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VITAL SIGNS Flashcards

1
Q

GUIDELINES FOR MEASURING VITAL SIGNS

A

• Normal vital sign ranges for the average healthy adult while resting are: Blood pressure: 90/60mm Hg to 120/80 mm Hg.
• Breathing: 12 to 18 breaths per minute. Pulse: 60 to 100 beats per minute.
• Establish a baseline for future assessments.
• Be able to understand and interpret values.
• Appropriately delegate measurement.
• Communicate findings.
• Ensure equipment is in working order.
• Accurately document findings.

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2
Q

Measurements of the body’s most basic functions.

A

VITAL SIGNS

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3
Q

The four main vital signs routinely
monitored by medical professionals and health care providers include the following:

A

Body temperature
Pulse rate
Respiration rate (rate of breathing)
Blood Pressure

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4
Q

Normal vital signs change with ___

A

age, sex, weight, exercise, etc.

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5
Q

TEMPERATURE RANGE

A

98.6 F to 100
36 C to 38 C

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6
Q

TEMPERATURE SITES

A

Oral
Rectal
Axillary
Tympanic membrane

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7
Q

A process called ____ controls the physiological and behavioral mechanisms that regulate heat loss and heat production.

A

thermoregulation

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8
Q

Neural and vascular control is governed by the ____, located between the cerebral hemispheres. The ___ works like a thermostat which establishes a comfortable body “set point”.

A

hypothalamus

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9
Q

___ controls heat loss
___ controls heat production

A

Anterior hypothalamus
Posterior hypothalamus

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10
Q

HEAT LOSSES (COOL OFF PROCESSES) THROUGH:

A

Perspiration
Respiration
Radiation
Conduction
Convection
Evaporation
Thermal radiation,
air infiltration

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11
Q

Is an effect of its role as body insulator, vasoconstriction, and temperature sensation.

A

skin temperature

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12
Q

Behavioral control depends upon a person’s ability to control body temperature through:

A

• The degree of temperature extreme
• The ability to sense comfort or discomfort
• Through processes or emotions
• The person’s mobility or ability to add or remove
clothing

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13
Q

FACTORS AFFECTING BODY TEMPERATURE

A

• Age
• Exercise
• Hormonal level
• Circadian rhythm
• Environment
• Temperature alterations
• The potential increase in body temperature is also affected by patient age, heart rate (HR), body size and type, as well as the loss of body
heat through metabolic processes

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14
Q

• ____ has a great effect on body temperature. Newborns temperature control mechanisms are immature.
• They can lose up to 80% of heat through their leads, until a child reaches puberty, temperature regulation is unstable.
• Also note that it is not unusual for older adults to reach temperatures no higher than 96.8°F

A

Age

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15
Q

• ______ stimulates muscle activity and requires an increased blood supply and increased carbohydrate and fat breakdown.
• ______ will increase heat production and body temperature.

A

Exercise

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16
Q

• Women experience greater fluctuations in body temperature than men.
• Hormonal variations occur during menstrual cycle and menopause.
• Women may experience hot flashes due to an inability to control vasodilation and
vasoconstriction.

A

Hormonal Level

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17
Q

• _____ changes the body temperature over the 24-hour period.
• The lowest body temperature occurs between ___ and ___ hours.
• The body reaches maximum temperature at ____ hours.
• The _____ does not change with age, but will change for those who work the night shift.
• This usually takes up to three weeks.
• The environment influences body temperature. When entering a warm room, a person’s body heat will raise.
• If outside without warm clothing, a person’s body temperature may be low due to ______

A

Circadian rhythm
0100, 0400
1800
circadian rhythm
radiant and conductive heat loss

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18
Q

• ________ are related to excess heat production, excessive heat loss, minimal heat production, minimal heat loss, or any combination of these.

A

Temperature alterations

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19
Q

• _____ occurs because the body is unable to keep pace with a heat production mechanism.
• This can be a result of the hypothalamus being unable to keep the “set point.”
• Pyrogens may be the cause.

