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
2
Q
What is the normal adult range for temperature?
A
96.8 to 100.4
3
Q
What is the normal temperature for the oral/tympanic/temporal areas?
A
97.6-99.6
4
Q
What is the normal rectal temperature?
A
98.6-100.4
5
Q
What is the normal axial temperature?
A
96.6-98.6
6
Q
What is the normal blood pressure for an adult?
A
less than 120/80 mmHg
7
Q
What is stage 1 prehypertension?
A
Systolic- 120 to 139
Diastolic- 80 to 89
8
Q
What is stage 2 hypertension?
A
systolic > 140
Diastolic >90
9
Q
What is hypotension?
A
systolic- <90 and syptomatic
10
Q
What is a normal pulse for an adult?
A
60-100 bpm
11
Q
What is a normal respiration count for an adult?
A
12-20 breaths per minute
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)
13
Q
What is hyperthermia?
A
inability to promote heat loss or reduce production
14
Q
What is hypothermia?
A
prolonged exposure to cold decreases the body’s inability to produce heat
can be accidental or intentional
15
Q
How does the body regulate temperature?
A
the hypothalamus controls heat production and loss
ex: shivering to increase temp
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
17
Q
Radiation
A
transfer of heat w/o direct contact
18
Q
Conduction
A
transfer of heat w/ direct contact
19
Q
Convection
A
transfer of heat away by air movement
20
Q
Evaporation
A
transfer of heat when a liquid turns into a gas
21
Q
Diaphoreses
A
visible perspiration
22
Q
Heatstroke
A
Body temp of 104 F or more
dangerous heat emergency with a high mortality rate
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
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
25
What is circadian rhythm?
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)
26
Fever (pyrexia)
Results in an alteration in the hypothalamic set point, fever starts at 100.4
27
What does a fever cause to happen?
causes an increase in metabolism and oxygen consumption
increased respiratory and heart rates
28
What is the correct placement of a thermometer while taking a rectal temp?
Adult- insert 1 1/2 inches
Child- insert 1 inch
Infant- insert 1/2 inch
29
Oral temp
easily influenced by hot or cold temps
about one degree lower than core temps
30
Axillary Temp
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
31
Tympanic Temp
One of the most rapid means of measurement
unaffected by PO intake
must remember to remove hearing aids before
32
Temporal Temp
Most accurate compared to a core temp
fewer errors than tympanic
33
What do you do for a patient with a fever?
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
34
What is pulse?
a palpable or audible bounding of blood flow noted at various points on the body
an indirect measure of circulatory status
35
Radial pulse
most common pulse site
assess the circulation to hand, should assess both sides together
36
Apical pulse
use if the pulse is abnormal
if taking meds that affect heart rate
if radial is inaccessible
37
Carotid Pulse
if the patient's condition suddenly worsens or if you need the pulse quickly
DO NOT measure bilaterally at the same time
38
Dorsalis Pedis
Top of the foot
assesses circulation to the foot, assess bilaterally
can use the Doppler if unable to palpate
39
What is the character of a pulse?
Rhythm- regular, irregular, dysrhythmia
Strength- 4+ (bounding), 3+ (strong), 2+ (normal), 1+ (barely feel), 0 (can't feel at all)
Equality
40
Documentation of a normal pulse
radial pulse 82, regular rate and rhythm, 2+, pedal pulses 2+, equal bilaterally
41
Documentation of an abnormal pulse
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
What do you do for a rapid pulse?
ask the patient to take slow, deep breaths; assess for pain, anxiety, and stress
43
What is PQRST?
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
What do you do for a patient's pain?
provide pain meds if ordered and timely
reduce activity
provide distraction activities
45
How do you determine how bad a patient's pain is?
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
When do you assess pain?
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
Documentation for Pain
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
What is gas exchange?
the process of transporting oxygen into cells and transport of carbon dioxide out of cells
49
What is ventilation and respiration?
O2 brought into cells and CO2 brought out
50
Ischemia
reduced blood flow
51
Hypoxia
lack of O2 causing damage
52
Hypoxemia
low amount of O2 in arterial blood
53
Respiratory acidosis
not enough CO2 is leaving the body
54
What is impaired gas exchange?
occurs because of ineffective ventilation reduced capacity for gas transport (reduced hemoglobin and/or red blood cells)
inadequate perfusion
55
Factors that influence gas exchange
exercise, acute pain, anxiety, smoking, body positions, medications, neurological injury, hemoglobin function
56
Assessment for gas exchange
rate: how many breaths per minute
rhythm: regular/irregular
depth: deep, normal, shallow
57
Eupnea
ventilation of normal depth and rate
58
Bradypnea
slow breathing, < 12
59
Apnea
cessation of breathing
60
Cheyne-Strokes
Deep rapid breathing, common with dying patients
61
Dyspnea
difficulty breathing
62
Orthopnea
change of breathing with movement
63
What is an indirect measurement of O2 saturation?
pulse oximetry
light absorption with a photodetector, light goes through and scans how much O2 is on hemoglobin
64
What is an acceptable pule ox reading?
95-100%
65
what factors can affect a pulse ox?
too loose/tight, polis/artificial nails, temp of extremities (cold), movement, lighting and skin pigmentation (not common), edema, and peripheral vascular disease
66
Documentation of normal gas exchange
respirations 18, regular. Deep and unlabored, pulse ox reading 98%
67
Documentation of abnormal gas exchange
respirations 32, shallow and labored, pulse ox reading 86%
68
What do you do for a patient with low O2?
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
What is blood pressure?
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
What are factors affecting arterial blood pressure?
cardiac output, peripheral resistance, blood volume, viscosity, elasticity
71
What equipment do you need to take a BP?
cuff (should be 20% larger than arm diameter),
sphygmomanometer, and stethoscope
listening to Korotkoff sounds
72
Step by step for how to take a BP
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
What factors affect blood pressure?
age, stress, ethnicity, daily variation, medications, activity/weight, smoking, gender (men tend to run higher)
74
Alternate sites for BP
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
Hypertension
major factor underlying stroke
contributing factor to heart attacks
frequently no symptoms
more common than hypotension
thickening of artery walls
loss of elasticity
76
Hypotension
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
Automatic blood pressure
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
What do you do for low BP
check O2 sats, provide fluids, educate the patient to call when getting up, place the patient in Trendelenburg
79
What do you do for high BP
assess for pain, reduce activity, assess for anxiety or stress
80
Things to remember
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
Febrile
having or showing the symptoms of fever
82
Afebrile
free from fever
83
FUO
fever of unknown origin
84
Tympanic
relating to or having an eardrum
85
Temporal
near the temples
86
Diffusion
movement of gas from a high concentration to a low concentration
87
Perfusion
passage of fluid through circ system to an organ or a tissue
88
Korotkoff Sounds
generated when a blood pressure cuff changes the flow of blood through the artery
