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[3] NUR114 | FUNDAMENTALS > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Reflects the physiologic state which govern the body’s organs
The first thing done to the client/patient when in the hospital

A

VITAL SIGNS

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2
Q

Purposes
- Identify (1) __________
- Monitor (2) __________
- Evaluate (3) __________
- Basis for (4) __________
- Part of (5) __________ in any setting

A

(1) problems
(2) condition
(3) response/s to intervention/s
(4) clinical problem-solving
(5) care

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3
Q

Main vital signs

A

Temperature, pulse, RR, blood pressure

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4
Q

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) __________

A

(1) admission
(2) home visits
(3) physician’s or hospital’s standards of practice
(4) surgical procedure or invasive diagnostic procedure
(5) blood products

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5
Q

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) __________

A

(1) medications / therapies
(2) general condition
(3) nursing interventions
(4) nonspecific symptoms of physical distress

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6
Q

TRUE OR FALSE:
GUIDELINES
1. KNOW THE CLIENT’S NORMAL/ USUAL RANGE/ LAST MEASUREMENT

  1. KNOW THE CLIENT’S MEDICAL HX, THERAPY & MEDICATION HE IS RECEIVING
  2. CONTROL ENVIRONMENTAL FACTORS THAT MAY INFLUENCE V/S VALUES
  3. MANNER OF APPROACH TO THE CLIENT MAY ALTER V/S
  4. MAKE CERTAIN THAT EQUIPMENT IS FUNCTIONAL & APPROPRIATE
  5. DECIDE FREQUENCY OF VITAL SIGNS ASSESSMENT
  6. USE AN ORGANIZED, SYSTEMATIC APPROACH TO MEASURE VITAL SIGNS
  7. VERIFY & COMMUNICATE SIGNIFICANT CHANGES
A
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7
Q

• Reflects balance between the heat produced and heat lost from the body

A

BODY TEMPERATURE

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8
Q
  • 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
A

CORE TEMPERATURE

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9
Q

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

A

(1) deep tissues
(2) 36 C– 37.4 C
(3) higher
(4) tympanic or rectal
(5) esophagus, pulmonary artery or bladder

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10
Q
  • Temperature of the skin, subcutaneous tissue and fat
  • Measured at oral and axillary sites
  • Rises and falls in response to the environment
A

SURFACE TEMPERATURE

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11
Q

SURFACE TEMPERATURE
- Temperature of the (1) __________
- Measured at (2) __________ sites
- Rises and falls in response to the (3) __________

A

(1) skin, subcutaneous tissue and fat
(2) oral and axillary
(3) environment

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12
Q

REGULATION OF BODY TEMPERATURE
1. __________
2. __________
3. __________

A
  1. Neural and vascular control
  2. Maintaining heat production and heat loss
  3. Behavioral control
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13
Q

REGULATION OF BODY TEMPERATURE
> Increased temp.
- Hypothalamus
- Sweating and vasodilation

> Decreased temp.
- Hypothalamus
- Shivering and vasoconstriction

A
  1. Neural and Vascular Control
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14
Q

REGULATION OF BODY TEMPERATURE
>Heat Production
- BMR
- Muscle Activity
- Thyroxine Output
- Sympathetic Response
- Fever

> Heat Loss
- Radiation
- Evaporation
- Convection
- Conduction

A
  1. Maintaining Heat Production & Heat Loss
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15
Q

• Transfer of heat by means of waves
• Transfer of heat from one surface to another surface, without contact

A

RADIATION

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16
Q

• Process by which water is converted into steam / vapor

A

EVAPORATION

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17
Q

• Transfer / dispersion of heat away by air currents

A

CONVECTION

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18
Q

• Transfer of heat from one object to another during direct contact

A

CONDUCTION

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19
Q
  • Adjustments initiated by an individual to maintain appropriate body temperature
A
  1. Behavioral Control
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20
Q

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

A

FALSE
SEXUAL ORIENTATION IS NOT INCLUDED

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21
Q

Fahrenheit: 97.6 - 99.6
Celcius: 36.5 - 37.4

A

Oral Temperature

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22
Q

Fahrenheit: 98.6 - 100.6
Celcius: 37.0 - 38.1

A

Rectal Temperature

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23
Q

Fahrenheit: 96.6 - 98.6
Celcius: 36.0 - 37.0

A

Axillary Temperature

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24
Q
  • 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
A

HYPERTHERMIA

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25
Q

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

A

(1) above usual range
(2) pyrexia, fever, febrile vs afebrile
(3) heat prod > heat loss
(4) 39 C / 40 C
(5) infection
(6) Hyperpyrexia