A

Fever or pyrexia

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20
Q

______ is an elevated body temperature resulting from the body’s inability to promote heat loss or reduce heat production

A

Hyperthermia

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21
Q

• ________ typically feel more comfortable at higher temperatures.

A

Old people, people with disabilities, babies and young children

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22
Q

• The average normal body temperature is generally accepted as _____. Some studies have shown that the “normal” body temperature can have a wide range, from ______ to _____. A temperature over _____ most often means you have a fever caused by an infection or illness.

A

98.6°F (37°C)
97°F (36.1°C), 99°F (37.2°C)
100.4°F (38°C)

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23
Q

ABNORMAL BODY TEMPERATURE:

• Heat loss during prolonged exposure to cold
• Classified by core temp (mild-severe)
• May be intentional (surgery)

A

HYPOTHERMIA

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24
Q

HYPOTHERMIA:
Early Signs
Later Signs
Frostbite

A

Early signs
• uncontrolled shivering, loss of memory, poor judgment
Later signs
• Cyanosis, decreased VS, cardiac dysrhythmias, loss of consciousness
Frostbite
• body exposure to subnormal temps

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25
• defined as a drop in body temperature below 95° F.
Hypothermia
26
TYPES OF THERMOMETERS:
Heat-Sensitive patches Electronic thermometers Tympanic thermometer
27
TYPES OF THERMOMETERS: • Patch placed on the skin; color changes on the patch indicate temperature readings
Heat-Sensitive patches
28
TYPES OF THERMOMETERS: • Consist of a rechargeable battery- powered display unit, a thin wire cord, and a temperature processing probe
Electronic thermometers
29
TYPES OF THERMOMETERS: • Special form of electronic thermometer; inserted into auditory canal
Tympanic thermometer
30
• This device may be a thermistor or a thermocouple and is incorporated into the tip of a probe.
Electronic thermometers
31
• _______ display either a predicted equilibrium temperature based on measurements taken over 15-30 seconds (in predictive mode) or an actual equilibrium temperature that is generally achieved in a minute or less (in continuous mode) • _________ are portable and can be used to measure oral, axillary and rectal temperatures.
Electronic thermometers
32
• when the temperature is above normal • fever is actually a body defense, it will destroy invading bacteria
PYREXIA, FEBRILE, OR HYPERTHERMIA
33
CLASSIFICATION OF FEVERS
Constant Intermittent Remittent
34
CLASSIFICATION OF FEVERS: • remains elevated consistently
Constant
35
CLASSIFICATION OF FEVERS • rises and falls
Intermittent
36
CLASSIFICATION OF FEVERS: • temperature never returns to normal until the patient become well
Remittent
37
• an abnormally low body temperature • is caused by prolonged exposures to very cold temperatures. When exposed to cold temperatures, your body begins to lose heat faster than it's produced. Lengthy exposures will eventually use up your body's stored energy, which leads to lower body temperature.
Hypothermia
38
HYPOTHERMIA Body Temperature - Symptoms -
Below 36C Skin paleness Tiredness
39
Normal Body Temperature - Symptoms -
36 - 36.9 C Lowest 5-6 AM Highest 4-6 PM
40
PYREXIA / SLIGHT FEVER Body Temperature - Symptoms -
37-37.9 C Perspiration Skin redness Headache
41
FEVER Body Temperature - Symptoms - Presence of infection -
Above 38 C General weakness Tachycardia/ Hyperpnea Skin paleness or redness ______________________ body defense Shivers Perspirations
42
ASSESSMENT OF PULSE
• Sites • Use of stethoscope • Character of pulse • Nursing process and pulse determination • You will select the most appropriate and age-specific site to measure the pulse. • Press gently against the pulse. • Take your time to note any irregularities in strength or rhythm. • If the pulse is regular and strong, measure the pulse for 30 seconds. Double the number to give the beats per minute (e.g.: 32 beats in 30 seconds means the pulse is 64 beats per minute).
