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Foundations Chpter 12 Vital Signs Chapter 13 Physical Assessments > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Guidelines for obtaining vital signs

A

Measure correctly, understand and interpret the values, communicate findings, document correctly, begin interventions as needed

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2
Q

What do vital signs measure

A

Temp, pulse, respirations, blood pressure, oxygen saturation, comfort or pain level. Accuracy of vital signs is critical, vital signs can be used for problem solving = “what’s wrong”

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3
Q

When are vital signs assessed

A

Baseline vitals taken on admission, discharge, transfer, change in condition

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4
Q

When are vital signs taken more frequently

A

Sicker pt = more vital signs

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5
Q

What can low respiratory rate indicate

A

Urgent or emergent problem

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6
Q

Temp above 105f

A

Can damage body cells

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7
Q

When to not take oral temp

A

On comatose pt

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8
Q

What can a rise in temperature of 1 degree do

A

Increase pulse rate by 4 beats per minute. Can also increase bl press and respirations

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9
Q

Hemorrhaging causes

A

Decrease in bl. Pressure pulse and respirations increase. Temp usually decreases

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10
Q

Norm temperature

A

98.6F. (37C). (Book)Variations from 97 to99.(36.1C to37.5C)

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11
Q

2 types of body temp

A

Core temp= deep tissue= constant
Surface temp= skin= changes

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12
Q

When does Hypothermia occur

A

Body temp abnormally low below 93.2Fx

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13
Q

What temp is considered a fever

A

Above100.4F. Exceeding 105F damages cells

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14
Q

Different methods of taking temperature

A

Heat sensitive patches
Electronic thermometer
Tympanic thermometer
Temporal artery method

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15
Q

Body temperature is regulated by what part of brain

A

Hypothalamus

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16
Q

Parts of the stethoscope

A

DIAPHRAGM =high pitched noise, movement of blood and air
BELL=low pitched noise, heart sounds vascular sounds
EARPIECE = toward nose
TUBING= hold still to minimize noise

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17
Q

What does pulse measure

A

Heart rate

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18
Q

Peripheral pulse points

A

Temporal, carotid, apical, brachial, radial, femoral, popliteal, pedal, dorsal is pedis

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19
Q

Where is apical pulse taken at

A

Mid clavicular line, 5th intercoastal space, apical pulse used for patients w/ heart problems

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20
Q

Where is radial pulse taken at

A

Measured in groove of wrist. Thumb/radial side of forearm. Is lateral to flexor tendon

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21
Q

Pulse deficit

A

Difference between the radial pulse and the apical. Apical pulse minus the radial pulse = pulse deficit both pulses are taken simultaneously

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22
Q

How do you assess respirations

A

Rate counting (12-20), Depth(observe movement of diaphragm), Quality, Rhythm

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23
Q

Breathing w/difficulty

A

Dyspnea

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24
Q

How many respirations for bradycardia

A

Less than 12

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25
Q

How many respirations for tachycardia

A

Faster than 20 per min

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26
Q

How many respirations for Cheyenne stokes

A

Varying periods of increasing depth /periods of apnea

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27
Q

Normal respirations

A

12-20 breaths per minute

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28
Q

Kussmaul breathing pattern

A

Rapid deep and labored

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29
Q

Where do you position lower extremity blood pressure cuff

A

Above politeal artery at mid thigh

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30
Q

Blood pressure is measured by what( metric)

A

Millimeters of mercury(mmHg)

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31
Q

Top number when measuring b/p

A

Systolic (force against arteries during contraction of the heart)

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32
Q

Bottom number when measuring b/p

A

Diastolic (force arteries when heart is relaxed)

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33
Q

What might raise pt. B/p

A

Fear of dr office, pain, anxiety, smoking, pregnancy, exercise, trauma

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34
Q

Vital signs normal limits

A

Temp= 97.6F-99.6F (36.4C-37.5C)
Pulse rate= 60-100 BPM
Respirations= 12-20 per min
Systolic BP= 100 to 120 mmHg
Diastolic BP= 70 to 80 mmHg
Pulse Ox= 95 to 100%
Slightly different ranges for older adults

