vital signs Flashcards
what is cardiopulmonary for?
Heart and lungs
when do you do you measure vital signs?
ALWAYS among admissions, before/during/after any procedure, change in patients conditions, per physician (every 4 hours), before/during/after blood transfusions, after medications or interventions that affect vital signs, and when a patient’s conditions change/or in distress
Normal vital signs- temperature (Fahrenheit)
96.8 -100.4
What temperature is considered a fever by the centers of disease?
100.4°F
Average oral mouth, tympanic, and temporal temperature?
98.6°
Average rectal temperature?
99.5°
Average axillary temp?
97.7°
Pulse is how many BPM? (adults)
60-100 BPM
Respiration is how many breaths per minute?
12-20 breaths per minute
Oxygen saturation is ____ %?
Greater than or equal to 95%
Normal blood pressure
120/80
What is elevated blood pressure?
Systolic is 120-129 and diastolic is over 80
Hypertension blood pressure is ____ than elevated
Greater
Stage 1 of hypertension, what is the systolic and diastolic rate?
Systolic 130-139 OR diastolic is 80-89
Stage 2 of hypertension, what is the systolic and diastolic rate?
Systolic is greater than or equal to 140 OR diastolic is 90
Body temperature is produced by the ____
Hypothalamus
When our body produces heat, it increases our ___ & ____?
BMR (basal metabolic rate) and heart rate
What is the largest organ on the body?
Skin
What factors affect the body temperature?
Age, hormonal, environment, temperature alterations, exercise, circadian rhythm (sleep)
Is gender a factor in affecting body temperature?
No
When is the body temperature the lowest?
Dead of the morning
Defense mechanism to fighting a viral infection?
Fever 100.4°
When you have a fever, you will have an increase in four things, what are these?
Metabolism, heart rate, respiratory rate, and oxygen consumption
____ inability to promote heat loss or reduce production
Hyperthermia
Hyperthermia can cause a ____ because you have a body temperature of 104° or higher and have a ____ mortality rate
Heatstroke, high
Hyperthermia you will have increased _____ & decreased _______
Heart rate, blood pressure (breathing faster)
No sweating is a sign of ______
Hyperthermia
______ is caused from prolonged exposure to cold and the body’s inability to produce heat
Hypothermia
During hypothermia, the body’s temperature is between ___ and _____
86° and 96.8°
What is the equation to convert Fahrenheit to Celsius?
C= (F-32) x 5/9
What is the equation to convert Celsius to Fahrenheit?
F= (9/5 x 29) + 32
____ temperature can be easily influenced by hot or cold foods and is approximately 1 degree lower than core temperature
Oral
What is the most accurate temperature reading compared to core temperature?
Temporal
List a few Nursing interventions for fever
Cool room environment, reduce external coverings, make sure clothes/bedding is dry, administer antipyretics as ordered are a few
On the stethoscope, the bell, you will hear ____ pitch sounds
Low
On a stethoscope, the diaphragm, you will hear ___ pitch sounds
High
Assessment of pulse sites (4)
Radial (first), apical (if you can’t do radial), carotid, and dorsal pedis
What is the baseline pulse?
60-100 BPM
Nursing intervention for a patient with a rapid pulse
Ask to take slow/deep breaths, assess pain (0-10), assess anxiety/stress
____ is the process of transporting oxygen into cells and transport carbon dioxide out of cells
Gas exchange
Movement of gases into and out of the lung
Ventilation
This is when the heart rate is lower than 60
Bradycardia
When the heart rate is higher than 100 (rapid heart rate)
Tachycardia
Assessment of respiration you will find the ___, ____, ____, and. ______
Rate, rhythm, depth, and Eupnea
Nursing interventions for low O2 saturation would be?
Check location of pulse ox, raise the head of the bed, ask to take slow/deep breaths, and apply oxygen if necessary and contact physician
_____ is the force exerted against the blood vessels by the blood
Blood pressure
5 factors that affect arterial blood pressure
Cardiac output, peripheral resistance, blood volume, viscosity, and elasticity
What is the korotkoff sounds?
Systolic is the first thump and diastolic is the last followed by silence
Major factor in underlying stroke, contributing factor to heart attacks, frequently no symptoms
Hypertension BP
Symptoms include skin mottling, clamminess, confusion, increased heart rate, or decreased urine output
Hypotension BP
What is more common, hypertension or hypotension?
Hypertension
Alternate blood pressure sites can be ____ or _____
Supine position or arterial line
Nursing interventions for low BP would be?
Check O2 saturation, provide fluids, educate patient to call when getting up, and place patient in Trendelenburg position (head down in bed)
Nursing interventions for high BP?
Assess for pain, reduce activity, assess for anxiety/stress, and rest
Having or showing signs of a fever
Febrile
Free from fever
Afebrile
Fever of unknown origin
FUO
Shortness of breath
Dyspnea
Discomfort when breathing while laying down
Orthopnea
Eupnea
Normal breathing
Do vital signs need to be taken at the same time every day?
Yes
When do you assess pain after pain medication have been given?
At least 30 minutes after
Nursing interventions for pain:
Provide pain medications if ordered and timely, reduce activity, and provide distractions
What is the scale list for pain?
0- 10
