Vital Signs Flashcards
What causes normal vital signs to change
Age, sex, weight, exercise tolerance, and condition
What should you do if you have an abnormal result?
If they have abnormal results do they physically look like they have abnormal results or was their a mistake or is that their baseline.
What are the 4 things you need to do as the nurse relative to vital signs?
measure correctly, understand and interpret, communicate, and intervene
What is a patients baseline
1st set of vitals
Why is the patient’a baseline important?
It allows the nurse to see changes in the patient
How frequent should you take vital signs on stable pts
Q4-6 hours
How frequent should you take vital sings on postsurgical pts
Q15 minutes
How frequent should you take vital signs on critical pts
Q15 minutes
How should you interpret a pts vital signs
compare with their normal or baseline values
What do you need to know about the pt to understand their vital signs
The pts medical history and possible diagnosis
What are some cases in which you should take vital signs?
On ADMISSION, physical ASSESSMENT, MORNING routines, change in health STATUS, before and after SURGERY or administration of MEDICATION or INTERVENTIONS.
What is the normal tamperature
97.6-99.6
What is the average oral temperature?
98.6
What is hyperthermia
> 104F
If a patient is afebrile what does that mean
They have no fever
If a patient has a fever of >100.4 how would you describe them
febrile
Why might doctors wait a couple of hours to give antifebrile medication
A fever is a defense mechenism of the body to destroy bacteria
What sight gives the highest reading?
Rectal>oral>axiallary
Which age populations run on the cooler side. Are they more susceptible to environmental temperature extremes
Infants and elderly people, yes.
Can newborns regulate their tempurature
No they have immature regulatory mechanisms
How does exrcise effect body temp
in increases
A college student just got broken up with right before her finals and she’s very stressed. What do we predict her temp to be
higher
It’s a hot day outside and your patient just got to the doctor’s office and you took their temp right away. What do you expect it will be.
Higher
Your patient is a 40 year old male who has been smoking for 20 years. What do you expect his temp to be and why?
Coller becuase smoking constricts the blood vessels.
Your patient just exercised or bathed how long should you wait to take their temp
1 hour
what patient just smoked or consumed cold or hot food or drink how long should you wait
30 minutes
What is the most common way to measure temperature
oral (mouth)
What is the least accurate way to measure temp
exillary (armpit)
You have a child and need to get their temp. Which way are you using?
tympanic (ear)
What is the last resort way to get a newborns temp, its also the most accurate
rectal (anus)
You have a critical patient and need an advanced way to get their temp what can you use
Foley catheter and esophageal
You have a 3 year old who needs their temp, can you use the oral way?
No, only 4 years old and up
Where do you put the oral themometer
In the sublingual pocket
Your patient has a history of seizures, just got an oral surgery, and is unconscious should you use the oral way to get their temp
NO
How far should you insert a lubricared rectal bulb?
1-1.5 inches
What may happen if you use the recatl method on a newborn
You may puncture their bowels
Why shouldn’t you use the rectal method to get a temp for quesriplegic patients?
They can’t feel anything below the neck, throughfore they can’t tell you if it hurts
Which way do you pull the ear for adUlt patients
Up and back
Which way do you pull the ear for chilDren
Down and back
What is the last resort method to get a temp other than rectal, and why
Temporal, it’s very inaccurate
What should you use when oral and rectal sites are inaccessible
Avillary, it’s the least accurate
What is the normal HR
60-100 BPM
You have a female patient, what do you expect about their HR
Females have higher HR than males
What causes bradycardia
<60 BPM, RESTING, heart BLOCK, AGE, ATHLETE
What causes tachycardia
> BPM, SHOCK, HEMORRHAGE, FEVER, acute PAIN, DRUGS
You need to get the central pulse of a patient, what is that
The apical pulse
When you are getting a pts HR from their radial or pedial pulse what are those considered
Peripheral pulses, they are located away from the heart
You have a 98 year old male compared to a 15 year female, their HR is higher or lower
Slower
You just ran a mile your HR will be higher or lower
higher
You girlfriend just dumped you and you are stressed out, is your HR higher or lower
higher
Does medication increase or decrease your HR
both
You pt comes in with their arm chopped off and they are losing a lot of blood (hypocolemic), is their HR higher or lower
higher
You have a child under 2 how should you get their HR
auscultate the apical pulse for a full minute
You feel an irregular pulse, what should you do
assess the apical pulse for a full minute
When assessing the HR how do you describe the rhythm
regular or irregular
When assessing the HR how do you describe the intensity
weak, normal, strong, or bounding (0-4)
You have an obese pt that has edema and poor circulation. When getting their HR what should you keep in mind
It will be difficult to palpate
How does HR change over the life spand
high, decreasing, normal, decrease
You have an older patient what should you understand about their HR
They are more at risk for arrhythmias and heart disease, and the heart can’t beat as fast during exercise
If your patient has an abnormally low or high heart rate, what questions should you ask your patient?
Their history, activites, if they are an athlete, or if they take any meds that could effect that heart
What is a full respiration cycle
an inhale and exhale
What is the average respiration range
12-20
What can affect respirations
AGE, EXERCISE, respiratory DISEASE, MEDS, PAIN, EMOTIONS
What is bradypnea and what can cause it
<12, head TRAUMA, MEDS (opioids, sedativies)
What is tachypnea and what can cause it
> 20, FEVER, ILLNESS
What you are getting your pts respirations what should you not tell them, and what should you do
don’t tell them you are counting their breaths, put your hand on their shoulder
When assesing a pts respirations what three things are you looking at
rate (how fast), rhythm (regular or irregulat), quality (even, unlabored)
If the patient is short of breath what is your first action
- sit them up (tripod position)
- Get another set of vitals
- interventions if needed
How does respirations change over the life span
higher, decreasing, normal, increased
What should you keep in mind about your 98 year olds respirations
their lung ELASTICITY decreses, and their respiratory MUSCLES are weakened
What is blood pressure measured in
mmHg
What is the average BP for an adult
120/80
What affects BP
AGE, EXERCISE, MEDS, PAIN, EMOTIONS
How is hypertension described
in stages
What is hypotension
<90 systolic
Describe systolic and diastolice pressures
Systolic: pressure when the heart CONTRACTS
Diastolic: pressure when heart is RELAXED
Your patient has a limb alert and a pulse oximeter on their left arm. Which arm should you use for their BP
The right arm
You have a pt who had a mastectomy, has a dialysis shunt, and an IV all in their left arm. What can you assume about that arm.
It’s likely on limb alert
Why shouldn’t you put the BP cuff on the side of the pulse oximete
It cuts off the blood flow and can effect the results
What is stage one hypertension, and what inventions are there
130-139/80-89, no meds, life style modifications
What is stage two hypertension
> 140/90
Your pt has primary hypertension, what does that mean
there is no known cause
Your pt has secondary hypertenion, what does that mean
caused by a known illness
Your patient is coming in to get their BP what should you tell them to avoid
They should avoid COFFEE, SMOKING, or EXERCISE
Where should your patients feet and arm be when getting their BP
they should be SITTING, feet should be on the FLOOR, and their arm should be at the same height as their HEART
If your patient’s arm is too high or the cuff is too big how will the BP read
The BP will read lower
If your patient’s arm is too low or the cuff is too small how will the SP read
The BP will read lower
How does the BP change over the years
lower, cardiovasular system improves, increases, normal, then increases
Why does BP increase in older adults
natural stiffening of arteries and changes in blood vessel elasticity
What must you think about when deciding to delegate vital signs to an aide or not
the patient must be stable, the techs must know the proper technique, and it must be accurate
