Vital Signs Flashcards
Vital Signs include
Temp
Pulse/ Pulse Ox
Respiration
Blood Pressure
Who orders the frequency of vitals?
Can a nurse take vital signs at any time?
MD orders frequency of vitals
Yes, a nurse can take vital signs at any time
Normal Oral Temperature
97 to 100 degrees
Most accurate body temperature
Rectal
Neutropenic
Low WBC
How does body temperature maintain normal/ core temp?
Heat production has to equal heat loss to maintain normal temp
How does body lose heat?
Through skin and lungs
Radiation
Conduction
Convection
Evaporation (Sweat and Fever)
What happens to the core temperature the older you get?
Core temperature gets lower
Factors that affect body temp
Age
Environment
Time of Day
Exercise
Stress
Hormones
Normal Temp Ranges
Oral
Axillary
Rectal
Tympanic
Oral -97-100 F
Rectal- 98-101 F
Tympanic- 97-100 F
Axillary- 96-99 F
How long should an apical pulse be listened to?
One full minute
What do pulses check for?
Circulation
What can happen to your heart rate the older you get?
Heart rate can increase
Bradycardia
< 60 BPM
Tachycardia
> 100 BPM
Apical Radial Rate
where 2 nurses check pulse for 1 min at the same time
One nurse checks apical
One nurse checks radial
If pulse deficit is greater than 10 BPM, it indicates a problem
Person should be lie flat w/ respiratory distress. T or F
Person should never be lied flat
Normal adult respiration rate
12-20/ min
tachypnea
rapid respiratory rate, more than 20 breaths per min
bradypnea
slow respiratory rate, less than 12 breaths per min
normal respiratory rate and depth
Eupnea
Abnormal breathing patterns
BIOTs ( random periods of shallow breath and apnea) NEURO PROBS
Cheyne- Stokes (cyclic periods of increased shallow breaths and apnea) HEART FAILURE, OD
Kussmal (deep, rapid respirations (acidosis/ renal failure)
A harsh inspiratory sound due to obstruction that may be compared to crowing/ upper respiratory
Stridor
wheezing is an
Adventitious breath sound
Dyspnea
Difficulty breathing
What can happen to blood pressure as you age?
Arteries become less elastic and extra fluid volume can increase BP
Normal systolic BP
Below 130
Normal Diastolic BP
Below 85
High Normal BPs
Systolic- 130-139
Diastolic - 85- 89
Orthostatic Hypotension
a condition that causes a sudden drop in blood pressure when standing up or sitting down
Doppler ultrasounds will only get which BP reading
Systolic readings
Important things for taking BP
Feet on floor/ uncross feet
Arm supported by pillow
Proper Cuff size
Are pain assessments subjective?
YES; Pain can be assessd at any time
Can nurses delegate vital signs?
Yes
