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Vital Signs Flashcards

1
Q

What causes normal vital signs to change

A

Age, sex, weight, exercise tolerance, and condition

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2
Q

What should you do if you have an abnormal result?

A

If they have abnormal results do they physically look like they have abnormal results or was their a mistake or is that their baseline.

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3
Q

What are the 4 things you need to do as the nurse relative to vital signs?

A

measure correctly, understand and interpret, communicate, and intervene

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4
Q

What is a patients baseline

A

1st set of vitals

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5
Q

Why is the patient’a baseline important?

A

It allows the nurse to see changes in the patient

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6
Q

How frequent should you take vital signs on stable pts

A

Q4-6 hours

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7
Q

How frequent should you take vital sings on postsurgical pts

A

Q15 minutes

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8
Q

How frequent should you take vital signs on critical pts

A

Q15 minutes

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9
Q

How should you interpret a pts vital signs

A

compare with their normal or baseline values

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10
Q

What do you need to know about the pt to understand their vital signs

A

The pts medical history and possible diagnosis

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11
Q

What are some cases in which you should take vital signs?

A

On ADMISSION, physical ASSESSMENT, MORNING routines, change in health STATUS, before and after SURGERY or administration of MEDICATION or INTERVENTIONS.

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12
Q

What is the normal tamperature

A

97.6-99.6

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13
Q

What is the average oral temperature?

A

98.6

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14
Q

What is hyperthermia

A

> 104F

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15
Q

If a patient is afebrile what does that mean

A

They have no fever

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16
Q

If a patient has a fever of >100.4 how would you describe them

A

febrile

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17
Q

Why might doctors wait a couple of hours to give antifebrile medication

A

A fever is a defense mechenism of the body to destroy bacteria

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18
Q

What sight gives the highest reading?

A

Rectal>oral>axiallary

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19
Q

Which age populations run on the cooler side. Are they more susceptible to environmental temperature extremes

A

Infants and elderly people, yes.

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20
Q

Can newborns regulate their tempurature

A

No they have immature regulatory mechanisms

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21
Q

How does exrcise effect body temp

A

in increases

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22
Q

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

A

higher

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23
Q

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.

A

Higher

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24
Q

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?

A

Coller becuase smoking constricts the blood vessels.

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25
Your patient just exercised or bathed how long should you wait to take their temp
1 hour
26
what patient just smoked or consumed cold or hot food or drink how long should you wait
30 minutes
27
What is the most common way to measure temperature
oral (mouth)
28
What is the least accurate way to measure temp
exillary (armpit)
29
You have a child and need to get their temp. Which way are you using?
tympanic (ear)
30
What is the last resort way to get a newborns temp, its also the most accurate
rectal (anus)
31
You have a critical patient and need an advanced way to get their temp what can you use
Foley catheter and esophageal
32
You have a 3 year old who needs their temp, can you use the oral way?
No, only 4 years old and up
33
Where do you put the oral themometer
In the sublingual pocket
34
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
35
How far should you insert a lubricared rectal bulb?
1-1.5 inches
36
What may happen if you use the recatl method on a newborn
You may puncture their bowels
37
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
38
Which way do you pull the ear for adUlt patients
Up and back
39
Which way do you pull the ear for chilDren
Down and back
40
What is the last resort method to get a temp other than rectal, and why
Temporal, it's very inaccurate
41
What should you use when oral and rectal sites are inaccessible
Avillary, it's the least accurate
42
What is the normal HR
60-100 BPM
43
You have a female patient, what do you expect about their HR
Females have higher HR than males
44
What causes bradycardia
<60 BPM, RESTING, heart BLOCK, AGE, ATHLETE
45
What causes tachycardia
>BPM, SHOCK, HEMORRHAGE, FEVER, acute PAIN, DRUGS
46
You need to get the central pulse of a patient, what is that
The apical pulse
47
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
48
You have a 98 year old male compared to a 15 year female, their HR is higher or lower
Slower
49
You just ran a mile your HR will be higher or lower
higher
50
You girlfriend just dumped you and you are stressed out, is your HR higher or lower
higher
51
Does medication increase or decrease your HR
both
52
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
53
You have a child under 2 how should you get their HR
auscultate the apical pulse for a full minute
54
You feel an irregular pulse, what should you do
assess the apical pulse for a full minute
55
When assessing the HR how do you describe the rhythm
regular or irregular
56
When assessing the HR how do you describe the intensity
weak, normal, strong, or bounding (0-4)
57
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
58
How does HR change over the life spand
high, decreasing, normal, decrease
59
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
60
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
61
What is a full respiration cycle
an inhale and exhale
62
What is the average respiration range
12-20
63
What can affect respirations
AGE, EXERCISE, respiratory DISEASE, MEDS, PAIN, EMOTIONS
64
What is bradypnea and what can cause it
<12, head TRAUMA, MEDS (opioids, sedativies)
65
What is tachypnea and what can cause it
>20, FEVER, ILLNESS
66
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
67
When assesing a pts respirations what three things are you looking at
rate (how fast), rhythm (regular or irregulat), quality (even, unlabored)
68
If the patient is short of breath what is your first action
1. sit them up (tripod position) 2. Get another set of vitals 3. interventions if needed
69
How does respirations change over the life span
higher, decreasing, normal, increased
70
What should you keep in mind about your 98 year olds respirations
their lung ELASTICITY decreses, and their respiratory MUSCLES are weakened
71
What is blood pressure measured in
mmHg
72
What is the average BP for an adult
120/80
73
What affects BP
AGE, EXERCISE, MEDS, PAIN, EMOTIONS
74
How is hypertension described
in stages
75
What is hypotension
<90 systolic
76
Describe systolic and diastolice pressures
Systolic: pressure when the heart CONTRACTS Diastolic: pressure when heart is RELAXED
77
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
78
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
79
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
80
What is stage one hypertension, and what inventions are there
130-139/80-89, no meds, life style modifications
81
What is stage two hypertension
>140/90
82
Your pt has primary hypertension, what does that mean
there is no known cause
83
Your pt has secondary hypertenion, what does that mean
caused by a known illness
84
Your patient is coming in to get their BP what should you tell them to avoid
They should avoid COFFEE, SMOKING, or EXERCISE
85
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
86
If your patient's arm is too high or the cuff is too big how will the BP read
The BP will read lower
87
If your patient's arm is too low or the cuff is too small how will the SP read
The BP will read lower
88
How does the BP change over the years
lower, cardiovasular system improves, increases, normal, then increases
89
Why does BP increase in older adults
natural stiffening of arteries and changes in blood vessel elasticity
90
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

Nursing Essentials (16 decks)

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