📝 Vital signs Flashcards
What are the commonly measured vital signs?
Vital signs commonly measured include body temperature, pulse rate, respiratory rate, blood pressure, and oxygen saturation.
When should vital signs be assessed in a healthcare facility?
Vital signs should be assessed:
On admission to any healthcare facility
Routinely throughout patient admission (every 4-6 hours)
Before, during, and after surgery or invasive procedures
In conjunction with medication that may affect vital signs
Prior to calling medical staff regarding patient concerns
Prior to and following transfer between wards or healthcare facilities
Following an episode of patient deterioration
During physical examination or when “something is not quite right”
What is the normal range for core body temperature?
The normal range for core body temperature is 35.8 to 37.5°C.
What factors can affect body temperature?
Factors affecting body temperature include age, gender, stress, environmental temperatures, surgery, and hormonal changes.
How is body temperature regulated?
Core body temperature is maintained within a constant range by the thermoregulatory center in the hypothalamus.
What is pyrexia?
Pyrexia is an elevated core temperature above 38°C, often occurring as a response to tissue injury or trauma.
What are the characteristics of a normal pulse?
A normal pulse should have a regular rhythm, appropriate rate according to age, adequate strength, and equal characteristics between pulse points.
How is pulse rate assessed?
Pulse rate is assessed by counting the pulsations in 1 minute, typically at common sites like the radial, brachial, carotid, or femoral arteries.
What is the normal range for oxygen saturation?
The normal range for oxygen saturation is between 95-100%.
What are the two components of blood pressure?
Blood pressure consists of systolic pressure (during ventricular contraction) and diastolic pressure (during ventricular relaxation).
What is the procedure for assessing orthostatic hypotension?
The procedure involves measuring blood pressure and pulse rate first in a supine position, then sitting, and finally standing, and comparing the findings.
What are the possible causes of hypertension and hypotension?
Hypertension can result from factors such as age, diet, ethnicity, and underlying health conditions. Hypotension may result from pathology, medications, or heart failure.
How should blood pressure cuff size be chosen?
The cuff width should be about 40% of the limb’s circumference, and the bladder inside the cuff should encase 2/3 of the limb.
What are the phases of Korotkoff sounds during blood pressure measurement?
The phases include the onset of tapping sounds (systolic pressure) followed by muffled sounds, knocking sounds, and finally silence (diastolic pressure).
What are common errors in blood pressure assessment and their contributing causes?
Errors may include falsely low or high assessments due to factors like cuff size, hearing deficits, environmental noise, and incorrect technique.
How should vital signs be documented?
Vital signs should be documented graphically on an observation and response chart, including accompanying symptoms, interventions, and clear, contemporaneous notes following facility protocol.
What is the process for escalating concerns if vital signs are outside normal limits?
The process involves reassessment, informing colleagues and management, considering physician notification, explaining findings to the patient, and escalating further if necessary.
What are the normal ranges for respiratory rate across different age groups?
Normal respiratory rate ranges from 12-20 breaths per minute in adults but varies across different age groups.
What are the characteristics of normal respirations?
Normal respirations should be regular in rhythm, with adequate depth and effort.
What factors can affect respiratory rate?
Factors affecting respiratory rate include exercise, temperature, emotions, medications, pulmonary conditions, pain, and neurological damage.
Define eupnoea
Eupnoea: Normal respirations for an adult (12-20 breaths/min)
Define Bradypnoea
Bradypnoea: Slow respiratory rate (<12 breaths/min in adults)
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Define Tachypnoea
Tachypnoea: Rapid respirations (>20 breaths/min)
Define Apnoea
Apnoea: Periods of no breathing
Define Dyspnoea
Dyspnoea: Difficult or labored breathing
Define Orthopnoea
Orthopnoea: Inability to breathe lying down, preferring an upright position.
How is oxygen saturation measured, and what is the normal range?
