Vital Signs Flashcards
Guidelines for obtaining vital signs
Measure correctly, understand and interpret the values, communicate findings, document correctly, begin interventions as needed
What do vital signs measure
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”
When are vital signs assessed
Baseline vitals taken on admission, discharge, transfer, change in condition
When are vital signs taken more frequently
Sicker pt = more vital signs
What can low respiratory rate indicate
Urgent or emergent problem
Temp above 105f
Can damage body cells
When to not take oral temp
On comatose pt
What can a rise in temperature of 1 degree do
Increase pulse rate by 4 beats per minute. Can also increase bl press and respirations
Hemorrhaging causes
Decrease in bl. Pressure pulse and respirations increase. Temp usually decreases
Norm temperature
98.6F. (37C). (Book)Variations from 97 to99.(36.1C to37.5C)
2 types of body temp
Core temp= deep tissue= constant
Surface temp= skin= changes
When does Hypothermia occur
Body temp abnormally low below 93.2Fx
What temp is considered a fever
Above100.4F. Exceeding 105F damages cells
Different methods of taking temperature
Heat sensitive patches
Electronic thermometer
Tympanic thermometer
Temporal artery method
Body temperature is regulated by what part of brain
Hypothalamus
Parts of the stethoscope
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
What does pulse measure
Heart rate
Peripheral pulse points
Temporal, carotid, apical, brachial, radial, femoral, popliteal, pedal, dorsal is pedis
Where is apical pulse taken at
Mid clavicular line, 5th intercoastal space, apical pulse used for patients w/ heart problems
Where is radial pulse taken at
Measured in groove of wrist. Thumb/radial side of forearm. Is lateral to flexor tendon
Pulse deficit
Difference between the radial pulse and the apical. Apical pulse minus the radial pulse = pulse deficit both pulses are taken simultaneously
How do you assess respirations
Rate counting (12-20), Depth(observe movement of diaphragm), Quality, Rhythm
Breathing w/difficulty
Dyspnea
How many respirations for bradycardia
Less than 12
How many respirations for tachycardia
Faster than 20 per min
How many respirations for Cheyenne stokes
Varying periods of increasing depth /periods of apnea
Normal respirations
12-20 breaths per minute
Kussmaul breathing pattern
Rapid deep and labored
Where do you position lower extremity blood pressure cuff
Above politeal artery at mid thigh
Blood pressure is measured by what( metric)
Millimeters of mercury(mmHg)
Top number when measuring b/p
Systolic (force against arteries during contraction of the heart)
Bottom number when measuring b/p
Diastolic (force arteries when heart is relaxed)
What might raise pt. B/p
Fear of dr office, pain, anxiety, smoking, pregnancy, exercise, trauma
Vital signs normal limits
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
What factors affect vital signs
Environment, age, stress, smoking, timeof day, pts. state of health, activity levels, pain, bleeding, position change, stage of menstrual cycle, hormones
Height and weight are necessary to
Assess growth and development
Drug dosage calculations
Assess efficacy of drug therapy
Weight change- may be sign of under lying desease
When should weight be measured
Same time of day
Same scale
Same clothing
2.2 lbs also equals
1 liter of fluids, 1 kilogram
What does pulse oximeter measure
Oxygen saturation, which is the measurements of how much oxygen is combined with hemoglobin in the red blood cell also provides pulse rate
What is hemoglobin
Protein on RBC
Body part used to measure pulse ox
Warm finger Can use toes or earlobes depending on probe
Cold hands,thick nails,nail polish,and artificial nails can interfere with measurement
Normal range for pulse ox
95-100%on room air(RA)
Cardiac output
Amount of blood ejected from heart in 1 min
Orthostatic hypertension
Drop in BP with change in position
When measuring height
Remove shoes, stand erect
Vital sign abbreviations
R next to number=rectal temp
Axnext to number=axillary temp
ap next to number= axillary temp
When is use of electronic BPmeasuring device inappropriate
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
Interventions for abnormal body temperature
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
Intervention for abnormal pulse
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
Interventions for pt. with abnormal respirations
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
Interventions for pts. with abnormal bl. pressure
1Repeat assessment, 2.