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35
Q

What factors affect vital signs

A

Environment, age, stress, smoking, timeof day, pts. state of health, activity levels, pain, bleeding, position change, stage of menstrual cycle, hormones

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36
Q

Height and weight are necessary to

A

Assess growth and development
Drug dosage calculations
Assess efficacy of drug therapy
Weight change- may be sign of under lying desease

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37
Q

When should weight be measured

A

Same time of day
Same scale
Same clothing

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38
Q

2.2 lbs also equals

A

1 liter of fluids, 1 kilogram

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39
Q

What does pulse oximeter measure

A

Oxygen saturation, which is the measurements of how much oxygen is combined with hemoglobin in the red blood cell also provides pulse rate

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40
Q

What is hemoglobin

A

Protein on RBC

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41
Q

Body part used to measure pulse ox

A

Warm finger Can use toes or earlobes depending on probe
Cold hands,thick nails,nail polish,and artificial nails can interfere with measurement

42
Q

Normal range for pulse ox

A

95-100%on room air(RA)

43
Q

Cardiac output

A

Amount of blood ejected from heart in 1 min

44
Q

Orthostatic hypertension

A

Drop in BP with change in position

45
Q

When measuring height

A

Remove shoes, stand erect

46
Q

Vital sign abbreviations

A

R next to number=rectal temp
Axnext to number=axillary temp
ap next to number= axillary temp

47
Q

When is use of electronic BPmeasuring device inappropriate

A

Arrythemias, excessive tremors, inability to cooperate to minimize arm motions, irregular heart rate, obese extremity, older adults, peripheral vascular obstruction(clots, narrowed vessels), seizures, shivering

48
Q

Interventions for abnormal body temperature

A

Repeat measurement, monitors q4 hours, limit physical activity, encourage fluid intake if not contra indicated( heart failure), give meds, if temp above normal assess for infection, if subnormal, cover pt. with more blankets,close doors-windows

49
Q

Intervention for abnormal pulse

A

1.Use different pulse sight, use Doppler, 2.Observe for cyanosis of tissue distal to weak pulse/ coldness of extremity, 3. observe for signs of dyspnea, fatigue, chest pain,syncope. 4.assess pulse deficit

50
Q

Interventions for pt. with abnormal respirations

A

1.Possible effects of meds or anesthesia, 2. Reposition to upright sitting. 3. Respirations below 10 or above 20 require immediate intervention 4. Observe for obstructed airway or snoring respirations

51
Q

Interventions for pts. with abnormal bl. pressure

A

1Repeat assessment, 2.

52
Q

Orthostatic bp

A
53
Q

Procedure for obtaining a manual blood pressure

A
54
Q

What is objective data

A

What the nurse sees and feels also laboratory findings, diagnostic imaging

55
Q

Subjective symptoms

A

Perceived by the pt., reported by pt., or pt. family
Reports of pain, nausea, vertigo, pruritis(itchy skin), anxiety and diplopia (double vision) if no tool is used for measurement, than it is subjective

56
Q

Objective signs

A

Can be seen, heard, and measured. As in rashes, skin color, altered vital signs, visible drainage or exudate, leakage from bl. Vessels, lab results, diagnostic imaging

57
Q

Disease and diagnosis

A

Disturbance of structures or function of that system organ/cell
DISEASE IS A PATHOLOGIC CONDITION OF THE BODY
Recognized by a set of signs and systems /clustered in groups

58
Q

Who makes medical diagnosis

A

Clinician (treats and cures)

59
Q

What are the nurses goals

A

Holistic treatment (form of healing that considers the whole person)
RNs make nursing diagnosis.
LPNs identity a patient problem

60
Q

Etiology of disease(cause)