Oxygen saturation is measured using pulse oximetry, with a normal range of 95-100%.
What are the considerations when measuring oxygen saturation in patients with chronic respiratory conditions?
Patients with chronic respiratory conditions may tolerate oxygen saturation levels between 88-94%.
Define blood pressure and its components.
Blood pressure is the force of blood pushing against the vessel walls. Its components include systolic pressure (during ventricular contraction) and diastolic pressure (during ventricular relaxation).
What are the determinants of blood pressure?
Blood pressure is influenced by cardiac output, vascular resistance, blood volume, blood viscosity, and vessel compliance.
Name some factors that can affect blood pressure measurements.
Factors affecting blood pressure measurements include age, circadian rhythm, gender, diet, ethnicity, exercise, weight, emotional state, body position, medications, and renal or neurological diseases.
What are the categories of blood pressure readings in adults?
Categories include normal, prehypertension, hypertension (stages 1, 2, and 3), low blood pressure, and hypotension.
Describe the process of escalating concerns if vital signs are outside normal limits.
The process includes reassessment, informing colleagues and management, considering physician notification, explaining findings to the patient, and potentially escalating further with MET calls or Code Blue activations.
What are the common vital sign assessment sites for measuring pulse and blood pressure?
Common sites for pulse assessment include the radial, brachial, carotid, and femoral arteries. For blood pressure measurement, the brachial and popliteal arteries are commonly used.
How is respiratory rate assessed, and for how long should it be measured?
Respiratory rate is assessed by counting breaths per minute, typically for a full minute, while ensuring the patient is unaware of the assessment.
What are the potential alterations in respiratory patterns, and what do they indicate?
Alterations include bradypnoea (slow breathing), tachypnoea (rapid breathing), apnoea (no breathing), dyspnoea (difficult breathing), and orthopnoea (difficulty breathing while lying down), each indicating different respiratory issues.
Describe the mechanism of pulse oximetry and its limitations.
Pulse oximetry measures oxygen saturation by passing light through capillary beds, but it may provide inaccurate results if the saturation falls below 70%.
What are the phases of Korotkoff sounds during blood pressure measurement, and what do they signify?
The phases include tapping sounds (systolic pressure onset), muffled sounds, knocking sounds, and silence (diastolic pressure cessation), representing different stages of blood flow.
What are the considerations when choosing an appropriate blood pressure cuff size?
The cuff should be about 40% of the limb’s circumference, with the bladder inside encasing 2/3 of the limb, to ensure accurate readings.
What errors can occur during blood pressure assessment, and how can they be minimized?
Errors include falsely low or high readings due to cuff size, hearing deficits, environmental noise, incorrect technique, and viewing angle. Minimization involves proper technique and equipment calibration.
What is the normal range for pulse rate across different age groups, and how does it change with age?
Pulse rate varies across different age groups, with newborns having higher rates compared to adults. For example, the normal range for adolescents to adults is 60-100 beats per minute.
Describe the characteristics of normal pulse and what they indicate about cardiovascular health.
Normal pulse characteristics include regular rhythm, appropriate rate, adequate strength, and equality between pulse points, indicating effective cardiovascular function.
What factors can affect pulse rate, and how do they influence cardiovascular health?
Factors such as exercise, temperature, emotions, medications, and underlying health conditions can affect pulse rate, reflecting the body’s response to various stimuli and overall cardiovascular health.
Explain the significance of tachycardia and bradycardia in relation to cardiac output.
Tachycardia (rapid heart rate) and bradycardia (slow heart rate) can both affect cardiac output, with tachycardia potentially increasing cardiac workload and bradycardia reducing cardiac efficiency.
How does blood pressure relate to cardiac output and peripheral vascular resistance?
Blood pressure is influenced by both cardiac output (the amount of blood ejected from the heart) and peripheral vascular resistance (the resistance to blood flow in the arteries), reflecting the balance between blood flow and resistance in the circulatory system.