43
These sites include: (Pulse)
• temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, or dorsalis pedis.
44
• When measuring the apical site, you will need to use a _____. • A stethoscope consists of _____.
stethoscope ear pieces, a diaphragm, bell, and tubing
45
• The pulse has various characteristics, including ______ • It will be important to establish a baseline for future comparison. • Be judicious when delegating the assessment of vital signs to nursing assistive personnel. • The rhythm should be regular; o however, both normal and abnormal variations will occur.
rate, rhythm, strength, and equality
46
PULSE RATE • The normal pulse for healthy adults ranges from _____. • The pulse rate may fluctuate and increase with ______. • Girls ages 18 and older and women, in general, tend to have faster heart rates than do boys and men.
60 to 100 beats per minute exercise, illness, injury, and emotions
47
PULSE: QUANTITY
• If the rate is particularly slow or fast, it is probably best to measure for a full 60 seconds in order to minimize the error.
48
PULSE: REGULARITY
• Is the time between beats, constant. • Irregular rhythms, are quite common
49
PULSE: VOLUME
• Does the pulse volume feel normal? • This reflects changes in stroke volume. • In hypovolemia, the pulse volume is relatively low
50
TACHYCARDIA • The pulse is faster than ______. • It may result from ______.
100 beats per minute shock, hemorrhage, exercise, fever, acute pain, and drugs.
51
BRADYCARDIA • The pulse is slower than ____. • It may result from ______.
60 beats per minute unrelieved severe pain, dru_ resting, and heart block
52
A point of maximum impulse is at ____.
fifth intercostal space
53
• represents the actual beating of the heart
Apical pulse
54
• difference between the radial and apical rates; • signifies that the pumping action of the heart is faulty
Pulse Deficit
55
ASSESSMENT OF VENTILATION
• Respirations are tied to all functions of body systems. • A sudden change in respiration may indicate a problem or can be a normal physiological response. • Box 32-11 presents factors that influence respiration. • Easy to asses
56
VENTILATORY RHYTHM • The ventilatory movements are described as _____ • Remember that ____ tend to breathe less regularly. • Take RR for _____, • Respiration is _____.
deep, normal, or shallow infants one full minute regular or irregular in rhythm
57
DIFFUSION AND PERFUSION • You will evaluate respiratory processes of diffusion and perfusion by ____. • The ______ that is bound with oxygen in the arteries is the percent of saturation of hemoglobin or SaO2 • This should be between _____.
measuring the oxygen saturation of blood percentage of hemoglobin 95% and 100%
58
• _____ is measured through a pulse oximeter. • SpO2 is a reliable estimate of SaO2 when it is higher than 70%
Arterial oxygen saturation
59
Normal Respiration
• Effortless • Regular • Smooth
60
RESPIRATORY RATE • Normal – ___ /min • Bradypnea – ___ /min • Tachypnea – ___/min • Apnea
RESPIRATORY RATE • Normal – 12 to 20 /min • Bradypnea – less than 10/min • Tachypnea – 25/min • Apnea
61
AVERAGE RESPIRATIONS • Infant to 2 years – ____/min • To puberty – ____/min • Adults – ____/min
24 to 32 20 to 25 12 to 18
62
RESPIRATORY RHYTHM
• Normal • Dyspnea (exertion/rest) • Cheynes-stokes respiration (irregular deep/slow/shallow) • Kussmaul’s breathing (deep)
63
NORMAL AND ABNORMAL RESPIRATION RATE AND RHYTHM
• EUPNEA – normal respirations • Apnea - absence/cessation of breathing • Bradypnea - abnormally slow <12 • Tachypnea- abnormally fast >20 • Dyspnea - exertion even on rest • Hyperpnea- labored, after exercise • Hyperventilation/Hypoventilation • Cheyne-Stokes - Irregular, deep/slow/shallow breathing • Kussmaus breathing - deep
64
ABNORMAL RESPIRATORY RATE
• Respiration rates over 25 or under 12 breaths per minute (when at rest) may be considered abnormal
65
NURSING PROCESS AND RESPIRATORY VITAL SIGNS
• Nursing diagnosis • Planning • Intervention • Evaluation
66
RESPIRATORY RATE
