Vital Signs Flashcards
Reflects the physiologic state which govern the body’s organs
The first thing done to the client/patient when in the hospital
VITAL SIGNS
Purposes
- Identify (1) __________
- Monitor (2) __________
- Evaluate (3) __________
- Basis for (4) __________
- Part of (5) __________ in any setting
(1) problems
(2) condition
(3) response/s to intervention/s
(4) clinical problem-solving
(5) care
Main vital signs
Temperature, pulse, RR, blood pressure
When to measure VS?
❖ On (1) _________ to a health care facility
❖When assessing the patient during (2) __________
❖In a hospital on a routine schedule according to a (3) __________
❖Before and after a (4) __________
❖Before, during, and after transfusion of (5) __________
(1) admission
(2) home visits
(3) physician’s or hospital’s standards of practice
(4) surgical procedure or invasive diagnostic procedure
(5) blood products
When to measure VS?
❖before, during, and after the administration of (1) __________ or applications of __________
❖when the patient’s (2) __________ changes
❖before and after (3) __________ that influence a VS
❖when the patient reports (4) __________
(1) medications / therapies
(2) general condition
(3) nursing interventions
(4) nonspecific symptoms of physical distress
TRUE OR FALSE:
GUIDELINES
1. KNOW THE CLIENT’S NORMAL/ USUAL RANGE/ LAST MEASUREMENT
- KNOW THE CLIENT’S MEDICAL HX, THERAPY & MEDICATION HE IS RECEIVING
- CONTROL ENVIRONMENTAL FACTORS THAT MAY INFLUENCE V/S VALUES
- MANNER OF APPROACH TO THE CLIENT MAY ALTER V/S
- MAKE CERTAIN THAT EQUIPMENT IS FUNCTIONAL & APPROPRIATE
- DECIDE FREQUENCY OF VITAL SIGNS ASSESSMENT
- USE AN ORGANIZED, SYSTEMATIC APPROACH TO MEASURE VITAL SIGNS
- VERIFY & COMMUNICATE SIGNIFICANT CHANGES
• Reflects balance between the heat produced and heat lost from the body
BODY TEMPERATURE
- Temperature of the deep tissues of the body
- Remains relatively constant within a range of 36 C– 37.4 C
- Relatively higher than surface temperature
- Measured in the tympanic or rectal sites
- Can also be measured through the esophagus, pulmonary artery or bladder via invasive devices
CORE TEMPERATURE
CORE TEMPERATURE
- Temperature of the (1) __________ of the body
- Remains relatively constant within a range of (2) __________
- Relatively (3) __________ than surface temperature
- Measured in the (4) __________ sites
- Can also be measured through the (5) __________ via invasive devices
(1) deep tissues
(2) 36 C– 37.4 C
(3) higher
(4) tympanic or rectal
(5) esophagus, pulmonary artery or bladder
- Temperature of the skin, subcutaneous tissue and fat
- Measured at oral and axillary sites
- Rises and falls in response to the environment
SURFACE TEMPERATURE
SURFACE TEMPERATURE
- Temperature of the (1) __________
- Measured at (2) __________ sites
- Rises and falls in response to the (3) __________
(1) skin, subcutaneous tissue and fat
(2) oral and axillary
(3) environment
REGULATION OF BODY TEMPERATURE
1. __________
2. __________
3. __________
- Neural and vascular control
- Maintaining heat production and heat loss
- Behavioral control
REGULATION OF BODY TEMPERATURE
> Increased temp.
- Hypothalamus
- Sweating and vasodilation
> Decreased temp.