Discuss the importance of regular monitoring of vital signs during a patient’s admission to a healthcare facility.
Regular monitoring of vital signs helps in assessing the patient’s baseline health status, detecting early signs of deterioration, and guiding appropriate interventions to maintain patient safety and well-being.
Describe the physiological mechanisms involved in heat production and heat loss in the regulation of body temperature.
Heat production occurs primarily through cellular metabolism, muscle movement, and hormonal regulation, while heat loss occurs through processes such as radiation, convection, evaporation, and conduction, regulated by the hypothalamus.
Explain the concept of normothermia and its significance in assessing body temperature.
Normothermia refers to a normal core body temperature within a specific range (e.g., 35.8-37.5°C) and is essential for maintaining physiological homeostasis and optimal cellular function.
Identify the different sites for temperature assessment and their respective advantages and limitations.
Temperature assessment sites include oral, axillary, rectal, tympanic, and temporal sites, each with advantages and limitations in terms of accuracy, accessibility, and patient comfort.
Describe the nursing interventions for managing alterations in body temperature, including preventive measures and treatment modalities.
Nursing interventions may include maintaining a thermally neutral environment, providing adequate hydration, implementing cooling or warming measures, administering antipyretic medications, and closely monitoring vital signs and fluid balance.
What is the normal range for adult body temperature?
a) 34.0°C - 36.0°C
b) 36.5°C - 37.5°C
c) 37.5°C - 38.5°C
d) 38.0°C - 39.0°C
Answer: b) 36.5°C - 37.5°C
Which of the following is a common site for pulse assessment?
a) Femoral artery
b) Popliteal artery
c) Radial artery
d) Carotid artery
Answer: c) Radial artery
What does tachypnoea refer to?
a) Slow respiratory rate
b) Rapid respiratory rate
c) Irregular respiratory rate
d) Absence of respiratory rate
Answer: b) Rapid respiratory rate
True or False: Hypothermia occurs when the core body temperature rises above 39°C.
False
True or False: Orthostatic hypotension is characterized by a decrease in blood pressure upon standing
True
True or False: Pulse oximetry provides an accurate estimation of arterial oxygen saturation in all cases, regardless of the patient’s condition
False
A patient’s temperature is measured as 38.2°C orally. What action should the nurse take?
a) Administer antipyretic medication.
b) Reassess the temperature using a different method (e.g., tympanic or temporal).
c) Document the temperature and continue to monitor the patient.
d) Immediately notify the healthcare provider
Answer: c) Document the temperature and continue to monitor the patient.
During a routine assessment, a nurse finds the patient’s blood pressure to be 150/90 mmHg. What should the nurse do next?
a) Reassess the blood pressure in the other arm.
b) Document the blood pressure and continue monitoring.
c) Notify the healthcare provider.
d) Administer antihypertensive medication
Answer: b) Document the blood pressure and continue monitoring.
Which of the following factors can affect pulse rate?
a) Emotional state
b) Blood viscosity
c) Environmental temperature
d) All of the above
Answer: d) All of the above
What is the normal respiratory rate for an adult?
a) 12-20 breaths per minute
b) 20-30 breaths per minute
c) 30-60 breaths per minute
d) 60-100 breaths per minute
Answer: a) 12-20 breaths per minute
Which of the following is a non-invasive method for measuring blood pressure?
a) Arterial line
b) Intra-arterial catheter
c) Sphygmomanometer
d) Central venous catheter
Answer: c) Sphygmomanometer
True or False: Hypotension is defined as a blood pressure reading consistently above 140/90 mmHg
False
True or False: Oxygen saturation is measured using a pulse oximeter, which provides an estimation of arterial oxygen saturation (SpO2)
True
True or False: Postural hypotension is a transient increase in blood pressure when changing positions from lying to standing
False
What are the four vital signs?
Answer: Temperature, pulse, respiration, and blood pressure.
What is the normal range for an adult’s body temperature?
