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Health Assessment - RLE > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Clinical measurement of temperature, pulse, respiration and blood pressure and give some indication of the state of health of an individual. Ir represents interrelated physiologic systems of the body

A

Vital Signs

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2
Q

Purposes of Vital Signs

A
  • universally communicate a patient’s condition and severity of disease
  • helps in identifying nursing diagnosis, assess interventions and make decisions concerning the reponse of patients to treatment
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3
Q

Normal Range of Temperature

A

36-37.5 degrees Celsius

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4
Q

temperature of internal organs

A

core temperature

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5
Q

temperature of skin, outside surface

A

surface temperature

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6
Q

Purposes of taking temperature:

A
  • establish data for subsequent evaluation
  • check whether the core temperature is within normal range
  • determine changes in response to specific therapies
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7
Q

surface-surface without contact

A

Radiation

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8
Q

molecule-molecule with contact

A

Conduction

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9
Q

dispersion of heat through air currents

A

Convection

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10
Q

continuous evaporation of moisture from the repiratory tract, oral mucoda and skin

A

Vaporation

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11
Q

patients having fever

A

febrile

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12
Q

Methods of taking Temperature:

A
  • Oral
  • Axillary
  • Rectal
  • Non-contact
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13
Q

it is the difference between heat produced and heat lost by the body and is measured through the use of a thermometer

A

Temperature

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14
Q

Contraindications for Oral Method

A
  1. infants
  2. unconscious and irrational patients
  3. patients who breath through their mouths
  4. those with disease of the oral cavity or surgery of the nose or mouth
  5. patients who have had taken cold or hot foods or fluids
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15
Q

Purposes of Rectal Method

A
  1. to obtain first temperature of newborn to check rectal patency
  2. to check core temperature of an adult
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16
Q

contraindications for Rectal Method

A
  1. patients with recent rectal surgery
  2. patients having diarrhea
  3. patients having disease of the rectum
  4. patients having cardiovascular alternation because the thermometer may stimulate the vagus nerve causing bradycardia or rhythm disorder
  5. Patients with leukemia which may traumatize the rectal mucosa causing bleeding
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17
Q

it is a rhythmical throbbing that results from a wave of blood passing through an artery as the heart contracts

A

Pulse

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18
Q

possible sites for taking pulse:

A

apical
radial artery
facial artery
temporal artery
dorsalis pedis
femoral artery
popliteal artery
carotid artery
bracial artery
posterior tibialis

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19
Q

what to note when taking pulse:

A

rate
rhythm or regularity
tension or compressibility
volume

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20
Q

normal pulse rate per minute (Average and Range): Newborn

A

130 (80-180)

21
Q

normal pulse rate per minute (Average and Range): 1 year

A

120 (80-140)

22
Q

normal pulse rate per minute (Average and Range): 5-8 years

A

100 (75-120)

23
Q

normal pulse rate per minute (Average and Range): 10 years

A

70 (50-90)

24
Q

normal pulse rate per minute (Average and Range): Teen

A

75 (50-90)

25
Q

normal pulse rate per minute (Average and Range): Adult

A

80 (60-100)

26
Q

normal pulse rate per minute (Average and Range): Older Adult

A

70 (60-100)

27
Q

purpose of taking pulse rate:

A

to obtain an estimate of the wuality of the heart’s action per minute

28
Q

if patient is a newborn or an infant, pulse will be assessed through the

A

brachial, apical and femoral artery

29
Q

the apical pulse is found where? (adult and children)

A

5th left intercostal space, midclavicular line (adults)
4th left intercostal space, miclavicular line (children)

30
Q

cardiac rate is best assessed on the?

A

apex part of the heart

31
Q

the heartbeat is usuallyt loudest over where?

A

at the apex part of the heart

32
Q

the two heart sounds are produced by?

A

closure of the heart valves

33
Q

normal respiration rate per minute (Average and Range): Newborn

A

35 (30-60)

34
Q

it is the exchange of oxygen and carbon dioxide between the atmnosphere and body cells and is initiated by the act of bretahing

A

Respiration

35
Q

normal respiration rate per minute (Average and Range): 1 year

A

30 (20-40)

36
Q

normal respiration rate per minute (Average and Range): 5-8 years

A

20 (15-25)

37
Q

normal respiration rate per minute (Average and Range): 10 year

A

19 (15-25)

38
Q

normal respiration rate per minute (Average and Range): Teen

A

18 (15-20)

39
Q

normal respiration rate per minute (Average and Range): Adult

A

16 (12-20)

40
Q

normal respiration rate per minute (Average and Range): Older Adult

A

16 (15-20)

41
Q

Purpose of taking RR

A

to obtain the respiratory rate per minute and an estimate of the patient’s respiratory status

42
Q

is the lateral force exerted by the blood on the arterial walls

A

Blood Pressure

43
Q

Purposes of taking Blood Pressure

A
  1. to aid in diagnosis
  2. to observe changes in a patient’s condition
44
Q

Contraindications for Brachial Artery Blood Pressure Measurement

A
  1. surgery including the breats, axilla, shoulder, arm or hands
  2. Venous Access Device such as AV shunt and IVF
  3. Injury or disease to the shoulder, arm or hands such as trauma, burn or application of cast or bandage
45
Q

Sites for BP taking:

A
  1. either arm on the antecubital space
  2. either leg on the popliteal space
  3. dorsalis pedis
46
Q

Normal BP

A

<120/<80

47
Q

Prehypertension

A

120-139 over 80-89

48
Q

Hypertension, Stage 1

A

140-159 over 90-99

49
Q

Hypertension, Stage 2

A

> 180 over >100

Health Assessment - RLE (6 decks)

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