- Hypothalamus
- Shivering and vasoconstriction
- Neural and Vascular Control
REGULATION OF BODY TEMPERATURE
>Heat Production
- BMR
- Muscle Activity
- Thyroxine Output
- Sympathetic Response
- Fever
> Heat Loss
- Radiation
- Evaporation
- Convection
- Conduction
- Maintaining Heat Production & Heat Loss
• Transfer of heat by means of waves
• Transfer of heat from one surface to another surface, without contact
RADIATION
• Process by which water is converted into steam / vapor
EVAPORATION
• Transfer / dispersion of heat away by air currents
CONVECTION
• Transfer of heat from one object to another during direct contact
CONDUCTION
- Adjustments initiated by an individual to maintain appropriate body temperature
- Behavioral Control
TRUE OR FALSE:
FACTORS AFFECTING TEMPERATURE
1. Environment
2. Diurnal variation / circadian rhythm
3. Exercise
4. Specific dynamic action of food
5. Hormonal activity
6. Sex
7. Age
8. Stress
9. Illness or injury
10.Medications
11. Sexual Orientation
FALSE
SEXUAL ORIENTATION IS NOT INCLUDED
Fahrenheit: 97.6 - 99.6
Celcius: 36.5 - 37.4
Oral Temperature
Fahrenheit: 98.6 - 100.6
Celcius: 37.0 - 38.1
Rectal Temperature
Fahrenheit: 96.6 - 98.6
Celcius: 36.0 - 37.0
Axillary Temperature
- Body temp. above usual range
- Related terminologies: pyrexia, fever, febrile vs afebrile
- Occurs when heat prod > heat loss
- Not harmful if stays below 39 C in adults; 40 C in children
- Can result from infection, but can also arise from heat exhaustion and heat stroke
- Hyperpyrexia– very high fever, occurs at 41 C
HYPERTHERMIA
HYPERTHERMIA
- Body temp. is (1) __________
- Related terminologies: (2) _____________
- Occurs when (3) ____________
- Not harmful if stays below (4) _________ in adults; _________ in children
- Can result from (5) __________, but can also arise from heat exhaustion and heat stroke
- (6) __________– very high fever, occurs at 41 C
(1) above usual range
(2) pyrexia, fever, febrile vs afebrile
(3) heat prod > heat loss
(4) 39 C / 40 C
(5) infection
(6) Hyperpyrexia
- Body temp. below usual range
- Mainly due to excessive heat loss, inadequate heat production, or an from an impaired hypothalamic thermoregulation
- Types: Induced vs. Accidental
- As body temp falls, so are HR, RR and BP
- Chemical reactions are slowed = decreased O2 demands
- Death may occur at temp < 34 C
HYPOTHERMIA
- Body temp. is (1) __________
- Mainly due to excessive heat loss, inadequate heat production, or an from an impaired (2) __________
- Types: (3) __________
- As body temp falls, so are (4) ___________
- Chemical reactions are slowed = decreased (5) __________
- Death may occur at temp (6) _________
(1) below usual range
(2) hypothalamic thermoregulation
(3) Induced vs. Accidental
(4) HR, RR and BP
(5) O2 demands
(6) < 34 C
METHODS/SITES FOR TAKING BODY TEMP:
1. _____________
2. _____________
3. _____________
4. _____________
- Oral/ by mouth
- Rectal/ from the rectum
- Axilla/ from the armpit
- Tympanic membrane
• More accessible and convenient
• Most practical clinical preferred method
• Measures around 0.5 C – 0.6 C below core body temp.
• Area under the tongue is in direct proximity to the sublingual artery
• Contraindications: uncooperative, unconscious, very young, shivering, prone to
seizures, mouth breather, post mouth surgery patients
ORAL Site
• Most accurate and reliable
• Differs about 0.1 C from core body temperature
• Done for newborns to also check for an imperforate anus
• Contraindications: rectal surgery, diarrhea or hemorrhoids and other diseases
of the rectum
RECTAL Site
• Safe and non-invasive
• Preferred site for newborns because it is safe and accessible
• Less potential for spreading microorganisms
• Thermometer must be left in place longer to obtain an accurate measurement
• Make sure that the area is dry and not wet with perspiration, deodorants, cream, or the like; do not rub the area dry vigorously as friction will increase
the temperature
AXILLARY Site
• Readily accessible; reflects core body temperature; very fast
• Can be uncomfortable and may injure the membrane if probe inserted too far
• Presence of cerumen can affect reading
• Right and left measurements can differ
• Must employ proper technique when straightening the ear canal for children
below 3 years old (back & down) and children above 3 years old (back & up)
TYMPANIC MEMBRANE
Recommended Placement Time per Site (Glass Thermometer)
ORAL - (1) __________
RECTAL - (2) ___________
AXILLARY - (3) ___________
(1) 3 minutes
(2) 2-3 minutes
(3) 5 minutes
➢ Looks like a glass thermometer & can be used at oral, axillary, and rectal sites
➢ It has a sensing tip at the end of the stem, an on/off button, and a display that
lights up during use.
