Vital Signs Flashcards
Monitor functions of the body
Should be thoughtful, scientific assessment
Often, someone other than a nurse measures a client’s this
vital signs
when are times to assess vital signs
- On admission to a health care agency to obtain baseline data
- When a client has a change in health status or reports symptoms
- Before and after surgery or an invasive procedure
- Before and/or after the administration of a medication that could affect the respiratory or cardiovascular systems
- Before and after any nursing intervention that could affect the vital signs
Deep tissues of the body
Remains relatively constant
Body temperature
Core
Skin, subcutaneous tissue, fat
Responds to environment
Surface
list factors affecting body’s heat production
- Basal metabolic rate (BMR)
- Muscle activity
- Thyroxine output
- Epinephrine, norepinephrine, and sympathetic stimulation/stress response
- Fever
Transfer of heat from surface of one object to surface of another without contact
Radiation
Transfer of heat from one molecule to a molecule of lower temperature
Conduction
Dispersion of heat by air currents
Convection
Insensible water loss
Insensible heat loss
Evaporation
list places where temperature regulates through
- Sensors in periphery and core
- Integrator in hypothalamus
- Effector system adjusting heat production/loss
- Most sensors in skin
list the different processes to increase body temperature
Shivering
Sweating
Vasoconstriction
list factors affecting body temp
Age
Diurnal variations (circadian rhythms)
Exercise
Hormones
Stress
Environment
what is the normal body temp
96.8 F to 99.5 F or 36 C and 37.5 C
list types of pyrexia
-Intermittent
-Remittent
-Relapsing
-Constant
list at least 10 nursing interventions
- Monitor vital signs.
- Assess skin color and temperature.
- Monitor white blood cell count, hematocrit value, and other pertinent laboratory reports for indications of infection or dehydration.
- Remove excess blankets when the client feels warm, but provide extra warmth when the client feels chilled.
- Provide adequate nutrition and fluids (e.g., 2,500-3,000 mL/ day) to meet the increased metabolic demands and prevent dehydration.
- Measure intake and output.
- Reduce physical activity to limit heat production, especially during the flush stage.
- Administer antipyretics (drugs that reduce the level of fever) as ordered.
- Provide oral hygiene to keep the mucous membranes moist.
- Provide a tepid sponge bath to increase heat loss through conduction.
- Provide dry clothing and bed linens.
- Provide a warm environment.
- Provide dry clothing.
- Apply warm blankets.
- Keep limbs close to the body.
- Cover the client’s scalp with a cap or turban.
- Supply warm oral or intravenous fluids.
- Apply warming pads
list areas where you can assess body temp
oral
rectal
axillary
tympanic membrane
skin/temporal artery
list types of thermometer
Electronic
Chemical disposable
Temperature-sensitive tape
Infrared (tympanic)
Temporal artery
how to convert from F to C
C = (Fahrenheit temperature - 32) × 5/9
how to convert from C to F
F = (Celsius temperature x 9/5) + 32
types of pulses
Pulse
Compliance
Cardiac output
Peripheral pulse
Apical pulse
list factors affecting the pulse
Age
Sex
Exercise
Fever
Medications
Excessively fast heart rate (over 100 bpm)
Tachycardia
Heart rate of less than 60 bpm in adults
Bradycardia
Pattern of beats and intervals between beats
Pulse rhythm
list the pulse sites
radial
temporal
carotid
apical
brachial
femoral
popliteal
posterior tibial
dorsalis pedis
External intercostal muscles and other accessory muscles
Costal (thoracic) breathing
Contraction and relaxation of the diaphragm observed by movement of the abdomen
Diaphragmatic (abdominal) breathing
what are the respiratory centers
Medulla oblongata
Pons
what are the chemoreceptors
Medulla
Carotid and aortic bodies
what things happen during inhalation
Diaphragm contracts (flattens).
Ribs move upward and outward.
Sternum moves outward.