• Try to do this as surreptitiously as possible, • Observing the rise and fall of the patient's hospital gown while you appear to be taking their pulse. • Respiration rates may increase with fever, illness • When checking respiration, also note whether a person has any difficulty breathing.
67
____ is the force exerted on the arterial wail by pulsing blood under pressure from the heart. Blood moves from higher to lower pressures.
Blood pressure
68
• The maximum peak pressure is known as _____. • When the ventricles relax, a minimal pressure is exerted against the arterial walls, known as _____.
systolic blood pressure diastolic blood pressure
69
• Blood pressure is measured in _____. • Blood pressure depends on ______. • _______ is the volume of blood ejected by the ventricles of the heart (stroke volume) multiplied by the heart rate,
millimeters of mercury (mmHg) cardiac output (CO) Cardiac output
70
• Blood pressure depends on _____. • ______ is determined by the tone of vasculature and diameter of blood vessels. • Blood flows through _______. • The size changes to meet the needs of surrounding structures and tissues.
peripheral resistance Peripheral resistance arteries, arterioles, capillaries, venues, and veins
71
• The ____ of circulating blood affects blood pressure. • Normal circulating volume is ____ • ______ of volume elevates blood pressure.
Volume 5000 ml Rapid infusion
72
• Decrease in volume, which can be caused by ______, causes blood pressure to fall. • The ______ of blood affects the ease of blood flow through small vessels.
hemorrhage or dehydration thickness or viscosity
73
• _____, or percentage of red blood cells, determines viscosity. • Normal arterial walls are _____. • As blood pressure increases, ______, • ______ prevents fluctuations in blood pressure, • Systolic pressure is elevated more than diastolic pressure as a result of _____.
• Hematocrit • elastic and easily distensible • the diameter of the vessels will increase to accommodate the pressure, • Distensibility • reduced arterial elasticity
74
FACTORS CONTROLLING BLOOD PRESSURE
Cardiac Output Vascular Resistance Volume Viscosity Elasticity of arterial walls
75
FACTORS CONTROLLING BLOOD PRESSURE Cardiac Output
Increased - with heavy exercise to meet body demand for increased metabolism = Increased BP Decreased - with pump-failure (weak pumping action after myocardial infarction, or in shock) = Decreased BP
76
FACTORS CONTROLLING BLOOD PRESSURE Vascular Resistance
Increased resistance (vasoconstriction) = Increased BP Decreased resistance (vasodilation) = Decreased BP
77
FACTORS CONTROLLING BLOOD PRESSURE Volume
Decreased volume (hemorrhage) = Decreased BP Increased volume (increased sodium and water retention, intravenous fluid overload) = Increased BP
78
FACTORS CONTROLLING BLOOD PRESSURE Viscosity
Increased viscosity (increased hematocrit in polycythemia) = Increased BPn
79
FACTORS CONTROLLING BLOOD PRESSURE Elasticity of arterial walls
Increased rigidity, hardening as in arteriosclerosis (heart pumping against greater resistance) = Increased BP
80
• The pressure exerted by the circulating volume of blood on the arterial walls, veins, and chambers of the heart.
Blood pressure
81
• The higher number; • represents the ventricles contracting
Systolic
82
• The second number, • represents the pressure within the artery between beats
Diastolic
83
• Difference between the systolic and diastolic
PULSE PRESSURE
84
• the average arterial pressure throughout one cardiac cycle, systole, and diastole.
MEAN ARTERIAL PRESSURE
85
NURSING PROCESS AND BLOOD PRESSURE DETERMINATION
• Assessment of blood pressure and pulse evaluates the general state of cardiovascular health. • Hypertension, hypotension, orthostatic hypotension, or narrow/wide pulse pressures define nursing diagnoses.
86
REMEMBER THE FOLLOWING FOR ACCURACY OF YOUR READINGS
• Instruct your patients to avoid coffee, smoking or any other unprescribed drug with sympathomimetic activity on the day of the measurement
87
POSITION OF THE ARM
• Raise patient arm so that the brachial artery is roughly at the same height as the heart. • If the arm is held too high, the reading will be artifactually lowered, and vice versa.
