Vital Signs Flashcards by Madison Hales

Elder speak?

Communication that conveys message of incompetence: “sweetie, honey, dear, etc.”
Evidence says: In older adults with dementia, Resistance To Care (RTC) increases with elder speak, disrupts nursing care, and increases costs of care by 30%

How well did you know this?

Not at all

Perfectly

Why do VS need to be accurate?

Therapeutic action can be taken from VS

How well did you know this?

Not at all

Perfectly

When to assess vital signs?

Admission, institutional policy, change in condition, before/after: surgical or invasive procedure, certain meds, certain activities
*know textbook norms and patient range norms (some abnorms may be normal for specific patient)

How well did you know this?

Not at all

Perfectly

Order to report VS?

temp
pulse
respiration
BP + MAP
pain
02

How well did you know this?

Not at all

Perfectly

Temperature physiology?

Regulated by hypothalamus
Heat production: metabolism is primary source- hormones, muscle movement, exercise increase metabolism
Heat loss: Skin (primary source), sweat evaporation, warming/humidifying inspired air, eliminating urine and feces

How well did you know this?

Not at all

Perfectly

Mechanisms of heat transfer?

Radiation: diffusion of heat by electromagnetic waves, ex. body gives off waves of heat from uncovered surfaces
Convection: heat dissemination by motion between areas of unequal density, ex. fan blows cool air across surface of warm body
Evaporation: conversion of liquid to vapor, ex. perspiration
Conduction: heat transfer to another object during direct contact, ex. body transfers heat to ice pack causing it to melt

How well did you know this?

Not at all

Perfectly

Temperature factors?

Circadian rhythms- lower morning, higher afternon
Age- elderly will be less
Gender- men lower
Physical activity- increase
Environmental temperature

How well did you know this?

Not at all

Perfectly

Fever types?

Intermittent: body temp returns to normal once every 24 hrs
Remittent: body temp does not return to normal, fluctuates degrees
Sustained/continuous: body temp remains above normal w/ minimal variations
Relapsing/recurrent: body temp returns to normal for 1+ days with 1+ episodes of fever, each lasting several days

How well did you know this?

Not at all

Perfectly

Terms

Afebrile: no fever
Febrile: temp/fever
Pyrexia: fever/temp

How well did you know this?

Not at all

Perfectly

Fever effects?

Decreased appetite
Headache
Hot skin
Flushed face
Thirst
Muscle aches
Fatigue
Fever blisters
Elderly- periods of confusion

How well did you know this?

Not at all

Perfectly

Fever interventions?

Maximize heat loss:
remove heavy blankets
keep clothing/linens dry
cool compress
ice packs
cooling blanket
Minimize heat production:
limit physical activity

*oral care

How well did you know this?

Not at all

Perfectly

Pulse physiology?

Palpable bounding of blood flow in peripheral artery
Regulated by cardiac sinoatrial node

How well did you know this?

Not at all

Perfectly

Pulse characteristics?

Rate, rhythm,
Amplitude 4 point scale-
0: Absent
1+: Weak
2+: Moderate
3+: Strong
4+: Bounding

How well did you know this?

Not at all

Perfectly

Pulse palpation detection sites?

Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis

How well did you know this?

Not at all

Perfectly

Where is the only place you can hear the heart?

apical

How well did you know this?

Not at all

Perfectly

Pulse assessment methods?

Palpate peripherals (cannot hear them)
Auscultate apical- 5th intercostal space
Doppler peripherals

How well did you know this?

Not at all

Perfectly

Pulse factors?

Age- aging affects metabolic rate, decreases
Sex- women slightly higher
Physical activity- increases w exercise, athletes may have decreased
Body temperature- elevated=increased, low=decreased
Stress- increase
Meds
Disease/health condition

How well did you know this?

Not at all

Perfectly

Tachycardia?

Rapid heart rate, 100+
Contributing factors:
decreased BP (blood loss, shock, trauma)
increased body temp
poor oxygenation of blood (COPD, anemia)
exercise
hyperthyroidism
pain
strong emotions
meds (epinephrine)

How well did you know this?

Not at all

Perfectly

Bradycardia?

Slow heart rate, less than 60
Contributing factors:
CAD, MI
decreased body temp
hypoxemia, sleep apnea
altered mental status (delirium)
hypothyroidism
increased intracranial pressure or nervous system conditions (CVA/stroke)
vagal stimulation (ocular pressure, vomiting)
meds (antiarrhythmics)

How well did you know this?

