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Fundamentals NUR 220 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Elder speak?

A

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%

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2
Q

Why do VS need to be accurate?

A

Therapeutic action can be taken from VS

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3
Q

When to assess vital signs?

A

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)

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4
Q

Order to report VS?

A

temp
pulse
respiration
BP + MAP
pain
02

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5
Q

Temperature physiology?

A

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

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6
Q

Mechanisms of heat transfer?

A

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

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7
Q

Temperature factors?

A

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

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8
Q

Fever types?

A

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

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9
Q

Terms

A

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

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10
Q

Fever effects?

A

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

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11
Q

Fever interventions?

A

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

*oral care

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12
Q

Pulse physiology?

A

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

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13
Q

Pulse characteristics?

A

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

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14
Q

Pulse palpation detection sites?

A

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

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15
Q

Where is the only place you can hear the heart?

A

apical

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16
Q

Pulse assessment methods?

A

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

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17
Q

Pulse factors?

A

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

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18
Q

Tachycardia?

A

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)

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19
Q

Bradycardia?

A

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)

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20
Q

Pulse deficit?

A

Difference between apical and peripheral
Need 2 people

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21
Q

Assessing respirations?

A

rate
depth
rhythm
work of breathing
symmetry

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22
Q

hypoventilation

A

low rate, shallow depth

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23
Q

hyperventilation

A

fast rate, deep depth

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24
Q

dyspnea

A

difficulty breathing

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25
Q

tachypnea

A

fast breathing

26
Q

orthopnea

A

difficulty breathing when lying down

27
Q

apnea

A

no breathing

28
Q

What is blood pressure?

A

force of blood against arterial walls

29
Q

systolic BP?

A

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

30
Q

diastolic BP?

A

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

31
Q

what is normal BP?

A

below 120/80

32
Q

what is elevated BP?

A

systolic between 120-129
AND
diastolic between 80-89

33
Q

what is stage 1 BP?

A

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

34
Q

what is stage 2 BP?

A

systolic at least 140
OR
diastolic at least 90

35
Q

what is a hypertensive crisis?

A

systolic over 180
AND/OR
diastolic over 120

36
Q

what is hypotension?

A

less than 90/60 WITH symptoms

37
Q

what is the decrease in orthostatic hypotension?

A

20 systolic, 10 diastolic

38
Q

how to assess orthostatic hypotension?

A

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

39
Q

limitations to automatic BP?

A

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

40
Q

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

A

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

41
Q

factors affecting BP?

A

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

42
Q

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

A

2300 mg per day, 11, $18

43
Q

purpose of BP two step method?

A

to not miss the auscultatory gap

44
Q

first Korotkoff sound?

A

systolic

45
Q

fifth Korotkoff sound?

A

diastolic

46
Q

how do you know you’ve found diastolic?

A

all sound disappears

47
Q

most commonly used artery for BP?

A

brachial

48
Q

when do you not take BP?

A

mastectomy, fistula, lymphedema, amputee, IV

49
Q

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

A

retake BP in other arm

50
Q

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

A

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

51
Q

numerical pain scale- mild, moderate, severe?

A

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

52
Q

what is FLACC? when to use?

A

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

53
Q

PAINAD use?

A

advanced dementia patients

54
Q

what to ask if patient says they have pain?

A

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

55
Q

what does SPO2 measure?

A

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)

56
Q

what is FIO2 and why is it important?

A

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

57
Q

what SPO2 is norms

A

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

58
Q

hypoxemia ____?

A

kills

59
Q

factors interfering with light transmission?

A

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

60
Q

factors interfering with arterial pulsations?

A

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

61
Q

what are the VS criteria for rapid response team?

A

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

62
Q

taylor vs jarvis?

A

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

Fundamentals NUR 220 (21 decks)

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