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CSON IM 1 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

When do you measure vital signs?

A

on admission
per physician order (every 4hrs, routine)
any change in the patient’s condition
before and after any major procedure
before and 15 minutes into a blood transfusion
after meds or interventions that affect vital signs

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2
Q

What is the normal adult range for temperature?

A

96.8 to 100.4

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3
Q

What is the normal temperature for the oral/tympanic/temporal areas?

A

97.6-99.6

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4
Q

What is the normal rectal temperature?

A

98.6-100.4

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5
Q

What is the normal axial temperature?

A

96.6-98.6

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6
Q

What is the normal blood pressure for an adult?

A

less than 120/80 mmHg

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7
Q

What is stage 1 prehypertension?

A

Systolic- 120 to 139
Diastolic- 80 to 89

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8
Q

What is stage 2 hypertension?

A

systolic > 140
Diastolic >90

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9
Q

What is hypotension?

A

systolic- <90 and syptomatic

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10
Q

What is a normal pulse for an adult?

A

60-100 bpm

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11
Q

What is a normal respiration count for an adult?

A

12-20 breaths per minute

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12
Q

What are the sites that a temperature can be taken at?

A

oral, axillary, tympanic membrane, temporal artery, rectal, esophageal, pulmonary artery, urinary bladder (the last four are highly invasive and not used normally)

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13
Q

What is hyperthermia?

A

inability to promote heat loss or reduce production

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14
Q

What is hypothermia?

A

prolonged exposure to cold decreases the body’s inability to produce heat
can be accidental or intentional

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15
Q

How does the body regulate temperature?

A

the hypothalamus controls heat production and loss
ex: shivering to increase temp

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16
Q

What are the two equations used to convert temperature to Celsius and Fahrenheit?

A

C= (F-32) x 5/9
F= (9/5 x C) + 32

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17
Q

Radiation

A

transfer of heat w/o direct contact

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18
Q

Conduction

A

transfer of heat w/ direct contact

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19
Q

Convection

A

transfer of heat away by air movement

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20
Q

Evaporation

A

transfer of heat when a liquid turns into a gas

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21
Q

Diaphoreses

A

visible perspiration

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22
Q

Heatstroke

A

Body temp of 104 F or more
dangerous heat emergency with a high mortality rate

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23
Q

What are the signs and symptoms of heatstroke?

A

dry, hot skin
confusion, excess thirst, muscle cramps, increased HR, decreased BP, and NO sweating

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24
Q

What are the factors that affect body temp?

A

age: babies and elderly
hormonal levels: menstrual cycle/menopause
environment and exercise
Circadian rhythm

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25
Q

What is circadian rhythm?

A

24hr sleep cycle
temps will drop in your sleep and are normally the highest around 6 pm (6 am if you work the night shift)

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26
Q

Fever (pyrexia)

A

Results in an alteration in the hypothalamic set point, fever starts at 100.4

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27
Q

What does a fever cause to happen?

A

causes an increase in metabolism and oxygen consumption
increased respiratory and heart rates

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28
Q

What is the correct placement of a thermometer while taking a rectal temp?

A

Adult- insert 1 1/2 inches
Child- insert 1 inch
Infant- insert 1/2 inch

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29
Q

Oral temp

A

easily influenced by hot or cold temps
about one degree lower than core temps

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30
Q

Axillary Temp

A

The safest way to take a temp
make sure clothing isn’t in between the skin and the probe
Must be left in place for 5-10 minutes

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31
Q

Tympanic Temp

A

One of the most rapid means of measurement
unaffected by PO intake
must remember to remove hearing aids before

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32
Q

Temporal Temp

A

Most accurate compared to a core temp
fewer errors than tympanic

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33
Q

What do you do for a patient with a fever?

A

obtain blood cultures if ordered; monitor vital signs; assess skin color, temp, and turgor; reduce frequency of activities to reduce O2 demand, maximize heat loss, give extra fluids, give a tepid water bath, oral hygiene, dry bed linens, give antipyretic meds as ordered

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34
Q

What is pulse?

A

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

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35
Q

Radial pulse

A

most common pulse site
assess the circulation to hand, should assess both sides together

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36
Q

Apical pulse

A

use if the pulse is abnormal
if taking meds that affect heart rate
if radial is inaccessible

37
Q

Carotid Pulse

A

if the patient’s condition suddenly worsens or if you need the pulse quickly
DO NOT measure bilaterally at the same time

38
Q

Dorsalis Pedis

A

Top of the foot
assesses circulation to the foot, assess bilaterally
can use the Doppler if unable to palpate

39
Q

What is the character of a pulse?

A

Rhythm- regular, irregular, dysrhythmia
Strength- 4+ (bounding), 3+ (strong), 2+ (normal), 1+ (barely feel), 0 (can’t feel at all)
Equality

40
Q

Documentation of a normal pulse

A

radial pulse 82, regular rate and rhythm, 2+, pedal pulses 2+, equal bilaterally

41
Q

Documentation of an abnormal pulse

A

radial pulse is tachycardic at 112, irregular value, diminished at 1+. Apical pulse at 110, irregular rate and rhythm; right pedal pulse 1+, left pedal pulse 0, audible with Doppler

42
Q

What do you do for a rapid pulse?

A

ask the patient to take slow, deep breaths; assess for pain, anxiety, and stress

43
Q

What is PQRST?

A

p- provokes/palliates
q- quality
r- region/radiation
s- severity/setting
t- timing
Pain is just as important as how well a patient is breathing

44
Q

What do you do for a patient’s pain?

A

provide pain meds if ordered and timely
reduce activity
provide distraction activities

45
Q

How do you determine how bad a patient’s pain is?

