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Module 1 Exam 1 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are the five main vital signs and their normal ranges?

A

Temperature(96.8-100.4)
Pulse(60-100bpm)
Blood Pressure (120/80 mmHg)
Respiration(10-20 breaths per min)
Oxygenation (95%-100%)
Secret sixth: Pain

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2
Q

When should you measure vitals?

A

-On admission
-On order
-Routinely (4 Hours)
-Before During and After(B.D.A.) any major procedure
-B.D.A. Blood Transfusion
-After any form of intervention(Usually Meds) that could measure vital signs
-When the pt’s conditions changes or they report that they’re having physical pain/distress

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3
Q

What is Body temperature?
What organ controls it?

A

Heat Produced vs Heat Lost
Hypothalmus

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4
Q

How do we produce heat?

A

-Metabolism(BMR)
-Shivering

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5
Q

How do we lose heat?

A

-Radiation(No contact)
-Conduction(Direct Contact)
-Convection(Air movement)
-Evaporation
-Diaphoresis(Perspiration/sweating)

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6
Q

What’re factors that affect temperature?

A

-Age
-Hormones
-Environment
-Exercise
-Sleep(Circadian Rhythm)
-Meds

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7
Q

What is a fever and its facts?

A
  • High Temperature
  • Only harmful if over 102.2
  • Take temperature multiple times a day
  • Ups metabolism and O2 consumption and HR and respiratory rate
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8
Q

What’re Hyperthermia and Heat stroke?

A

-Hyperthermia: Inability to promote heat loss or reduce production, resulting in a high temperature
- Heatstroke: Very hight heat emergency with a very high mortality rate, body temp of 104 or more

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9
Q

What is the difference between hyperthermia and heatstroke.

A

-Heatstroke results in DRY AND HOT SKIN, as well as confusion excess thirst and muscle cramps, this increases HR and decreases BP, once again NO SWEATING

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10
Q

What is hypothermia?

A

-Prolonged exposure to cold decreases the body’s ability to produce heat, resulting in a cold body temp
-Can be accidental but also intentional
-Temps are 86F - 96.8

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11
Q

Whatre the conversion equations for Celsius to Fahrenheit?

A

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

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12
Q

Facts on Oral Temperature?

A
  • It can be easily influenced by food and drinks
  • One of the most common
  • ~1 degree lower than the core body temperature
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13
Q

Facts on rectal temperature?

A
  • In adults go 1-1.5in in the anus
  • Feces could cause innacurate readings
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14
Q

Facts on axillary temperature?

A
  • Armpit
  • 5-10 minutes
  • Moisture can reduce the temp
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15
Q

Facts on tympanic temp?

A
  • One of the most rapid measurements
  • PO intake does not matter
    -Take off hearing aids
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16
Q

Temporal temp?

A
  • Closest to core temp
  • Fast reading
  • Easy to use
  • Very few errors
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17
Q

A patient has a fever, what can you do for them?

A

-Cool room
- Reduce the coverings on patient
- Keep cloths and linen dry
- Limit activities
- Give antipyretics
- Encourage patient to take fluids
- Take blood samples if ordered to
- Check pt’s VS, skin color, temp, and lab work and turgor?

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18
Q

What is pulse?

A
  • Audible bounding of blood flow at certain body points
  • Also indicates circulatory status indirectly
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19
Q

What are the sites of assessment for the pulse and noteworthy facts?

A

-Radial
Most common
Best used for patient teaching
Assess both hands at once for one pulse
- Apical
only use if pulse is abnormal or radial is inaccessible
could change if meds that affect HR are taken
-Carotid
If patient condition is worsened or if you need a pulse quickly
DO NOT DO BOTH SIDES AT ONCE
- Dorsalis Pedis
Top of foot
Assess both at the same time

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20
Q

How can you categorize pulse rhythm?

A

Regular, irregular, or dysrhythmia

21
Q

How can you categorize the strength of pulse

A

4+, 3+(strong), 2+(Normal), 1+(Weak),0

22
Q

What should you do if the pt has a rapid pulse?