A

Hereditary= transmitted genetically parent (grandparent) to child
Congenital= occurring at birth or shortly thereafter blindness
Infectious= hiv , measles TB
Deficiency= lack of nutrients, iron deficiency as in scurvy(lack of vit C), rickets(lack of vit D)
Metabolic=loss of homeostasis DM
Neoplastic= abnormal growth of new tissues
Inflammatory=hay fever, bronchitis
Degenerative= may be progressive MS, osteoarthritis
Iatrogenic= treatment
Unknown etiology
Traumatic=physical, psychological, any abuse, loss of any kind, weathering ( think of Maslow)
Environmental= CO2, asbestos,
Autoimmune= IBD, Gillian barre, lupus

61
Q

What is a Risk factor

A

Increase your chances of becoming Ill/accident

62
Q

Some risk factors are

A

Habits, environmental condition, genetic predisposition, physiologic condition, age, lifestyle( often mechanisms of coping) and social detriments(education,health and healthcare, social and community)

63
Q

Terms used to describe disease

A

Chronic=slow onset, long effects persist over long period further described as early or late, Terminal, Remission
Acute=sudden onset, severe S/S
Functional disease= no apparent structural origin as in mental illness, nervous system

64
Q

Inflammation

A

Protective response of the body tissues, healing and defensive response after irritation, injury, or invasion by organisms. S/Sx

65
Q

Infection

A

Invasion of microorganisms
Bacteria,viruses fungi or parasites
Produces tissue damages/Sx

66
Q

Frequently noted signs and symptoms

A

Aorexia= no appetite, Cyanosis=deoxygenated blood, Diaphorisis= sweating, Ecchymosis= bruising, Edema=swelling, Erythema= red, Fetid=stinky, Jaundice= yellowing, Sclera icterus=white of eyes are yellowish, Ortopenia=shortness of breath while lying flat. need to change position to breath well, Pallor=pale, Purelant drainage=pus/slough, Sallow=yellowish looking skin

67
Q

For medical assessment you must

A

First Get consent, evaluation of pt. condition (are the well/unwell)

68
Q

Who conducts physical exam

A

Clinician= dr., midwife, PA
Follow physicians orders unles they ar unethical, immoral or illegal
Nurse Carrie’s out certain functions

69
Q

What is Nursing assessment

A

Observation done by senses of touch, smell, sight and hearing

70
Q

During nursing assessment you must

A

Perform hand hygiene, Document, get consent, assess LOC level of consciousness

71
Q

Items needed for nursing assessment

A

Penlight, stethoscope, sphygmomanometer, thermometer, watch. W/second hand, gloves, tongue blade

72
Q

What to ask to obtain HPI= history of present illness aka

A

O=onset
P=precipitation, provocative, palliative
Q=quality/quantity
R=region/radiation
S=severity
T=treatments
U=understanding
V=values goals/expectations

73
Q

What is biographic data

A

Date of birth, gender, address, marital status, family members names, occupation health insurance benefits

74
Q

What is the chief complaint

A

It is the reason for seeking health care

75
Q

Nursing physical assessment

A

Initial assessment is done byRN
Ongoing assessments the responsibility of LPN and RN

76
Q

When to perform admission assessment

A

As soon as possible

77
Q

Techniques for physical assessment

A

Non abdomen=inspection. Palpate. Auscultation, Percussion
Abdomen exams only= 1st inspection, 2nd auscultation, 3rd palpation

78
Q

For cultural considerations you should

A

Focus on humility

79
Q

Head to toe assessment

A

Neurological. Skin and hair. Head and neck. Mouth and throat. Eyes ears nose. Chest lungs heart and vascular system. Gastrointestinal system. Genitourinary system. Rectum. Legs and feet

80
Q

What neurological assessment entails

A

Speech: clear, slurred.thick nonverbal
Tongue: midline or deviates
Facial symmetry: symmetrical/droop
Affect: flat right hostile sad
Syncope: faints
Follows commands