88
IN ORDER TO MEASURE THE BP • ______ is the pressure at which you can first hear the pulse. • ______ is the last pressure at which you can still hear the pulse • Avoid moving your hands or the head of the stethoscope while you are taking readings as this may produce noise that can obscure the ______.
Systolic blood pressure Diastolic blood pressure Sounds of Koratkoff
89
BLOOD PRESSURE FOR ADULT
• Physician will want to see multiple blood pressure measurements over several days or weeks before making a diagnosis of hypertension and initiating treatment.
90
ABNORMAL RESULTS: (BLOOD PRESSURE)
Pre-high blood pressure Stage 1 high blood pressure Hypotension (blood pressure below normal) Hypertension
91
WHAT ABNORMAL RESULTS MEAN: • systolic pressure consistently • 120 to 139, or diastolic 80 to 89
Pre-high blood pressure
92
WHAT ABNORMAL RESULTS MEAN: • systolic pressure consistently • 140 to 159, or diastolic 90 to 99
Stage 1 high blood pressure
93
WHAT ABNORMAL RESULTS MEAN: • may be indicated by a systolic pressure lower than 90, or a pressure 25 mmHg lower than usual
Hypotension (blood pressure below normal)
94
WHAT ABNORMAL RESULTS MEAN: • High blood pressure greater than 139-89.
Hypertension
95
NORMAL BLOOD PRESSURE (mmHg) • Normal blood pressure ______. • Prehypertension: ______
100/60 and 139/89 120,139-80,89
96
HYPERTENSION Risk Factors
• More common than hypotension • Thickening of walls • Loss of elasticity • Family history • Asymptomatic RISK FACTORS • obesity, • smoking, • alcohol consumption, • high salt. • A person has increased heart rate, no control over family history • Higher incidents for high blood pressure exist in those with diabetes, of African American descent
97
HYPOTENSION RISK FACTORS:
• 90 mmHg • Dilation of arteries • Loss of blood volume • Decrease of blood flow to vital organs • Orthostatic/postural RISK FACTORS: • pallor, • skin mottling, • clamminess, confusion, • increased heart rate, • decreased urine output.
98
REMEMBER THE FOLLOWING FOR ACCURACY OF YOUR READINGS
• Orthostatic (postural) measurements of pulse and blood pressure are part of the assessment for hypovolemia.
99
• ______ occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position. • Clients who are _______ are at risk for orthostatic hypotension.
Orthostatic or postural hypotension dehydrated, anemic, on prolonged bed rest, or who have had a recent blood loss
100
• Also called postural hypotension —is a form of low blood pressure that happens when standing after sitting or lying down.
Orthostatic hypotension
101
BLOOD PRESSURE MAY BE AFFECTED BY MANY DIFFERENT CONDITIONS
• Cardiovascular disorders • Neurological conditions • Kidney and urological disorders • Sudden weight gain • High blood pressure • Pre-eclampsia in • pregnant women • Psychological factors such as stress, anger, or fear
102
• measurement of gas exchange and red blood cell oxygen carrying capacity has become available in all hospitals and many clinics. • provide important information about cardio-pulmonary dysfunction and is considered by many to be a fifth vital sign
Oxygen Saturation
103
MEASUREMENT OF ARTERIAL OXYGEN SATURATION
• Pulse oximeter • Allows indirect measurement of oxygen saturation • Sp02 is a reliable estimate of Sa02 • Measurement is affected if extremity is cold, edematous or if nail polish is present (interference with light transmission)
104
HEALTH PROMOTION AND VITAL SIGNS
• Monitor vital signs. • Include age-related factors, • Include environmental and activity factor. • When teaching clients regarding their vital signs, it is important to emphasize health promotion and activities that support health. • You may need to teach clients and their families to assess and record vital signs. • Stress that vital signs should be taken at the same time every day • Food and activity will alter the readings. • Vital signs are useful in detecting or monitoring medical problems. Vital signs can be measured in a medical setting, at home, at the site of a medical emergency, or elsewhere.

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