Not at all

Perfectly

Pulse deficit?

Difference between apical and peripheral
Need 2 people

How well did you know this?

Not at all

Perfectly

Assessing respirations?

rate
depth
rhythm
work of breathing
symmetry

How well did you know this?

Not at all

Perfectly

hypoventilation

low rate, shallow depth

How well did you know this?

Not at all

Perfectly

hyperventilation

fast rate, deep depth

How well did you know this?

Not at all

Perfectly

dyspnea

difficulty breathing

How well did you know this?

Not at all

Perfectly

tachypnea

fast breathing

orthopnea

difficulty breathing when lying down

apnea

no breathing

What is blood pressure?

force of blood against arterial walls

systolic BP?

highest pressure on arterial walls, contraction of the ventricles (systole)

diastolic BP?

lowest pressure on arterial walls, ventricles at rest (diastole)

what is normal BP?

below 120/80

what is elevated BP?

systolic between 120-129 AND diastolic between 80-89

what is stage 1 BP?

systolic 130-139 OR diastolic 80-89 lifestyle changes start at 130/80 and meds if at risk for CV

what is stage 2 BP?

systolic at least 140 OR diastolic at least 90

what is a hypertensive crisis?

systolic over 180 AND/OR diastolic over 120

what is hypotension?

less than 90/60 WITH symptoms

what is the decrease in orthostatic hypotension?

20 systolic, 10 diastolic

how to assess orthostatic hypotension?

lay down for 5 mins, take BP and pulse sit for 3-5 mins, retake stand for 3-5 mins, retake

limitations to automatic BP?

vulnerable to error: -arrhythmias -older adults -obese extremity may not work with hypotension

Normal MAP? Need a MAP of ____ or more to perfuse vital organs? How to find MAP?

70-100, 60 diastolic x2 + systolic divided by 3

factors affecting BP?

age- older= vessel stiffness increase BP race- AA increased chance hypertensive circadian rhythm- lower in morning higher in afternoon exercise weight emotional state- increase BP body position- lowest=supine meds disease smoking- vasoconstriction

if reduced salt intake by _____, this could reduce high BP by _____ million and save _____ billion health care dollars per year?

2300 mg per day, 11, $18

purpose of BP two step method?

to not miss the auscultatory gap

first Korotkoff sound?

systolic

fifth Korotkoff sound?

diastolic

how do you know you've found diastolic?

all sound disappears

most commonly used artery for BP?

brachial

when do you not take BP?

mastectomy, fistula, lymphedema, amputee, IV

what to do if BP reading indicates hyper or hypo tension?

retake BP in other arm

the pulse (feel) of a fistula is _____ and the sound of a fistula is _____

thrill, bruit (whooshing) bruit normal in fistula, abnorm in heart

numerical pain scale- mild, moderate, severe?

mild: 1-3 moderate: 4-6 severe: 7-10

what is FLACC? when to use?

Face, Legs, Activity, Cry, Consolability when patients cannot communicate

PAINAD use?

advanced dementia patients

what to ask if patient says they have pain?

onset location functional limitations interventions functional goals reassess every 4 hrs or sooner

what does SPO2 measure?

amount of hemoglobin saturated with oxygen in arterial blood, measures oxygenation NOT ventilation *rough measurement bc can have 100% SPO2 but 6 hemoglobin (male: 14-18, female: 12-16)

what is FIO2 and why is it important?

fraction of inspired air important: 88% on oxygen more emergent than 88% on room air *when low, raise head of bed to help lungs expand

what SPO2 is norms

healthy adult: around 95% adult w disease: less than 92% abnorm for everyone: less than 85%

hypoxemia ____?

kills

factors interfering with light transmission?

outside light sources carbon monoxide patient motion jaundice dark skin pigmentation (signal loss) saturation estimation (false high)

factors interfering with arterial pulsations?

peripheral vascular disease hypothermia low cardiac output hypotension peripheral edema tight probe arrhythmias edema

what are the VS criteria for rapid response team?

pulse: over 140, less than 40 resp: over 28, less than 8 BP: systolic greater than 180 or less than 90 SPO2: less than 90% despite supplementation *also call RR for acute mental status change

taylor vs jarvis?

taylor: T: 35.8-37.5 P: 60-100 R: 12-20 SpO2: 95-100 jarvis: T: 35.8-37.3 P: 60-100, 50=brady R: 10-20 SpO2: 97-99 on RA or 95 w normal Hgb