minute

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8
Q

respirations

A

12-20 breaths per minute

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9
Q

blood pressure: normal adults

A

less that 120/80 mmHg

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10
Q

pre-hypertensive

A

systolic: 120-139
diastolic: 80-89

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11
Q

hypertensive

A

systolic: > (greater than) 140
diastolic: > (greater than) 90

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12
Q

hypotensive

A

systolic: < (less than) 90 and symptomatic

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13
Q

body temperature

A

heat produced
heat lost
help balance body temperature
no single temperature is normal for every individual

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14
Q

temperature sites

A

oral, rectal, tympanic membrane (ear), temporal artery, esophageal, pulmonary artery (arterial line), and urinary bladder

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15
Q

temperature regulation

A

anterior and posterior hypothalamus: internal thermostat

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16
Q

posterior hypothalamus

A

heat production
BMR: basal metabolic rate
shivering

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17
Q

anterior hypothalamus

A

heat loss
- radiation
-conduction
-convection
-evaporation
-diaphoresis: sweating

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18
Q

skin regulates body temperature through

A

skin: only for a few minutes
vasoconstriction: goose bumps
sensation: body sensing hot and cold

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19
Q

radiation

A

transfer of heat from surface of one object to surface of another without direct contact between the 2

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20
Q

conduction

A

transfer of heat from one object to another with direct contact

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21
Q

convection

A

transfer of heat away by air movement

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22
Q

evaporation

A

transfer of heat energy when a liquid is exchanged to a gas
ex. sweat evaporating to cool down body

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23
Q

diaphoresis

A

visible perspiration
med term for sweating

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24
Q

factors affecting body temperature

A

age: very young- hypothalamus is not fully developed; very old: loose skin layering
hormonal level: women can tell ovulation based on body temperature
environment: skin eventually cannot keep the body warm/cool
exercise: metabolic process creates heat
circadian rhythm: body resting itself; middle of sleep= lowest body temperature
temperature alterations: fever, virus, bacteria, etc. ; taking a antipyretic to lower body temperature

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25
Q

fever (pyrexia)

A

usually not harmful if below 102.2 F
important defense mechanism
temp should be taken several times throughout day: when the body is the most active, its temp will be the highest
results from an alteration in the hypothalamic set point: set point can get raised and body does not adjust quick enough
causes increase in metabolism and oxygen consumption
increased heart rate and respiratory rate

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26
Q

hyperthermia

A

inability to promote heat loss or reduce production

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27
Q

heat stroke

A

long exposure to heat, body has expelled all fluids
dangerous heat emergency/high mortality rate
body temp 104 F or more
signs and symptoms:
-most important: dry, hot skin
-confusion, excess thirst, muscle cramps
-vital signs: increased HR, decreased BP
-no sweating

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28
Q

heat exhaustion

A

right before heat stroke
diaphoresis (sweating) results in excess water and electrolyte loss
need to replace
want to SLOWLY bring temp down

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29
Q

hypothermia

A

extremely slows down the body
prolonged exposure to cold decrease’s body’s ability to produce heat
can be accidental or intentional (typically done in hospital setting)
temps <86-96.8
below 86 F is not suitable for life

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30
Q

oral temperature

A

probe under tongue ~1 degree lower than core temp
temperature easily influenced by hot or cold foods
one of the most frequently used methods of attaining temperature
may be glass (mercury) or electronic

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31
Q

rectal temperature

A

typically done in children or someone with hypothermia
placement of thermometer:
-adult: insert 1.5 inches
-child: insert 1 inch
-infant: insert .5 inch
placement of thermometer into feces may give inaccurate readings

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32
Q

axillary temperature

A

arm pit: least accurate
considered the safest
must be left in place for 5-10 minutes
moisture in axillary area may reduce temp reading

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33
Q

tympanic

A

ear canal, must get into ear canal or will not be accurate
one of the most rapid means of measurement
unaffected by PO intake
must remember to remove hearing aids before using

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34
Q

temporal temperature

A

most accurate compared to core temp
head of scanner must always be touching skin
fast read: 2-3 seconds
easy to use
fewer errors than tympanic

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35
Q

what do you do for a fever?

A

obtain blood culture
monitor VS, assess skin color, temperature, turgor and lab work
reduce frequency of activities to low O2 demand
maximize heat loss: take blanket off, cool to the point that they are not shivering
extra fluids: as they start to lose heat they might sweat
tepid water bath: not to shock the body with freezing ice pack
oral hygiene: mouth is filled with bacteria
dry bed linens: as they sweat bed gets wet and cold and could induce shivering
antipyretic meds as ordered: fever reducer medications ex. Tylenol or Motrin

36
Q

pulse

A

palpable or audible bounding of blood flow noted at various points on the body
an indirect measure of circulatory status

37
Q

radial pulse

A

wrist
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 (to ensure adequate blood flow to both hands)

38
Q

apical pulse

A

listening with stethoscope
if pulse is abnormal
if taking meds that affect HR
if radial pulse is inaccessible (ex. cast)
5th intercostal space, mid clavicular, on left side

39
Q

corotid

A

only in case of emergency and NEVER at the same time
if patient condition suddenly worsens
need pulse quickly
do not measure bilateral at the same time (reduces blood flow to the brain)