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26
Q
  • 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
A

HYPOTHERMIA

27
Q
  • 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) _________
A

(1) below usual range
(2) hypothalamic thermoregulation
(3) Induced vs. Accidental
(4) HR, RR and BP
(5) O2 demands
(6) < 34 C

28
Q

METHODS/SITES FOR TAKING BODY TEMP:
1. _____________
2. _____________
3. _____________
4. _____________

A
  1. Oral/ by mouth
  2. Rectal/ from the rectum
  3. Axilla/ from the armpit
  4. Tympanic membrane
29
Q

• 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

A

ORAL Site

30
Q

• 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

A

RECTAL Site

31
Q

• 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

A

AXILLARY Site

32
Q

• 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)

A

TYMPANIC MEMBRANE

33
Q

Recommended Placement Time per Site (Glass Thermometer)

ORAL - (1) __________
RECTAL - (2) ___________
AXILLARY - (3) ___________

A

(1) 3 minutes
(2) 2-3 minutes
(3) 5 minutes

34
Q

➢ 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

A

Digital Thermometer

35
Q

➢ 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

A

Electronic Thermometer

36
Q

➢ 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

A

Tympanic / Infrared Thermometer

37
Q

➢ Varies from liquid crystal dots, bars, or heat-sensitive tape / patches that change color
➢ Can be reused several times

A

Chemical Thermometer

38
Q

FAHRENHEIT
❖ Freezing point: @ (1) __________
❖ Boiling point of water: @ (2) __________

A

(1) 32 F
(2) 212 F

39
Q

CELSIUS
❖ Freezing point: @ (1) __________
❖ Boiling point of water: @ (2) __________

A

(1) 0 C
(2) 100 C

40
Q

CONVERSION OF CELSIUS TO FAHRENHEIT

A

Multiply by 9/5 & add 32

41
Q

CONVERSION
38 C to F

A

= 38(9/5) + 32
= 342/5 + 32
= 68.4 + 32 = 100.4 F

42
Q

CONVERSION FAHRENHEIT TO CELSIUS

A

Subtract 32 & multiply by 5/9

43
Q

CONVERSION
100 F to C

A

= 100-32 x 5/9
= 68 x 5/9
= 340/9 = 37.77 C
= 37.8 C

44
Q

▪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

A

PULSE

45
Q

Represents the stroke volume output & compliance of arteries

A

Pulse Wave

46
Q

➢ Each heart contraction – empties __________ of blood

A

70 ml (SV)

47
Q

Cardiac Output (CO) Formula

A

SV (Stroke Volume) x HR (Heart Rate)/min

48
Q

➢Adult @ rest – heart pumps __________

A

4-6 L/min

49
Q

✓ Number of pulse beats in one full minute

A

Pulse Rate

50
Q

Normal Range of PR

A

60-100 beats/min (adult & adolescence )

51
Q

Rapid pulse rate exceeds 100 beats/min @ rest (adult) can exceed 150 beats/min

A

Tachycardia

52
Q

Awareness of one’s own heart contraction and can accompany tachycardia

A

Palpitation

53
Q

Slow pulse rate less than 60 beats/min (adult)

A

Bradycardia

54
Q
  • Pattern by which heartbeats are spaced, normally regular with each beat
A

Pulse Rhythm / Regularity

55
Q
  • Irregular pattern/rhythm of heartbeats
A

Dysrhythmia / Arrhythmia

56
Q

Quality of pulsation felt usually is related to the amount of blood pumped with each heartbeat , or the force of heart contraction

A

Pulse Volume / Amplitude

57
Q

AVERAGE: 140 PR/min
RANGE: 120 - 160 PR/min

A

Newborn - 1 month old

58
Q

AVERAGE: 120 PR/min
RANGE: 80 - 140 PR/min

A

1 month - 1 year

59
Q

AVERAGE: 110 PR/min
RANGE: 80 - 130 PR/min

A

1 - 2 Years

60
Q

AVERAGE: 100 PR/min
RANGE: 75 - 120 PR/min

A

2 - 6 Years

61
Q

AVERAGE: 95 PR/min
RANGE: 75 - 110 PR/min

A

6 - 12 Years

62
Q

AVERAGE: 80 PR/min
RANGE: 60 - 100 PR/min

A

Adolescence to Adult

63
Q

AVERAGE: 70 PR/min
RANGE: 60 - 100 PR/min

A

Older Adult

[3] NUR114 | FUNDAMENTALS (15 decks)

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