Vital signs Flashcards
1
Q
When should you take vital signs?
A
- When a patient is brought to the department for any invasive diagnostic procedure
- Before and after the patient receives medication/as required by preprocedural screening (usually CT).
- Any time the patient’s general condition suddenly changes. (LOC)
2
Q
What are Cardinal Signs?
A
Quick, objective and non-invasive evidence of patient condition.
3
Q
Is a physician’s order required to measure vital signs?
A
4
Q
T/F
Vital signs are measured against accepted ranges.
A
True
5
Q
What are Physiologic responses indicators of?
A
Indicators of adversity or response to therapy.
6
Q
Is pain considered to be a vital sign?
A
Yes
7
Q
What is measured when taking a patients vital signs?
A
- Body temperature
- Pulse
- Respiration.
(Measured to monitor life supporting functions)
8
Q
Is blood pressure considered a vital sign?
A
Blood pressure is not a true vital sign category, but is often measured with the other three in the overall assessment of the patient.
9
Q
What is this describing?
Physiologic balance between heat produced in cells and heat lost to environment
A
Body temperature
10
Q
T/F
Humans are cold blooded.
A
False; Humans are warm blooded
11
Q
How much of a fluctuation in body tempurature has to occur before cellular functions and cardiopulmonary demands are affected?
A
A fluctuation of 2-3 ◦C
12
Q
List 3 factors that can influence body temperature:
A
-Time of day
-weight
-hormone levels
(metabolic activites)
13
Q
What part of the body performs thermoregulation?
A
The hypothalamus
14
Q
How does the body preserve heat?
A
Shivering and vasoconstriction
15
Q
How does the body regulate heat loss?
A
Diaphoresis and peripheral vasodilation
16
Q
What is a normal body temperature?
A
37 °C (98.6 °F )
17
Q
What is the Common body tempertature daily variation?
A
0.5 – 1°C (1 – 2 °F).
18
Q
What is the common body temperature for infants (3m-3years)
A
37.2 – 37.61°C (99 – 99.7 °F)
19
Q
What is the common body temperature for Child (5 – 13 years)?
A
36.56 - 37 °C (97.8 – 98.6 °F).
20
Q
What can hypothermia result from?
A
- Induced medically
- Trauma to hypothalamus
21
Q
How does hypothermia cause the body to shut down?
A
Reduces patient’s need for O2 and therefore, cardiopulmonary system slows down (bradycardia)
22
Q
What does hyperthermia mean?
A
Elevated Body temperature
23
Q
What does Febrile mean?
A
Related to fever
24
Q
What is hyperthermia ussually caused by?
A
Usually due to disease process
25
How does hyperthermia cause the body to shut down?
As body temperature increases, body demands for O2 increase, CO2 production increases
26
How is the site for Measuring Body Temperature chosen?
1. Patient’s age
2. State of mind
3. Ability to cooperate in the procedure.
27
# T/F
Site used must be included when recording or reporting. Why or why not?
True; because the reading varies depending where it is measured
28
Where is oral temperature taken?
Mouth (under tongue)
29
When is oral temperature taken?
Used in adults and cooperative children
30
What is the normal oral body temperature?
37 °C O or 98.6 °F O
31
Where is axiallary temperature taken?
Armpit
32
What is the most useful area for taking temperature with infants?
Axillary
33
What is a normal axillary body temperature?
36.4 – 36.7 °C Ax or 97.6 - 98 °F Ax
34
Why is axillary temperature sometimes unreliable?
Time and precision of placement
35
Where is a rectal temperature taken?
Anal opening to rectum
36
What is the most reliable form of measuring body temperature?
Rectally
37
What is the colour of the Probe cover for rectal thermometers?
Probe cover is red
38
When should rectal temperature not be taken?
Should not be taken if the patient is restless or has rectal pathology.
39
When is rectal temperature used?
Used normally only on infants
40
What is a normal rectal body temperature?
37.5 °C R or 99.6 °F R
41
What is the Tympanic (Aural) Temperature meausring?
Temperature of the blood vessels in the tympanic membrane of the ear.
42
What is a normal tympanic body temperature?
36.4 °C T or 97.5 °F T
43
What are the forms of Core body temperature readings?
1. Rectal temperature
2. Tympanic temperature
44
What is being shown here?
A tympanic thermometer
45
What is being shown here?