Answer: 36.0°C to 37.5°C.
Which part of the brain regulates body temperature?
Answer: The thermoregulatory center in the hypothalamus.
Which hormone increases metabolism and heat production?
Answer: Adrenaline and noradrenaline (sympathetic neurotransmitters).
What is the primary source of heat in the body?
Answer: Metabolism.
What is the term for an abnormal increase in body temperature?
Answer: Hyperthermia.
At what age might a neonate have a normal blood pressure reading of 73/55 mmHg?
Answer: At birth.
What is the normal respiratory rate for an adult?
Answer: 12-20 breaths per minute.
Which part of the body is primarily responsible for heat loss?
Answer: The skin.
What is the medical term for a rapid heart rate?
Answer: Tachycardia.
Which factor can affect pulse rate?
Answer: Emotional state.
What is the term for the temporary cessation of breathing?
Answer: Apnoea.
What is the average pulse rate for an adult?
Answer: 60-100 beats per minute.
Which age group has the highest normal pulse rate range?
Answer: Neonates (80-180 beats per minute).
Which technique is used to measure blood pressure non-invasively?
Answer: Sphygmomanometer.
What is the normal range for diastolic blood pressure in adults?
Answer: 60-80 mmHg.
What term describes difficulty in breathing?
Answer: Dyspnoea.
Which mechanism of heat transfer involves the conversion of a liquid to vapor?
Answer: Evaporation.
What is the term for a low body temperature?
Answer: Hypothermia.
What factors can affect body temperature?
Answer: Circadian rhythms, age, gender, stress, and environmental temperatures.
At what time of day is body temperature usually lower?
Answer: In the early morning.
What term is used to describe an elevated body temperature?
Answer: Fever or pyrexia.
What is the normal range of body temperature variation from the average?
Answer: 0.3°C to 0.6°C.
Which age group is more sensitive to changes in environmental temperature?
Answer: The very young and the very old.
How much higher can a fever be than the upper limit of normal body temperature?
Answer: Just above the upper limit of normal.
What is the medical term for a fever that alternates between periods of fever and normal temperature?
Answer: Intermittent fever.
Which gender tends to have more fluctuations in body temperature?
Answer: Women.
What term describes a body temperature below the normal range?
Answer: Hypothermia.
Which hormone secretion in women can increase body temperature?
Answer: Progesterone.
What is the usual peak elevation time of a person’s temperature?
Answer: Late afternoon, between 4 pm and 7 pm.
What is the primary mechanism by which the body loses heat to the environment?
Answer: Radiation, convection, evaporation, and conduction.
What is the medical emergency term for a fever above 41°C?
Answer: Hyperpyrexia.
What type of fever fluctuates several degrees above normal but does not return to normal between fluctuations?
Answer: Remittent fever.
What are some physical effects of increased body temperature?
Answer: Loss of appetite, headache, hot dry skin, flushed face, thirst, and general malaise.
What is the term for a fever that returns to normal suddenly?
Answer: Crisis.
What is the average normal temperature for an adult measured orally?
Answer: 37.0°C.
What term describes the body’s response to extreme heat exposure or excessive heat production without a change in the hypothalamic set point?
Answer: Hyperthermia.
An elevation of the body temperature above normal is labelled:
a.Pyrexia
b.Hypothermia
c.Hypertension
d.Afebrile
The correct answer is a. Pyrexia is an elevation of body temperature. Hypothermia (b) is low body temperature. Hypertension (c) is elevated blood pressure. Afebrile (d) means that there is not an elevation of body temperature.
For which of the following people would you use an oral thermometer?
a.A 6-month-old infant
b.Person receiving oxygen therapy
c.A 42-year-old healthy woman
d.Unconscious person
The correct answer is c. Use of oral thermometers is contraindicated in infants (a), people receiving oxygen therapy (b) and unconscious people (d).
