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FUNDA > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

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

A

vital signs

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2
Q

when are times to assess vital signs

A
  • 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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3
Q

Deep tissues of the body
Remains relatively constant

A

Body temperature
Core

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4
Q

Skin, subcutaneous tissue, fat
Responds to environment

A

Surface

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5
Q

list factors affecting body’s heat production

A
  • Basal metabolic rate (BMR)
  • Muscle activity
  • Thyroxine output
  • Epinephrine, norepinephrine, and sympathetic stimulation/stress response
  • Fever
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6
Q

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

A

Radiation

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7
Q

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

A

Conduction

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8
Q

Dispersion of heat by air currents

A

Convection

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9
Q

Insensible water loss
Insensible heat loss

A

Evaporation

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10
Q

list places where temperature regulates through

A
  • Sensors in periphery and core
  • Integrator in hypothalamus
  • Effector system adjusting heat production/loss
  • Most sensors in skin
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11
Q

list the different processes to increase body temperature

A

Shivering
Sweating
Vasoconstriction

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12
Q

list factors affecting body temp

A

Age
Diurnal variations (circadian rhythms)
Exercise
Hormones
Stress
Environment

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13
Q

what is the normal body temp

A

96.8 F to 99.5 F or 36 C and 37.5 C

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14
Q

list types of pyrexia

A

-Intermittent
-Remittent
-Relapsing
-Constant

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15
Q

list at least 10 nursing interventions

A
  • 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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16
Q

list areas where you can assess body temp

A

oral
rectal
axillary
tympanic membrane
skin/temporal artery

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17
Q

list types of thermometer

A

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

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18
Q

how to convert from F to C

A

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

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19
Q

how to convert from C to F

A

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

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20
Q

types of pulses

A

Pulse
Compliance
Cardiac output
Peripheral pulse
Apical pulse

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21
Q

list factors affecting the pulse

A

Age
Sex
Exercise
Fever
Medications

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22
Q

Excessively fast heart rate (over 100 bpm)

A

Tachycardia

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23
Q

Heart rate of less than 60 bpm in adults

A

Bradycardia

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24
Q

Pattern of beats and intervals between beats

A

Pulse rhythm

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25
Q

list the pulse sites

A

radial
temporal
carotid
apical
brachial
femoral
popliteal
posterior tibial
dorsalis pedis

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26
Q

External intercostal muscles and other accessory muscles

A

Costal (thoracic) breathing

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27
Q

Contraction and relaxation of the diaphragm observed by movement of the abdomen

A

Diaphragmatic (abdominal) breathing

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28
Q

what are the respiratory centers

A

Medulla oblongata
Pons

29
Q

what are the chemoreceptors

A

Medulla
Carotid and aortic bodies

30
Q

what things happen during inhalation

A

Diaphragm contracts (flattens).
Ribs move upward and outward.
Sternum moves outward.
Size of the thorax enlarges

31
Q

Breaths per minute

A

Rate

32
Q

Breathing normal in rate and depth

A

Eupnea

33
Q

Absence of breathing

A

Apnea

34
Q

Deep, rapid respirations

A

Hyperventilation

35
Q

Shallow respirations

A

Hypoventilation

36
Q

list the different respiratory rhythms

A
  • Regular
  • Irregular
  • Cheyne-Stokes breathing
37
Q

list the irregular pulse rhythms

A
  • Dysrhythmia
  • Arrhythmia
38
Q

list the sounds of breathing

A

Stridor, stertor, wheeze, bubbling

39
Q

Measure of exertion of blood as it flows through arteries

A

Arterial blood pressure

40
Q

Contraction of the ventricles

A

Systolic

41
Q

Ventricles at rest
Lower pressure present at all times

A

Diastolic

42
Q

list the determinant of blood pressure

A

Pumping action of heart
Peripheral vascular
Arteriosclerosis
Blood volume
Blood viscosity
Hematocrit

43
Q

list factors affecting blood pressure

A

Age
Exercise
Stress
Race
Sex
Medications
Obesity
Diurnal variations
Medical conditions
Temperature

44
Q

Blood pressure below normal

A

Hypotension

45
Q

Blood pressure persistently above normal

A

Hypertension

46
Q

sites for blood pressure

A

upper arm
thigh

47
Q

list methods of blood pressure

A

Direct (invasive Monitoring)
Indirect
Auscultatory gap
Korotkoff sounds
Auscultatory
Palpatory

48
Q

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

A

phase 1

49
Q

The period during deflation when the sounds have a muffled, whooshing, or swishing quality

what phase of Korotkoff’s sounds

A

phase 2

50
Q

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

A

phase 3

51
Q

The time when the sounds become muffled and have a soft, blowing quality

what phase of Korotkoff’s sounds

A

phase 4

52
Q

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

A

phase 5

53
Q

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

A

Pulse oximeter

54
Q

factors affecting oxygen saturation readings

A

Hemoglobin
Circulation
Activity
Carbon monoxide poisoning

55
Q

assessment of temp

A

Assess relation to time, age, and previous reading
Food eaten, smoked, exercise

56
Q

assessment of pulse rate

A

Determine the need for assessing peripheral and apical pulses
Assess factors affecting pulse

57
Q

assessment of respiratory rate

A

Observe for signs of respiratory distress
Determine the baseline respiratory rate and character of respirations
Assess for factors that may affect the respiratory

58
Q

assessment of blood pressure

A

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

59
Q

assessment of apical-radial pulse

A

Locate apical and radial sites
Pulse deficit
Two-nurse method may be more accurate

60
Q

Movement of air in and out of the lungs

A

Ventilation

61
Q

list the auscultatory breath sounds

A

normal (vesicular)
tracheal (tubular)
wheeze
rhonchi
fire crackles
coarse crackles
stridor

62
Q

soft
nonmusical
inspiration/expiration

A

normal (vesicular)

63
Q

hollow
nonmusical
inspiraion/expiration

A

tracheal (tubular)

64
Q

musical
high pitches
inspiration/expiration

A

wheeze

65
Q

musical
low pitches
inspiration/expiration

A

rhonchi

66
Q

short
explosive
nonmusical
mid to late inspiration

A

fire crackles

67
Q

short
explosive
nonmusical
early inspiration
throughout expiration

A

coarse crackles

68
Q

musical
high pitched
audible to unaided ear

A

stridor

FUNDA (6 decks)

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