A
  • Ask pt to take slow and deep breaths
  • Assess for pain, anxiety, or stress
23
Q

What is gas exchange?

A

O2 in and CO2 out

24
Q

Ventilation

A

Movement of gas into and out of the lungs

25
Q

Diffusion

A

exchange of O2 and CO2 between alveoli and RBC’s

26
Q

Perfusion

A

Distribution of RBC’s to and from the pulmonary capillaries

27
Q

What causes impaired gas exchange?

A
  • Poor ventilation
  • Low capacity for gas(Usually from low hemoglobin or RBC’s)
  • Poor perfusion
28
Q

What are the assessments of respiration?

A
  • Rate: Breaths/min
  • Rhythm: Regular or Irregular
  • Depth: Deep, normal, or shallow
29
Q

What factors can affect respiration?

A
  • Exercise
  • Acute pain
  • Anxiety
  • Smoking
  • BODY POSITION
  • Meds
  • Neurological injury
  • Hemoglobin Function
30
Q

What are the alterations in respiration?

A
  • Bradypnea: Slow (<10 breaths/min
  • Tachypnea: Fast (>24 breaths per min)
  • Apnea: Moments with no breathing occurring (sleep apnea)
  • Cheyenne Stroke: Regular cycle of fast breathing to slow then to apnea
  • Biot’s Respiration: Normal breathing then apnea
31
Q

What does pulse oximetry measure?

A

O2 saturation in the blood

32
Q

What does Pulse saturation (SpO2) estimate?

A

arterial saturation (SaO2)

33
Q

Normal Pulse oximetry range?

A

95%-100%

34
Q

What can affect Pulse Ox?

A

-Positioning of device
- Polish or fake nails
- Temp of finger
- Movement
- Light
- Skin color
- Edema
- Peripheral vascular disease

35
Q

What can you do if Pulse ox is low?

A
  • CHECK POSITION OF PULSE OX
  • Raise bed’s head
  • Ask pt to take slow and deep breaths
  • Give O2 if necessary and tell the physician after
36
Q

What is BP and how is it measured?

A

-Blood Pressure: Force exerted against blood vessels
- mmHg with Systolic and Diastolic numbers

37
Q

What are factors affecting BP?

A
  • Cardiac output
  • Peripheral Resistance(resistance of BV)
  • Blood volume
  • Viscosity
  • Elasticity
38
Q

Factors affecting BP?

A
  • Age
  • Stress
  • Ethnicity
  • Gender
  • Changes daily
  • Meds
  • Activity and weight
  • Smoking
39
Q

What are hypertension usually factors of? And are there usually symptoms of Hypertension

A
  • Stoke and Heart attack
  • No
40
Q

Symptoms of Hypotension?

A
  • Skin mottling
  • Clamminess
  • Confusion
  • ^ HR
  • Low urine output
41
Q

If taking BP in the thigh, what is usually off?

A

Systolic pressure is usually higher by about 10-40mmHg

42
Q

What to do for low BP readings?

A
  • Check O2 saturation
  • Give fluids
  • Tell pt to call when they need to get up
  • Put pt in trendelburg position
43
Q

What to do if High BP?

A
  • Assess for pain, anxiety, or stress
  • Reduce activity
  • Rest
44
Q

What is PQRST for pain assessment?

A
  • Provokes/palliates:
  • Quality: How bad is it
  • Region/Radiation: Where and is it radiating?
  • Severity and setting:
  • Timing:
45
Q

When should you assess for pain?

A

Often
- before procedures, activity and meds
-at least 30 mins after pain meds are given
- NEVER assume their pain, it is what they say it is

46
Q

How to measure pain?

A

Ask for a scale of 1-10

47
Q

What to do for pain?

A
  • Give meds if ordered
  • Lower activity
  • Give any distraction possible if wanted
48
Q
A

Module 1 Exam 1 (6 decks)

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