40
Q

dorsalis pedis

A

top of foot
assesses status of circulation to foot
via doppler if unable to palpate
assess bilaterally

41
Q

rate: assessment of pulse

A

baseline is 60-100
if abnormal, obtain apical

42
Q

rhythm: assessment of pulse

A

regular
irregular
dysrhythmia

43
Q

strength

A

4+ (bounding), 3+, 2+ (normal), 1+ (faint), 0 (cannot palpate

44
Q

gas exchange

A

the process of transporting oxygen into cells
transport of carbon dioxide out of cells

45
Q

ventilation

A

movement of gasses into and out of the lungs

46
Q

respirations

A

inspiration and expiration
the exchange of gas in alveoli

47
Q

ischemia

A

insufficient oxygen supply to tissue, which can lead to the death of cells

48
Q

hypoxia

A

not enough oxygen reaching the cell

49
Q

hypoxemia

A

not enough oxygen to the red blood cells

50
Q

respiratory acidosis

A

build up of CO2

51
Q

impaired gas exchange

A

ineffective ventilation: not able to ventilate in and out
reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)
inadequate perfusion: not creating enough RBC

52
Q

diffusion

A

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

53
Q

perfusion

A

distribution of red blood cells to and from the pulmonary capillaries

54
Q

rate: assessment of respirations

A

how many breaths per minute

55
Q

rhythm

A

regular/irregular

56
Q

depth

A

deep, normal, shallow

57
Q

eupnea

A

ventilation of normal rate and depth

58
Q

factors influencing respirations

A

exercise
acute pain
anxiety
smoking
body position: sitting up= expanding chest= better breathing
medications
neurological injury
hemoglobin function: part of RBC responsible for transporting oxygen in blood

59
Q

bradypnea

A

slower than normal respirations

60
Q

apnea

A

absence of breathing

61
Q

cheyne-stokes respirations

A

increase of rate and depth, then decrease, then apnea

62
Q

dyspnea

A

difficulty breathing

63
Q

orthopnea

A

breathing that changes with body position

64
Q

tachypnea

A

rapid or above normal rate

65
Q

assessment of diffusion and perfusion

A

indirect measurement of oxygen saturation
-pulse oximetry
light absorption with photo detector
pulse saturation (SpO2) estimates arterial saturation (SaO2)
acceptable range 95%-100%

66
Q

factor affecting pulse ox reading

A

too tight/too loose
polish, artificial nails: darker the polish the harder to read
temperature of extremity: if the extremity is cold, O2 might read low
movement
lighting
skin pigmentation: darker skin can read low
edema: low due to swelling
peripheral vascular disease

67
Q

blood pressure

A

force exerted against the blood vessels by the blood
measured in millimeters of mercury (mmHg)

68
Q

systolic pressure

A

top number
max amount of pressure

69
Q

diastolic pressure

A

bottom number
lowest amount of pressure

70
Q

pulse pressure

A

systolic-diastolic

71
Q

factors that affect arterial blood pressure

A

cardiac output: amount of blood heart is pumping through
peripheral resistance
blood volume: high blood volume= high blood pressure
viscosity: thickness of the blood (high viscosity= thick blood)
elasticity: ability for vessels to contract and expand

72
Q

ideal environment for BP

A

quiet room, comfortable temp
sitting is preferred position
record both arms initially
same arm every reading
avoid sites with IV fluids
rest at least 5 minutes before assessing
ask patient not to speak: can raise your BP up to 40%

73
Q

factors that influence blood pressure

A

age, stress, ethnicity, gender, daily variation, medications, activity, weight (high BMI might= high BP), and smoking

74
Q

hypertension

A

major factor underlying stroke
contributing factor to heart attacks
frequently no symptoms
thickening of walls
loss of elasticity
family history
risk factors: smoking, obesity, diet, etc.

75
Q

hypotension

A

do not consider till patient is symptomatic
-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: blood pressure decreases as patient changes position

76
Q

automatic blood pressure machines

A

much more susceptible to error
used when frequent assessment is needed
baseline BP manually first
unable to accurately detect low BP
do not talk with patient during reading
- can increase BP by 10%-40%

77
Q

alternate BP sites: thigh

A

supine position (not ideal) have pt bend knee
systolic pressure usually higher by 10-40 mmHg
diastolic the sane

78
Q

alternate BP sites: arterial line

A

typically done in ICU
catheter inserted in an artery
reading monitored electronically

79
Q

Pain mnemonic: P

A

provokes/palliates: what makes it worse/better

80
Q

Pain mnemonic: Q

A

quality: type of pain

81
Q

Pain mnemonic: R

A

region/radiation: where is pain and where does it radiate to?

82
Q

Pain mnemonic: S

A

severity and setting: how severe and when does pain happen?

83
Q

Pain mnemonic: T

A

timing: does it happen at a particular time of day

84
Q

pain assessment

A

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 patients pain level is

85
Q

documentation

A

record values in EMR (electronic medical record)
record any accompanying symptoms in nurses notes
document interventions initiated
document follow up assessment

86
Q

korotkoff sounds

A

5 stages
phase 1: a sharp thump
phase 2: a blowing or whooshing sound
phase 3: a crisp intense tapping
phase 4: a softer blowing sound that fades
phase 5: silence

Vital Signs (3 decks)

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