Which of the following potentially harmful consequences may occur as a result of insertion of a rectal thermometer?
a.An increase in heart rate
b.A decrease in heart rate
c.An involuntary loss of stool
d.An increase in respiration
The correct answer is b. Insertion of a rectal thermometer may stimulate the vagus nerve, which, in turn, would decrease heart rate. This may potentially be harmful for people with cardiac problems.
While taking an adult’s pulse, a student finds the rate to be 140 beats/min. What should the student do next?
a.Check the pulse again in 2 hours.
b.Check the blood pressure.
c.Record the information.
d.Report the rate.
The correct answer is d. A rate of 140 in an adult is an abnormal pulse and should be reported to the instructor or the nurse in charge of the person.
A patient complains of severe abdominal pain. When assessing the vital signs, the nurse is likely to find:
a.An increase in the pulse rate
b.A decrease in body temperature
c.A decrease in blood pressure
d.A decrease in respiration
The correct answer is a. The pulse often increases when an individual is experiencing pain. Pain does not affect body temperature and may increase (not decrease) blood pressure. Pain is more likely to increase the respiration rate
The difference between the apical and radial pulse rates is called the:
a.Pulse deficit
b.Pulse amplitude
c.Ventricular rhythm
d.Heart arrhythmia
The correct answer is a. The difference between the apical and radial pulse rate is called the pulse deficit. The other responses are names given to volume and rhythm of the pulse.
The normal respiratory rate in adults is considered to be:
a.1 to 6 breaths/min
b.12 to 20 breaths/min
c.60 to 80 breaths/min
d.100 to 120 breaths/min
The correct answer is b. The normal respiratory rate for adults is 12 to 20 breaths/min.
A person is experiencing dyspnoea. To facilitate respirations, you would:
a.Remove pillows from under the head
b.Elevate the head of the bed
c.Elevate the foot of the bed
d.Take the blood pressure
The correct answer is b. Dyspnoea means difficult respirations. Elevating the head of the bed allows the abdominal organs to descend, giving the diaphragm greater room for expansion and facilitating lung expansion. Any other intervention would not facilitate respirations.
Blood pressure is the measurement of the:
a.Flow of blood through the circulation
b.Force of blood against arterial walls
c.Force of blood against venous walls
d.Flow of blood through the heart
The correct answer is b. Blood pressure is the measurement of the force of blood against arterial walls. Other responses are incorrect in describing blood pressure.
With ageing, blood pressure is often higher as a result of:
a.Loss of muscle mass
b.Changes in exercise and diet
c.Decreased peripheral resistance
d.Decreased elasticity in arterial walls
The correct answer is d. With ageing, elasticity in arterial walls is decreased, contributing to an elevated blood pressure reading. The other responses may contribute to changes in readings, but they are not the physiological basis for blood pressure findings in the older adult.
In recording a blood pressure of 120/80mmHg, the 120 represents the:
a.Pulse rate
b.Diastolic pressure
c.Systolic pressure
d.Pulse deficit
The correct answer is c – 120 is the systolic pressure. The diastolic pressure is 80. The other responses relate to pulse rather than blood pressure.
It is important to have the appropriate cuff size when taking the blood pressure. A cuff that is too large or too small may result in:
a.An incorrect reading
b.Injury to the person
c.Prolonged pressure on the arm
d.Loss of Korotkoff sounds
The correct answer is a. A blood pressure cuff that is not the right size may cause an incorrect reading. It will not cause injury (b) or loss of sounds (d).
A person has intravenous fluids infusing in the right arm. When taking a blood pressure on this person, you would:
a.Take the blood pressure in the right arm
b.Take the blood pressure in the left arm
c.Use the smallest possible cuff
d.Report an inability to take the blood pressure
The correct answer is b. The blood pressure should be taken in the arm opposite the one with the infusion. Blood pressure should not be taken in the arm with an intravenous infusion because the pressure of inflating the cuff may allow the artery to clot.