Temperature sensitive patches
46
Where are Temperature sensitive patches placed?
Abdomen/forehead
47
# T/F
With a temperature sensitive patch, If abnormal temperature is indicated, a more accurate method can be used to verify reading.
True
48
What are the ways to measure body temperature?
1. Temporal Artery Thermometers
2. Temperature Sensitive Patches
3. Tympanic Temperature
4. Rectal Temperature
5. Axillary Temperature
6. Oral Temperature
49
# T/F
Measurements approximately 1 °F higher with a Temporal Artery Thermometer than oral readings.
True
50
What is being shown here?
Temporal Artery Thermometer
51
What does pulse indicate?
Reflects rapidity of heart contractions.
52
Why should you not press too hard while taking a pulse?
May obliterate if you press to hard
53
What is a normal pulse rate in an adult?
60 – 90 beats per minute (BPM)
54
What is the normal pulse rate in a Child (4 – 10 years)?
90 – 100 BPM
55
What is the normal pulse rate in an infant?
120 BPM
56
What does taking an Apical Pulse entail?
Listening to heart directly and Counting heartbeat over 1 min
57
# T/F
An apical pulse may be lower than the radial pulse.
False; An apical pulse will never be lower than the radial pulse.
58
Where should you take an apical pulse reading?
5th intercostal space, 3 – 4 inches lateral to left sternal margin .
59
What are the different sites on the body that a pulse reading can be measured?
1. Apical pulse
2. Radial pulse
3. Brachial Pulse
4. Carotid Pulse
5. Femoral Pulse
6. Popliteal Pulse
7. Temporal Pulse
8. Dorsalis Pedis Pulse
9. Posterior Tibial Pulse
60
Where on the body is a radial pulse taken?
At wrist (at base of thumb)
61
What is the most acessible spot to take a pulse reading?
On the wrist (radial pulse)
62
Where is a brachial pulse taken?
-Antecubital fossa above the elbow below the brachial artery
63
Where is a carotid pulse taken?
At angle of mandible over carotid artery
64
When is a carotid pulse ussually taken?
Typically, during CPR
65
How do you take a carotid pulse?
Push up with fingers slightly anterior and below the angle of the mandible.
66
Where is a femoral pulse taken?
Over femoral artery in groin
67
Where is a popliteal pulse taken? When would you take this kind of pulse?
-Behind knee
-Taken in a trauma situation
68
Where is a temporal pulse taken?
Over temporal artery (in front of ear)
69
Where is the Dorsalis Pedis Pulse taken?
At the top of the foot in line with the groove between the 1st and 2nd toes (between the extensor tendon of the great and second toe)
70
# T/F
The Dorsalis Pedis Pulse may be congenitally absent
True
71
Where is the Posterior Tibial Pulse taken?
Medial aspect of ankles
72
# T/F
Unfit individuals and hyperthermic patients often have a low heart rate.
False; Fit individuals and hypothermic patients often have a low heart rate.
73
When should a pulse baseline reading be taken?
Baseline should be obtained prior to start of invasive diagnostic imaging procedures at rest
74
Where is the most accurate spot to take a pulse on infants?
Apical most accurate for infants.
75
**What does the assesment of a patients pulse indicate?**
Assess strength and regularity of pulse as well as number of beats per minute.
76
# T/F
Manual palpation provides a quantitative assessment, where as rate provides a qualitative assessment.
False; Manual palpation provides a qualitative assessment, where as rate provides a quantitative assessment.
77
What is Tachycardia and what is the average BPM for those who have it?
Abnormally rapid heart rate (>100 BPM)
78
What is Bradycardia and what is the average BPM for those who have it?
Abnormally slow heart rate (<60 BPM)
79
What does a graph of an ECG specifically indicate?
Graph of voltage versus time of the electrical activity of the heart
80
What types of cardiac abdormalities does an ECG demonstrate?
1. cardiac rhythm disturbances
2. inadequate coronary artery blood flow
3. electrolyte disturbances
81
What is the simplest and fastest way of evaluating the heart’s activity?
Using an ECG
82
What is the baseline of an ECG is called?
Isoelectric line
83
What does the isolectric line signify?
Resting membrane potentials
84
Label 1-2
1. Isoelectric line
2. Deflections
85
What are defelections?
The positive or negative change in the isoelectric line over the peroid of the cycle?