➢ It takes 1-60 seconds to measure body temperature, depending on the site and product used.
➢ Needs to wipe rather than soaked with alcohol when cleaning
Digital Thermometer
➢ Has a temperature sensitive probe covered with a disposable sheath and attached by a coiled wire to a display unit
➢ Has probes for oral / axillary as well as rectal use
Electronic Thermometer
➢ Uses infrared technology that detects warmth radiating from the eardrum
➢ Probe is covered with a probe cover prior insertion to the ear canal
➢ Ready may take 1-3 seconds
Tympanic / Infrared Thermometer
➢ Varies from liquid crystal dots, bars, or heat-sensitive tape / patches that change color
➢ Can be reused several times
Chemical Thermometer
FAHRENHEIT
❖ Freezing point: @ (1) __________
❖ Boiling point of water: @ (2) __________
(1) 32 F
(2) 212 F
CELSIUS
❖ Freezing point: @ (1) __________
❖ Boiling point of water: @ (2) __________
(1) 0 C
(2) 100 C
CONVERSION OF CELSIUS TO FAHRENHEIT
Multiply by 9/5 & add 32
CONVERSION
38 C to F
= 38(9/5) + 32
= 342/5 + 32
= 68.4 + 32 = 100.4 F
CONVERSION FAHRENHEIT TO CELSIUS
Subtract 32 & multiply by 5/9
CONVERSION
100 F to C
= 100-32 x 5/9
= 68 x 5/9
= 340/9 = 37.77 C
= 37.8 C
▪A wave of blood created by contraction of the left ventricle of the heart
▪Distention or pulsation of arteries produced by the wave of blood
▪A wave can be felt when direct pressure is applied at pulse sites
PULSE
Represents the stroke volume output & compliance of arteries
Pulse Wave
➢ Each heart contraction – empties __________ of blood
70 ml (SV)
Cardiac Output (CO) Formula
SV (Stroke Volume) x HR (Heart Rate)/min
➢Adult @ rest – heart pumps __________
4-6 L/min
✓ Number of pulse beats in one full minute
Pulse Rate
Normal Range of PR
60-100 beats/min (adult & adolescence )
Rapid pulse rate exceeds 100 beats/min @ rest (adult) can exceed 150 beats/min
Tachycardia
Awareness of one’s own heart contraction and can accompany tachycardia
Palpitation
Slow pulse rate less than 60 beats/min (adult)
Bradycardia
- Pattern by which heartbeats are spaced, normally regular with each beat
Pulse Rhythm / Regularity
- Irregular pattern/rhythm of heartbeats
Dysrhythmia / Arrhythmia
Quality of pulsation felt usually is related to the amount of blood pumped with each heartbeat , or the force of heart contraction
Pulse Volume / Amplitude
AVERAGE: 140 PR/min
RANGE: 120 - 160 PR/min
Newborn - 1 month old
AVERAGE: 120 PR/min
RANGE: 80 - 140 PR/min
1 month - 1 year
AVERAGE: 110 PR/min
RANGE: 80 - 130 PR/min
1 - 2 Years
AVERAGE: 100 PR/min
RANGE: 75 - 120 PR/min
2 - 6 Years
AVERAGE: 95 PR/min
RANGE: 75 - 110 PR/min
6 - 12 Years
AVERAGE: 80 PR/min
RANGE: 60 - 100 PR/min
Adolescence to Adult
AVERAGE: 70 PR/min
RANGE: 60 - 100 PR/min
Older Adult
