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NUR 220 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

“Infantilizing communication”

A

sweetie, dearie, honey pie, sweet pea

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2
Q

elder speak

A

conveys a message of incompetence of the reciever

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3
Q

Resistance to care (RTC) in older adults with dementia

A

-increases, when elder speak, is used
-disrupts nursing care
-increases cost of care by 30%

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4
Q

When to assess vital signs in acute care settings

A

-admission
-institutional policy
-change in pt’s condition
-before/after surgical or invasive procedures
-before/after certain medications
-before/after activity in certain cases

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4
Q

Vital Signs

A

Temperature, Pulse, Respiration, Blood pressure, Pain, Pulse Oximetry Sp02 and FI02

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5
Q

Nursing Process: ADPIE

A

Assessment
Diagnosis
Planning
Implementation
Evaluation

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6
Q

Assessment of VS requires you to make judgments of what?

A

the means of :measurement, equipment, and frequency of Vitals

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7
Q

Normal Oral temp range

A

35.8-37.5 degrees Celsius

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8
Q

Normal Pulse rate

A

60-100 bpm

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9
Q

Normal Respiration rate

A

12-20 breaths/min

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10
Q

Normal Blood pressure

A

lower than 120/80

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11
Q

Factors affecting Body Temp

A

-circadian rhythms (cold in AM, hot in PM)
-age and gender (elder and males have lower temps)
-physical activity (generates heat)
-environmental temp (surroundings)

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12
Q

heat production

A

-metabolism
-hormones
-exercise

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13
Q

heat loss

A

-skin
-sweat
-warming and humidifying air
-eliminating urine and feces

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14
Q

Core Temps

A

temperature at deep tissue
-RED=rectal
-tympanic
-temporal artery
-pulmonary artery
-bladder
-esophagus

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15
Q

Surface Temps

A

gives a reflection of core temperature
-oral=BLUE
-axilla
-skin surface chem strips

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15
Q

afebrile

A

without fever/temp

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16
Q

febrile

A

fever/ high temp

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17
Q

pyrexia

A

fever

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18
Q

physical effects of fever

A

-decreased appetite
-headache
-hot skin
-flushed face
- thirst
-muscle aches
-fatigue
-ELDERLY MAY HAVE PERIODS OF CONFUSION

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19
Q

Interventions for patients with a fever

A

maximize heat loss & minimize heat production
-remove heavy blankets
-keep clothing and linens dry
-cool compresses
-ice packs
-cooling blankets
-limit physical activity
-oral care

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20
Q

what is a pulse?

A

the palpable bounding of blood flow in a peripheral artery, regulated by the SA node in heart
-count for 30 sec x 2
-lub/dub = 1

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21
Q

characteristics of peripheral pulse

A

rate, rhythm, amplitude (0-4+)

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22
Q

sites to detect pulse

A

temporal, carotid, femoral, popliteal, post tibial, dorsalis pedis

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23
Q

where is the apical pulse

A

5th ICS, mid-clavicular line

24
Q

tachycardic

A

fast pulse >100

25
Q

bradycardic

A

slow <60

26
Q

pulse deficit

A

2 people listen, 1 listens to the apical, 1 listens to the radial and subtract

27
Q

hypoventilation

A

slow rate and shallow breath

28
Q

hyperventilation

A

fast rate and deep breath

29
Q

dyspnea

A

difficulty breathing

30
Q

tachypnea

A

fast breathing

31
Q

orthopnea

A

difficulty breathing laying down/ can only breath sitting up

32
Q

apnea

A

without breathing

33
Q

What is blood pressure?

A

force of the blood against arterial walls

34
Q

systolic

A

highest pressure on the walls, contraction of ventricles

35
Q

diastolic

A

lowest pressure on the walls, ventricles at rest

36
Q

elevated B/P

A

120-129 / 80-89

37
Q

Stage 1 HTN

A

130-139/ 80-89
-lifestyle changes should begin
- medication if patient is as risk for CV event

38
Q

Stage 2 HTN

A

at least 140/90

39
Q

Hypertensive crisis

A

> 180 / >120

40
Q

factors affecting BP

A

age, race, circadian rhythm, food intake, exercise, weight, emotional state, body position, drugs & meds, diseases, SMOKING

41
Q

Reducing salt intake to less than what is recommended?

A

2,300 mg per day

42
Q

bruit

A

what you hear (flow)

43
Q

thrill

A

what you feel (bounding)

44
Q

orthostatic B/P

A

supine to upright and blood pressure doesn’t compensate (lower b/p drops 20mmHg/10mmHG)

45
Q

primary hypertension

A

unidentified reason

46
Q

secondary hypertension

A

elevated due to disease

47
Q

need a mean arterial pressure (MAP) of ____mmHg or greater to perfuse vital organs

A

60mmHg

48
Q

Pain

A

is always what the patient says it is

49
Q

FLACC scale

A

pain scale in babies
(face, leg, activity, crying, consolability)

50
Q

PAINAD

A

pain in advanced dementia

51
Q

reassess pain how often?

A

Q4 hours

52
Q

why do we undertreat pain?

A

-personal bias
-thinking pain is a part of aging
-may lead to resp. depression or addiction
-insufficient education
-older adults fear they will be addicted
-cognitive or communication impairments

53
Q

Pulse ox Sp02

A

measures the amount of hemoglobin saturated with O2 in arterial blood
-normal healthy adult >95%
-DOES NOT MEASURE VENTILATION
-less than 85% is abnormal in EVERYONE

54
Q

abnormal Sp02 reading

A

leave it on, raise the HOB, take deep breaths

55
Q

light interference with pulse ox

A

-outside light
-carbon monoxide
-the patient is moving
-dark pigmentation (false high)

56
Q

pulse interference with pulse ox

A

-PVD,
-hypothermia
-low cardiac output
-hypotension
-peripheral edema
-tight probe
-arrhythmias

57
Q

criteria for rapid response team

A

-HR >140bpm or less than 40bpm
-RR >28 or less than 8
-systolic BP >180mmHg or less than 90 mmHg
-O2 less than 90%
-acute change in mental status

58
Q

hypotension

A

<90/60 with S&S

NUR 220 (7 decks)

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