86
What does the P wave represent?
Represents depolarization of the atrial muscle cells.
87
When does atrial contraction begin?
Atrial contraction begins at the peak of the P wave
88
When does the SA node fire?
SA node fires at the start of the P wave
89
What does the QRS complex represent?
Represents depolarization of the ventricular muscle cells.
90
What does the S portion on an ECG represent?
The S portion is the return to baseline.
91
What part of the ECG signifies the initial downward deflection?
The Q portion is the initial downward deflection
92
When does contraction begin on the ECG?
Contraction commences at the peak of the R portion.
93
What portion of an ECG signifies the initial upward deflection.
The R portion is the initial upward deflection.
94
What does the U wave represent?
U wave represents the repolarization of the papillary muscles and the Purkinje fibers.
95
What generates the T wave?
Repolarization of the ventricles
96
In QRS
97
What triggers the PR interval?
Atrial depolarization
98
What ends the PR interval?
The start of ventricular depolarization
99
At what interval does the impulse travel through the AV node?
The PR interval
100
Label 1-5
1. QRS complex
2. ST segment
3. QT interval
4. PR interval
5. PR segment
101
How many mV have occured over 5mm of an ECG chart?
.5mV
102
How much time has passed over 1mm of an ECG chart?
.04 seconds
103
How much time has passed over 5mm of an ECG chart?
.20 seconds
104
# T/F
If the intervals between peak of QRS complexes (RR intervals) are consistent, ventricular rhythm is regular
True
105
Is this a normal or abnormal rythm of the heart?
Normal
106
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107
What is STEMI?
Profoundly life threatening heart attack and associated with atherosclerosis (CAD) whcih results in ST elevation.
108
What pathology is being shown here?
STEMI
109
# What is this describing?
The action of inhaling oxygen and exhaling carbon dioxide while breathing.
(One inspiration + One expiration)
Respiration
110
What do the diaphragmatic muscles do during inspiration?
1. Move downward
2. Push abdominal contents outward
3. Expand chest cavity
111
What is the normal adult respiration rate?
12 –20 breaths/min
112
What is the normal Child (1-10 years) respiration rate?
20-30 breaths/min
113
What is the noraml Newborn/Infant (under 1 year) respiration rate?
30-60 breaths/min
114
What can respiration of fewer than 10 breaths per minute for an adult result in?
Cyanosis, apprehension, restlessness, and change in LOC.
115
What three factors must be assessed for during the Assessment of Respiration?
1. Rate of respiration
2. Pattern of respiration (regular or irregular)
3. Depth of respiration
116
What determines tidal volume?
The depth of respiration
117
What is the abbreviation for respiration charting?
R
118
What is dyspnea? What does it present as?
-Difficulty breathing.
-Often presents as shortness of breath (SOB).
119
# What pathology is this describing?
Causes include exercise, fever, infection, pain, heart failure, chest trauma, decreased oxygen in blood, and central nervous system pathology.
Tachypnea
120
What is the respiratory rate for those with Tachypnea?
Greater than 20 breaths per minute
| In adults
121
What is Bradypnea?
An abnormal decrease in respiratory rate.
122
# What pathology is this describing?
Results from depression of the respiratory centers of the brain – common with drug overdoses, head trauma and hypothermia.
Bradypnea
123
What is Orthopnea?
Difficulty breathing unless sitting up or standing erect.
124
What is Apnea?
Absence of spontaneous ventilation.
125
What is Stridor caused by?
Caused by narrowing or obstruction of airway
126
What is stridor a first sign of?
May also be the first sign of a serious and even, life-threatening disorder
127
What is blood pressure the product of?
Pressure is product of flow and resistance.
128
# T/F
BP is the reflection of resistance the blood meets in the systemic vasculature when it is ejected from the left ventricle of the heart during systole.
True
129
What is Peripheral Vascular Resistance?
Resistance of the circulatory system (arterioles) that is used to create BP.
130
Will Vasoconstriction cause an increase or decrease in PVR?
An increase
131
Will Vasodilation cause an increase or decrease in PVR?
↓ PVR (shock)
132
# T/F
PVR is mediated on a neuro-hormonal level.
True
133
What is cardiac output and how do you calculate it?
The amount of blood your heart pumps each minute.
Cardiac Output = Stroke Volume x Heart Rate
134
What three things are mediating blood pressure dependant on?
