Vital Signs Flashcards by Christian Cunanan

Monitor functions of the body
Should be thoughtful, scientific assessment
Often, someone other than a nurse measures a client’s this

vital signs

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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

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Deep tissues of the body
Remains relatively constant

Body temperature
Core

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Skin, subcutaneous tissue, fat
Responds to environment

Surface

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list factors affecting body’s heat production

Basal metabolic rate (BMR)
Muscle activity
Thyroxine output
Epinephrine, norepinephrine, and sympathetic stimulation/stress response
Fever

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Transfer of heat from surface of one object to surface of another without contact

Radiation

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Transfer of heat from one molecule to a molecule of lower temperature

Conduction

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Dispersion of heat by air currents

Convection

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Insensible water loss
Insensible heat loss

Evaporation

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list places where temperature regulates through

Sensors in periphery and core
Integrator in hypothalamus
Effector system adjusting heat production/loss
Most sensors in skin

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list the different processes to increase body temperature

Shivering
Sweating
Vasoconstriction

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list factors affecting body temp

Age
Diurnal variations (circadian rhythms)
Exercise
Hormones
Stress
Environment

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what is the normal body temp

96.8 F to 99.5 F or 36 C and 37.5 C

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list types of pyrexia

-Intermittent
-Remittent
-Relapsing
-Constant

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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

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list areas where you can assess body temp

oral
rectal
axillary
tympanic membrane
skin/temporal artery

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list types of thermometer

Electronic
Chemical disposable
Temperature-sensitive tape
Infrared (tympanic)
Temporal artery

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how to convert from F to C

C = (Fahrenheit temperature - 32) × 5/9

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how to convert from C to F

F = (Celsius temperature x 9/5) + 32

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types of pulses

Pulse
Compliance
Cardiac output
Peripheral pulse
Apical pulse

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list factors affecting the pulse

Age
Sex
Exercise
Fever
Medications

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Excessively fast heart rate (over 100 bpm)

Tachycardia

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Heart rate of less than 60 bpm in adults

Bradycardia

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Pattern of beats and intervals between beats

Pulse rhythm

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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