81
Q

How skin should appear

A

Warm dry and intact. Good turgor. No lesions check palms and soles of feet

82
Q

Head and neck assessment

A

Check eyes. Ears. Nose. Mouth and mucous membranes. Neck(jugular vein distinction is not a normal finding)

83
Q

Cardiovascular assessment

A

Check apical pulse rate
Check capillary refill it should take less than 3 seconds = brisk can use toe nails or fingers upper/lower extremities
Check Legs and feet
Edema= pitting or non pitting. pitting edema grading scale from 1-4. note location Press against boney prominence for 5 sec
IV fluid= type, rate, site
Pedal and radial pulses=check strength 0= absent, 1= thread, 2=weak, *4=BOUNDING

84
Q

Focused neurovascular assessment (peripheral vascular)
What actions are taken to perform peripheral vascular assessment

A

Assess radial, brachial, ulnar, femoral, popliteal, dorsalis pedis, and posterial tibial pulses
Assess pulse rate by counting. Check rhythm for regularity. Measure strength by using scale
Begin with the most distal pulse (rate rhythm strength)
Check capillary refill
Check symmetry

85
Q

Expected heart sounds

A

LUB/S1= 1st sound heard when AV valve closes. Beginning of systole. Listen at the Apex
Dub/s2= 2nd sound heard when semi-lunar valve closes listen at base of heart

86
Q

Ausculatory Landmarks

A
87
Q

What are Bruit sounds

A

ABNORMAL SOUNDS. Turbulent blood in blood vessels swishing sounds

88
Q

What are Thrill sounds

A

ABNORMAL SOUNDS. Felling/palpating turbulent blood in blood vessel. Vibration
This is an expected finding with dialysis access points likeAV fistulas and AV shunts

89
Q

Respiratory portion of physical assessment

A

Check anterior and posterior.
Check chest wall movement for depth
Pattern=Regular/Irregular; tachypnea; orthopnea; dyspnea
Check O2 sat w/ pulse oximeter
Supplemental oxygen (NC, RA,mask, NRB)

90
Q

During atrial contraction which valves are open/closed

A

A/V valves are open S/L valves are closed

91
Q

During ventricular contraction which valves are open/closed

A

A/V valves are closed. S/V valves are open

92
Q

Abdominal assessment

A

Inspect= distended/non distended. Flat/round
Auscultate bowel sounds=each quadrant for 1 min. Active, hyperactive, hypo active, absent
Palpitation= masses, tenderness/ non tender *REBOUND TENDERNESS

93
Q

Genitourinary assessment

A

C= color
O= Oder
C= clear/cloudy
A= amount; small, moderate, large(ml)
Catheters= indwelling, nephrostomy, suprapubic, urostomy

94
Q

Assessment of genitals, perineum, and rectum

A

Assess for= lumps, lesions, lice, discharge moisture, hemorrhoids, bleeding

95
Q

Documentation

A

Be objective, clear, complete and concise
If you didn’t write it you didn’t do it

96
Q

Priorities of care

A

1.ABCs=ALWAYS airway, breathing, circulation
2.Safety
3.Prevention

97
Q

Which body system does each belong to

A

Respitory rate= Respitory
Pedal pulses=cardiovascular
Edema of legs =cardiovascular and lymphatic
awake alert oriented =neuro
BP= cardiovascular Renal?
Lung sounds = Respitory
Heart sounds=cardiac
Bowel sounds=GI system listen 1 min each quadrant

98
Q

lung sounds (abnormal)

A

Start at apex
**Crackles= wet popping sounds heard in CHF
Wheezes= sibilant(hissing sound) sonorous
Pleural friction rub=sounds like rubbing (caused by pleural membranes)
Ronchi= resembles snoring
Bronchi=loud and harsh midrange pitch

99
Q

Metabolic

A

Diabetes

100
Q

Stehoscope

A

Diaphragm= high pitched
Bell= low pitched sound

Foundations Chpter 12 Vital Signs Chapter 13 Physical Assessments (1 decks)

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