vital signs Flashcards
what are your 5 measurements when taking vital signs
temp, pulse, BP, resp. rate, O2 saturation
when do you measure vital signs?
Admission, per physician order, any changes in patients condition, before major procedures, during blood transfusion, after meds that affect vital signs
normal oral/tympanic/temporal temp range
97.6-99.6
normal rectal temp range
98.6-100.4
normal axilla temp range
96.6-98.6
normal pulse range
60-100 BPM
normal respiration range
12-20 BPM
normal BP
less than 120/80 mmHg
pre-hypertensive BP range
sys.: 120-139 dia.:80-89
hypertensive BP range
Sys. greater than 140 dia. greater than 9-
hypotensive BP range
sys. less than 90 and symptomatic
what are the 2 things body temp. shows
heat produced and heat lost
acceptable temp. range
96.8-100.4
radiation
transfer of heat from surface of one object to another without direct contact
conduction
transfer of heat from one object to another with direct contact
convection
transfer of hat away by air movement
evaporation
transfer of heat energy when a liquid is changed to a gas
diaphoresis
visible perspiration
6 factors affecting body temp
age, hormonal level, environment, exercise, circadian rhythm, temperature alterations
pyrexia
fever
when is pyrexia harmful
above 102.2
what increases when someone has a fever ( 4 things )
metabolism, oxygen consumption, heart rate, respiratory rate
hyperthermia
inability to promote heat loss or reduce production
heatstroke
body temp 104 or more
heatstroke signs and symptoms
DRY, HOT SKIN, confusion, excess thirst, muscle cramps, increased HR, decreased BP, no sweating
heat exhaustion
diaphoresis resulting is excess water and electrolyte loss, body needs to replace
hypothermia
prolonged exposure to cold which decreases body’s ability to produce heat, temps less than 86 ranging to 96.8
fahrenheit to celsius conversion
C= (F-32) x 5/9
celsius to fahrenheit conversion
F= (9/5 x C) +32
oral temperature is approx. ___ degree lower than core temp
1
adult rectal temp. placement
1.5 in
child rectal temp. placement
1 in
infant rectal temp. placement
.5 in
You have delegated vital signs to the nursing assistant. She tells you that the patient has just finished a cup of hot coffee. The nurse’s most appropriate advice would be to
A. take the oral temperature as planned
B. take a rectal temperature.
C. wait 30 minutes and take an oral temperature.
D. advise the patient to drink a glass of cold water.
C
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
pulse
palpable bounding of blood flow noted at various points of the body
what is the pulse showing
an indirect measure of circulatory status
what do you do if you get a abnormal radial pulse?
obtain an apical pulse
why do you check pulse on both wrists at the same time
to assess for abnormal rhythm or strength on one or both sides
what is considered a normal pulse rhythm
2+
what is gas exchange
the process of transporting oxygen into cells and carbon dioxide out of cells
what are the 3 catagories of oxygenation?
ventilation, transport, perfusion
impaired gas exchange
diffusion of gases becomes impaired
ventilation
movement of gases into and out of the lung
diffusion
movement of oxygen and carbon dioxide between alveoli and red blood cells
perfusion
distribution of red blood cells to and from the pulmonary capillaries
rate of respirations
haw many breaths per min.
rhythm of respirations
regular or irregular
depth of respirations
deep, normal, or shallow
eupnea
ventilation of normal rate and depth
bradypnea
slow breaths with normal depth <10 BPM
tachypnea
rapid, shallow breathing >24 BPM
apnea
pauses in breathing
cheyne-stokes
rate and depth of breathing increase until apnea
biots respiration
normal breathing followed by a period of apnea
acceptable SpO2 range
95%-100%
what is BP
force exerted against the blood vessels by the blood
what do you measure BP in
millimeters of mercury
Hypotension symptoms
skin mottling, clamminess, confusion, high HR, low urine output
P in PQRST
provokes/palliates
R in PQRST
quality
R in PQRST
region/radiation
S in PQRST
Severity and setting
T in PQRST
timing