Size of the thorax enlarges
Breaths per minute
Rate
Breathing normal in rate and depth
Eupnea
Absence of breathing
Apnea
Deep, rapid respirations
Hyperventilation
Shallow respirations
Hypoventilation
list the different respiratory rhythms
- Regular
- Irregular
- Cheyne-Stokes breathing
list the irregular pulse rhythms
- Dysrhythmia
- Arrhythmia
list the sounds of breathing
Stridor, stertor, wheeze, bubbling
Measure of exertion of blood as it flows through arteries
Arterial blood pressure
Contraction of the ventricles
Systolic
Ventricles at rest
Lower pressure present at all times
Diastolic
list the determinant of blood pressure
Pumping action of heart
Peripheral vascular
Arteriosclerosis
Blood volume
Blood viscosity
Hematocrit
list factors affecting blood pressure
Age
Exercise
Stress
Race
Sex
Medications
Obesity
Diurnal variations
Medical conditions
Temperature
Blood pressure below normal
Hypotension
Blood pressure persistently above normal
Hypertension
sites for blood pressure
upper arm
thigh
list methods of blood pressure
Direct (invasive Monitoring)
Indirect
Auscultatory gap
Korotkoff sounds
Auscultatory
Palpatory
The pressure level at which the first faint, clean tapping or thumping sounds are heard. These sounds gradually become more intense. To ensure that they are not extraneous sounds, the nurse should identify at least two consecutive tapping sounds.The first tapping sound heard during deflation of the cuff is the systolic blood pressure
what phase of Korotkoff’s sounds
phase 1
The period during deflation when the sounds have a muffled, whooshing, or swishing quality
what phase of Korotkoff’s sounds
phase 2
The period during which the blood flows freely through an increasingly open artery and the sounds become crisper and more intense and again assume a thumping quality but softer than in phase 1
what phase of Korotkoff’s sounds
phase 3
The time when the sounds become muffled and have a soft, blowing quality
what phase of Korotkoff’s sounds
phase 4
The pressure level when the last sound is heard. This is followed by a period of silence. The pressure at which the last sound is heard is the diastolic blood pressure in adults
what phase of Korotkoff’s sounds
phase 5
Noninvasive device that estimates arterial oxygen saturation (Sao₂) by means of sensor attached to client’s finger
Records oxygen in peripheral arterial blood, so reported as SpO2
Detects hypoxemia before clinical signs and symptoms
Pulse oximeter
factors affecting oxygen saturation readings
Hemoglobin
Circulation
Activity
Carbon monoxide poisoning
assessment of temp
Assess relation to time, age, and previous reading
Food eaten, smoked, exercise
assessment of pulse rate
Determine the need for assessing peripheral and apical pulses
Assess factors affecting pulse
assessment of respiratory rate
Observe for signs of respiratory distress
Determine the baseline respiratory rate and character of respirations
Assess for factors that may affect the respiratory
assessment of blood pressure
Assess for signs and symptoms of hypertension and/ or hypotension
Assess for the presence of other factors that will affect Blood pressure
Assess blood pressure cuffs containing latex
Assess which arm to use
assessment of apical-radial pulse
Locate apical and radial sites
Pulse deficit
Two-nurse method may be more accurate
Movement of air in and out of the lungs
Ventilation
list the auscultatory breath sounds
normal (vesicular)
tracheal (tubular)
wheeze
rhonchi
fire crackles
coarse crackles
stridor
soft
nonmusical
inspiration/expiration
normal (vesicular)
hollow
nonmusical
inspiraion/expiration
tracheal (tubular)
musical
high pitches
inspiration/expiration
wheeze
musical
low pitches
inspiration/expiration
rhonchi
short
explosive
nonmusical
mid to late inspiration
fire crackles
short
explosive
nonmusical
early inspiration
throughout expiration
coarse crackles
musical
high pitched
audible to unaided ear
stridor