A

There are many different scales to use but the most common is a 0-10 scale
You might see orders written like give Tylenol for 1-4, hydrocodone for 5-8, and morphine for 9-10

46
Q

When do you assess pain?

A

always assess pain before procedures, activity, and medicate if available
always reassess pain at least 30 minutes after pain meds have been given
do not assume you know what your patients pain level is

47
Q

Documentation for Pain

A

1000- patient complains of constant dull achy pain to right food. The pain level is “9” on a 1-10 scale. Medicated with morphine 5 mg IM in right hip per orders
1030- The patient reports pain in the right foot has decreased to “3” on a 1-10 scale and is tolerable

48
Q

What is gas exchange?

A

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

49
Q

What is ventilation and respiration?

A

O2 brought into cells and CO2 brought out

50
Q

Ischemia

A

reduced blood flow

51
Q

Hypoxia

A

lack of O2 causing damage

52
Q

Hypoxemia

A

low amount of O2 in arterial blood

53
Q

Respiratory acidosis

A

not enough CO2 is leaving the body

54
Q

What is impaired gas exchange?

A

occurs because of ineffective ventilation reduced capacity for gas transport (reduced hemoglobin and/or red blood cells)
inadequate perfusion

55
Q

Factors that influence gas exchange

A

exercise, acute pain, anxiety, smoking, body positions, medications, neurological injury, hemoglobin function

56
Q

Assessment for gas exchange

A

rate: how many breaths per minute
rhythm: regular/irregular
depth: deep, normal, shallow

57
Q

Eupnea

A

ventilation of normal depth and rate

58
Q

Bradypnea

A

slow breathing, < 12

59
Q

Apnea

A

cessation of breathing

60
Q

Cheyne-Strokes

A

Deep rapid breathing, common with dying patients

61
Q

Dyspnea

A

difficulty breathing

62
Q

Orthopnea

A

change of breathing with movement

63
Q

What is an indirect measurement of O2 saturation?

A

pulse oximetry
light absorption with a photodetector, light goes through and scans how much O2 is on hemoglobin

64
Q

What is an acceptable pule ox reading?

A

95-100%

65
Q

what factors can affect a pulse ox?

A

too loose/tight, polis/artificial nails, temp of extremities (cold), movement, lighting and skin pigmentation (not common), edema, and peripheral vascular disease

66
Q

Documentation of normal gas exchange

A

respirations 18, regular. Deep and unlabored, pulse ox reading 98%

67
Q

Documentation of abnormal gas exchange

A

respirations 32, shallow and labored, pulse ox reading 86%

68
Q

What do you do for a patient with low O2?

A

ask patient to take slow, deep breaths
check the probe
apply O2 is necessary and orders present
raise head of bed to help patient breath

69
Q

What is blood pressure?

A

force exerted against blood vessels by the blood
measured in millimeters of mercury (mmHg)
systolic pressure/diastolic pressure
pulse pressure (difference in the two)

70
Q

What are factors affecting arterial blood pressure?

A

cardiac output, peripheral resistance, blood volume, viscosity, elasticity

71
Q

What equipment do you need to take a BP?

A

cuff (should be 20% larger than arm diameter),
sphygmomanometer, and stethoscope
listening to Korotkoff sounds

72
Q

Step by step for how to take a BP

A
  1. determine proper cuff and site
  2. position arm at heart level, palm up
  3. wrap the cuff snuggly above the upper arm
  4. place stethoscope in ears and close valve
  5. inflate the cuff to 30 mmHg above baseline
  6. slowly release pressure bulb
  7. note first clear sound
  8. note when sound disappears
  9. record reading
73
Q

What factors affect blood pressure?

A

age, stress, ethnicity, daily variation, medications, activity/weight, smoking, gender (men tend to run higher)

74
Q

Alternate sites for BP

A

thigh/lower leg- systolic pressure is usually 10-40 mmHg higher and diastolic stays the same
Arterial line- catheter inserted in an artery, reading monitored electronically

75
Q

Hypertension

A

major factor underlying stroke
contributing factor to heart attacks
frequently no symptoms
more common than hypotension
thickening of artery walls
loss of elasticity

76
Q

Hypotension

A

symptons include- skin mottling, clamminess, confusion, increased HR, or decreased urine output
SBP < 90 mmHg
dilation of arteries
loss of blood volume
decrease of blood flow to vital organs

77
Q

Automatic blood pressure

A

used when frequent assessment is needed
baseline BP manually first- new PT
more susceptible to error
unable to accurately detect low BP
do not talk with the patient during the reading

78
Q

What do you do for low BP

A

check O2 sats, provide fluids, educate the patient to call when getting up, place the patient in Trendelenburg

79
Q

What do you do for high BP

A

assess for pain, reduce activity, assess for anxiety or stress

80
Q

Things to remember

A

nurse is responsible for measurement of vitals
you must know a baseline to determine what is off
assure equipment is functional
know history, therapies, and medications
obtain vital signs in a systemic organized way
vital signs should be taken at same time every day

81
Q

Febrile

A

having or showing the symptoms of fever

82
Q

Afebrile

A

free from fever

83
Q

FUO

A

fever of unknown origin

84
Q

Tympanic

A

relating to or having an eardrum

85
Q

Temporal

A

near the temples

86
Q

Diffusion

A

movement of gas from a high concentration to a low concentration

87
Q

Perfusion

A

passage of fluid through circ system to an organ or a tissue

88
Q

Korotkoff Sounds

A

generated when a blood pressure cuff changes the flow of blood through the artery

CSON IM 1 (5 decks)

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