1. Pumping action of the heart
2. Blood Volume
3. Blood Viscosity
4. Elasticity of the arterial vessel wall
135
# T/F
Slowing down the heart rate, increases how hard the heart must work
False; Slowing down the heart rate, reduces how hard the heart must work
136
What pathologies decrease blood volume?
Dehydration/hemorrhage
137
What are two types of diuretics that decrease blood pressure/volume?
1. hydrochlorothiazide (HCTZ),
2. Lasix
138
What determines the viscosity of the blood?
The number of red blood cells in the blood plasma
139
# T/F
With an increased number, the blood becomes less viscous and subsequently, increases the blood pressure
False; With an increased number, the blood becomes more viscous and subsequently, increases the blood pressure
140
What are three examples of blood thinners?
Aspirin, coumadin, heparin
141
# T/F
Vasoconstriction can result in increased blood pressure
True
142
# What type of medication is this?
Blocks the production of angiotensin (vasoconstrictor), causing the blood vessels to relax, resulting in drop in BP.
ACE inhibitors
143
# T/F
Males usually have higher blood pressure than females
True
144
# T/F
BP is lower in the morning after a night of sleep
True
145
# T/F
BP decreases after a large intake of food.
False; Increases after a large intake of food.
146
What is the highest point of blood pressure reached in the cardiac cycle called?
The Systolic Pressure
147
What is the lowest point of blood pressure reached in the cardiac cycle called?
Diastolic Pressure
148
# T/F
Relaxation of the ventricles generates the lowest point of blood pressure.
True
149
What is a normal systolic blood pressure in an adult?
95 - 120 mmHg
150
What is a normal diastolic blood pressure in adults?
60 - 80 mmHg
151
What is a normal systolic blood pressure in a child?
104 - 120
152
What is a normal diastolic blood pressure in a child?
60 - 80 mmHg
153
What is a normal systolic blood pressure in adolecence?
85 -130 mmHg
154
What is a normal diastolic blood pressure in adolecence?
45 - 85 mmHg
155
When is a patient is considered hypertensive?
If systolic BP is consistently higher than 140mm Hg and diastolic greater than 90mm Hg.
156
What are the categories of hypertension?
mild, moderate, or severe.
157
When is a patient considered hypotensive?
A patient is considered hypotensive blood pressure is consistently lower than 95/60 mm Hg.
158
What are the two ways to meausre blood pressure?
1. Sphygmomanometer
2. Stethescope
159
What are the two types of Sphygmomanometers?
1. Mercury manometer
2. Aneroid manometer
160
What is the most accurate Sphygmomanometer?
Mercury manometer
161
What is being shown here?
Mercury manometer
162
What is being shown here?
163
Label 1-5
1. Rubber tubing
2. Bulb
3. Valve
4. Manometer Gauge
5. Inflatable Cuff
164
Label 1-6
1. Binural
2. Eartips
3. Tubing
4. Diaphragm
5. Binaural spring
6. Bell
165
Where do you place your fingers on the stethescope when taking a blood pressure reading?
Place your fingers around the base of the bell
166
What is the patient prep for taking blood pressure?
1. Have patient sitting upright or lying down with arm reclined and supported.
2. At rest for 3-5 min.
3. Sleeves should be rolled up, no tight clothing around arm
167
How is cuff size selected for a blood pressure reading?
Cuff should be selected according to patient size
168
What artery is ussually used to measure blood pressure?
Typically measured over brachial artery
169
How do you measure blood pressure using a Manometer?
1. Inflate cuff to exceed systolic pressure in artery by 30 – 40 mm Hg
2. Release air in cuff until pressure in cuff matches systolic pressure
3. When no sounds are heard anymore, diastolic pressure value has been reached
170
What is cyanosis?
Bluish tinge due to lack O2 in tissues, build up of deoxyhemoglobin.
171
Where does core cyanosis develop?
Mucous membranes; tongue, lips or the lining of mouth
172
Where does peripheral cyanosis develop?
Nail beds
173
What is pallor? Where does is it most evident?
-Absence of color (Unhealthy pale appearance)
-Most evident in face and palms.
174
What is diaphoretic skin?
Excessive sweating
175
What does fever feel like to the touch?
Hot and dry skin
176
What does syncope feel like to the touch?
Cold and clammy skin