Orthostatic bp
Procedure for obtaining a manual blood pressure
What is objective data
What the nurse sees and feels also laboratory findings, diagnostic imaging
Subjective symptoms
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
Objective signs
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
Disease and diagnosis
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
Who makes medical diagnosis
Clinician (treats and cures)
What are the nurses goals
Holistic treatment (form of healing that considers the whole person)
RNs make nursing diagnosis.
LPNs identity a patient problem
Etiology of disease(cause)
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
What is a Risk factor
Increase your chances of becoming Ill/accident
Some risk factors are
Habits, environmental condition, genetic predisposition, physiologic condition, age, lifestyle( often mechanisms of coping) and social detriments(education,health and healthcare, social and community)
Terms used to describe disease
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
Inflammation
Protective response of the body tissues, healing and defensive response after irritation, injury, or invasion by organisms. S/Sx
Infection
Invasion of microorganisms
Bacteria,viruses fungi or parasites
Produces tissue damages/Sx
Frequently noted signs and symptoms
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
For medical assessment you must
First Get consent, evaluation of pt. condition (are the well/unwell)
Who conducts physical exam
Clinician= dr., midwife, PA
Follow physicians orders unles they ar unethical, immoral or illegal
Nurse Carrie’s out certain functions
What is Nursing assessment
Observation done by senses of touch, smell, sight and hearing
During nursing assessment you must
Perform hand hygiene, Document, get consent, assess LOC level of consciousness
Items needed for nursing assessment
Penlight, stethoscope, sphygmomanometer, thermometer, watch. W/second hand, gloves, tongue blade
What to ask to obtain HPI= history of present illness aka
O=onset
P=precipitation, provocative, palliative
Q=quality/quantity
R=region/radiation
S=severity
T=treatments
U=understanding
V=values goals/expectations
What is biographic data
Date of birth, gender, address, marital status, family members names, occupation health insurance benefits
What is the chief complaint
It is the reason for seeking health care
Nursing physical assessment
Initial assessment is done byRN
Ongoing assessments the responsibility of LPN and RN
When to perform admission assessment
As soon as possible
Techniques for physical assessment
Non abdomen=inspection. Palpate. Auscultation, Percussion
Abdomen exams only= 1st inspection, 2nd auscultation, 3rd palpation
For cultural considerations you should
Focus on humility
Head to toe assessment
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
What neurological assessment entails
Speech: clear, slurred.thick nonverbal
Tongue: midline or deviates
Facial symmetry: symmetrical/droop
Affect: flat right hostile sad
Syncope: faints
Follows commands
How skin should appear
Warm dry and intact. Good turgor. No lesions check palms and soles of feet
Head and neck assessment
Check eyes. Ears. Nose. Mouth and mucous membranes. Neck(jugular vein distinction is not a normal finding)
Cardiovascular assessment
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
Focused neurovascular assessment (peripheral vascular)
What actions are taken to perform peripheral vascular assessment
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
Expected heart sounds
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
Ausculatory Landmarks
What are Bruit sounds
ABNORMAL SOUNDS. Turbulent blood in blood vessels swishing sounds
What are Thrill sounds
ABNORMAL SOUNDS. Felling/palpating turbulent blood in blood vessel. Vibration
This is an expected finding with dialysis access points likeAV fistulas and AV shunts
Respiratory portion of physical assessment
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)
During atrial contraction which valves are open/closed
A/V valves are open S/L valves are closed
During ventricular contraction which valves are open/closed
A/V valves are closed. S/V valves are open
Abdominal assessment
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
Genitourinary assessment
C= color
O= Oder
C= clear/cloudy
A= amount; small, moderate, large(ml)
Catheters= indwelling, nephrostomy, suprapubic, urostomy
Assessment of genitals, perineum, and rectum
Assess for= lumps, lesions, lice, discharge moisture, hemorrhoids, bleeding
Documentation
Be objective, clear, complete and concise
If you didn’t write it you didn’t do it
Priorities of care
1.ABCs=ALWAYS airway, breathing, circulation
2.Safety
3.Prevention
Which body system does each belong to
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
lung sounds (abnormal)
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
Metabolic
Diabetes
Stehoscope
Diaphragm= high pitched
Bell= low pitched sound
