Vital Signs Flashcards
Below what rate is bradycardia?
<60 bpm
Normal range for respirations per minute in an adult
12-20 bpm
Above what rate is tachycardia?
> 100bpm
Normal adult pulse rate range for adults
60-100 bpm
Normal temperature range for adults?
36.1-38.2C
97-100F
At what temperature is it considered a fever?
100.1F
37.8C
Pros & Cons of oral temperatures?
Pro- easy, fast
Cons- affected by food and drink, cannot use for infants, cannot use in PT with oral and facial trauma
Pros & Cons of rectal temperatures?
Pros- good for infants
Cons- can damage rectum, uncomfortable, not for elderly, not for ppl on thinners
Pros & Cons of tympanic temperatures?
Pros- fast, non-invasive
Cons- cannot use for ppl with ear infections, cannot use for kids under 6mo, no hearing aids
Pros & Cons of temporal temperatures?
Pro- most accurate**, fast, safe
Cons- cannot use on head traumas, hats/head coverings, sweaty ppl
Pros & Cons of axillary temperatures?
Pros- safe, easy, any age
Cons- least accurate, slow
Normal heart rate for infants?
120-160bpm
Normal heart rate for toddler?
90-140bpm
Normal heart rate for preschoolers?
80-110 bpm
Normal heart rate for adolescents?
60-90bpm
What is cardiac output?
Amount of blood coming out of heart every minute
What is stroke volume?
Amount of blood ejected from the ventricles during each beat
What is the apical pulse?
the most accurate area for auscultation of the pulse
What is Eupnea?
normal resp. w/ equal rate and depth
What are Kussmaul respirations
resp. that are regular but abnormally deep and increased in rate
What are blots respirations
irregular resp of variable depth (usually shallow) alternating with periods of apnea
what are cheyne-stokes respirations?
gradual increase in depth of resp, followed by gradual decrease and then a period of apnea
What is normal pulse oximetry? more assessment needed? cause for concern?
Normal- 95-100
More assessment-90-95
Concern- <90%
What is systolic pressure? diastolic?
S- the peak pressure during ejection - when heart is filling
D- heart is at rest/ventricles relax
What can happen if BP cuff is too big? too small?
B- too low of a BP
S- too high
What is considered hypotension?
systolic <90mmhg
diastolic<50mmhg
What is considered hypertension?
a systolic >140mmhg
a diastolic >90mmhg
What is difficulty breathing also called?
Dyspnea
what affects both pulse and blood pressure?
Autonomic nervous system
What is the amount of air moving in and out with each breath
Tidal volume
What is the bodys thermostat?
Hypothalamus
A client who has received an opioid analgesic will most likely exhibit which of the following vital sign changes?
Decreased respiratory rate
Your client just finished a cup of hot tea. How long will you wait before checking their temperature?
30 mins
To assess a client’s blood pressure, the nurse will do which of the following?
A.) Obtain the reading in the early morning.
B.) Inflate the cuff to 30 mm Hg higher than the point they last palpated a pulse.
C.) Assist the client to the bathroom to void.
D.) Apply the cuff loosely around the client’s arm.
Inflate the cuff to 30 mm Hg higher than the point they last palpated a pulse
Your client is diagnosed with congestive heart failure. The pulse is weak, thready and easily obliterated by light pressure. What is the quality of this pulse?
1
If you obtain a slow radial pulse, how will you check to make sure your count is accurate?
Obtain an apical pulse rate.
A client who has been a smoker for 40 years has been diagnosed with pneumonia. What alterations in their vital signs would you expect?
Increase in respirations, Spo2 on lower end of normal, possible elevated blood pressure and pulse.
Evaluate the following blood pressures. Are they high, low or normal?
116/90
80/50
184/102
140/90
86/32
116/90 – high diastolic
80/50 – both low
184/102 – both high
140/90 - both high
86/32 – both low
core temperature
temp of deep tissues
radiation
transfer of heat from the surface of one object to the surface of another without direct contact
conduction
transfer of heat from one object to another with direct contact
ability to control temperature depends on:
-degree of temperature extreme
-person’s ability to sense feeling comfortable
-thought processes or emotions
-person’s mobility or ability to remove or add clothes
pyrexia
fever
nursing diagnoses related to thermoregulation
risk for imbalanced body temperature
-hyperthermia
-hypothermia
-ineffective thermoregulation
febrile states in hypersensitive response to drugs are often accompanied by…
allergy symptoms such as rash or pruritis
pharmacologic type of fever therapy
-pharmacologic therapy includes nonsteroidal drugs and corticosteroids
nonpharmacologic type of fever therapy
nonpharmacologic therapy includes tepid sponge baths, bathing with alcohol water solutions, applying ice packs to the axillae and groin sites, and cooling fans
pulse deficit
DIFFERENCE BETWEEN APICAL AND RADIAL PULSE
pulse pressure
difference between systolic and diastolic pressure
