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Healthcare Fundamentals 2 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are vital signs

A
  • Are clinical measurements that include blood pressure, pulse, body temperature, respiration, and oxygen saturation.
  • Provides a baseline of data to compare to future findings
  • Identify trends, or patterns, that may indicate a change in a client’s condition.
  • Guide treatment decisions and nursing interventions.
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2
Q

Blood pressure

A

A measurement of the force, or pressure, of the circulating
blood on the interior walls of the blood vessels.

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3
Q

Pulse

A

The rhythmic dilation of the arteries that occurs with the beating of the heart.

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4
Q

Body temperature

A

The balance of heat produced by the body and the heat
lost to the environment.

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5
Q

Respiration rate

A

The number of breaths taken per minute.

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6
Q

Oxygen saturation

A

The estimated amount of oxygen bound to the
hemoglobin molecule in red blood cells, indicating the amount of oxygen
being transported to body tissues.

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7
Q

Systolic and diastolic

A

Systolic BP: The maximum amount
of pressure exerted when the
heart contracts and forces blood
into the aorta.
Diastolic BP: The minimum amount
of pressure exerted when the heart
is relaxed.

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8
Q

Cardiac output (Exam)

A

BP is a direct reflection of cardiac output.
* Cardiac output = volume of blood pumped into the circulatory system in 1 minute
Cardiac Output = Stroke Volume x Heart Rate CO = SV x HR
* Stroke volume is amount of blood ejected by the
ventricle during one heart contraction.

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9
Q

Equation for cardiac output (Exam)

A

Cardiac Output = Stroke Volume x Heart Rate CO = SV x HR

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10
Q

hypertension (Exam)

A
  • Hypertension is a blood pressure above the expected reference range.
  • A client is diagnosed with stage I hypertension when the systolic pressure
    is 130 to 139 mm Hg or the diastolic pressure is 80 to 89 mm Hg.
  • When a client’s systolic pressure is greater than 140 mm Hg or the
    diastolic pressure is greater than 90 mm Hg, they have stage II
    hypertension.
  • A hypertensive crisis occurs when the systolic pressure is greater than 180
    mm Hg and/or the diastolic pressure is greater than 120 mm Hg.
  • Greatly increases risk for heart attack or stroke
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11
Q

hypertension can cause (Exam)

A

increase in: heart issues, drinking caffeine, pain, fever, exercise, Increase in sodium
decrease in: fever

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12
Q

nursing interventions for hypertension (Exam)

A
  • Encourage lifestyle changes
  • exercise, stress reduction techniques,
    a low-sodium diet, and weight loss if
    needed
  • Provide the client with information
    about antihypertensive
    medications, if prescribed by the
    provider, including expected
    adverse effects and when the
    provider should be notified.
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13
Q

hypotension

A
  • Hypotension = blood pressure below the expected reference range
  • In the absence of baseline data, a systolic pressure less than 90 mm Hg or a diastolic pressure less than 60 mm Hg is typically considered hypotension for an adult.
  • Manifestations of hypotension can
    include dizziness, nausea, blurred vision, increased pulse, and fatigue
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14
Q

what is a common thing to cause hypotension

A

sepsis

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15
Q

extreme hypotension -> shock manifestations

A
  • cold, pale skin
  • rapid breathing (tachypnea)
  • weak and rapid pulse
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16
Q

treatments for shock

A
  • rapid IV fluid infusion or rapid administration of blood products
  • medications that increase contractility of heart muscle and BP
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17
Q

orthostatic hypotension

A
  • drop in blood pressure that occurs after standing up from sitting, or sitting up from a lying position.
  • Causes include dehydration, general hypotension, heart failure, or disorder of CNS.
  • To assess for orthostatic hypotension, check blood pressure while client is lying, sitting and standing with 1 minute between positions.
    * These patients are fall risks
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18
Q

nursing interventions for hypotension

A
  • Increase fluids.
  • Place in a supine position unless medically contraindicated.
  • Evaluate the medications the client is taking.
  • Instruct the client about the risk for dizziness and falling.
  • Encourage the client to change positions slowly.
  • Avoid extremes in temperature.
  • Stay well hydrated.
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19
Q

pulse

A
  • The pulse is the rhythmic dilation of the arteries and pulsation of blood flow
    that occurs with each contraction of the heart.
  • The expected reference range for an adult is 60 to 100 beats per minute.
20
Q

pulse rate is a variable and influences by many factors including?

A

body position
age
activity level
health conditions
body temperature

21
Q

auscultate and palpating at the apex

A

Apical pulse - auscultated and palpated at the apex of the heart
- Auscultation = should hear S1 and S2 (“lub dub”)
Apex of the heart heard (in adults and children over 7) at:
- left side of chest
- 5th intercostal space
- midclavicular line
Rhythm regular or irregular?
- listen and count for 1 full minute if irregular

22
Q

grading pulses via palpation

A
  • 0 = pulse that is absent/nonpalpable (none)
  • +1 = pulse that is weak/diminished (weak)
  • +2 = pulse that is normal
  • +3 = pulse that is increased/strong (fast)
  • +4 = pulse that is bounding (racing)
23
Q

tachycardia

A

pulse greater than 100, some clients may experience no symptoms.
some may feel a “racing” feeling in the chest

24
Q

possible causes of tachycardia

A

exercise
anxiety
certain medications
caffeine and nicotine
abnormality in the electrical system of the heart

25
Q

nursing interventions for tachycardia

A
  • Educate on possible causes to prevent it (use of nicotine or caffeine)
    • provide resources/pamphlets
  • Encourage relaxation techniques
    • meditation
    • yoga
    • guided imagery
  • Valsalva maneuver
    • Bearing down as if having a bowel movement
26
Q

bradycardia

A

pulse less than 60 beats per minute
- there are often no symptoms in physically fit individuals. others may report, dizziness, fatigue, SOB, chest pain, or confusion

27
Q

possible causes of bradycardia

A

expected in physically fit individuals
congenital cardiac abnormalities
heart failure
heart muscle damage
hypothyroidisim

28
Q

nursing interventions for bradycardia

A
  • Instruct client to change positions slowly
  • Take all medications as prescribed
  • Keep all scheduled medical appointments
  • Notify provider of any changes in health status
29
Q

body temp

A
  • The measurement of the balance of heat produced by the body and the heat lost to the environment.
  • Measured in degrees
  • degree celsius (common for charting)
  • degree fahrenheit
  • Expected body temperature is between 36° C and 38° C (96.8° F and 100.4° F).
  • Average temperature for most clients is 37° C (98.6° F).
30
Q

ways of measuring body temp

A

oral
tympanic membrane
temporal artery
axillary
rectal

31
Q

hyperthermia

A
  • A fever is an increase in body temperature above the expected reference range of 38° C (100.4° F).
  • Commonly caused by infection.
  • Symptoms may include a flushed face, diaphoresis, skin that feels “hot,” tachycardia, and increased respiratory rate.
32
Q

nursing interventions for hyperthermia

A
  • Encourage sips of cool fluids.
  • Remove excess clothing.
  • Administer medications as ordered.
  • Antipyretics to reduce or prevent fever
  • Antibiotics or antivirals if an infection
    is present
  • Place the client in a cooler environment.
  • Give a tepid bath.
33
Q

hypothermia

A
  • Abnormally low body temperature
  • Early symptoms include:
    • shivering
    • decreased motor skills
    • impaired peripheral perfusion
  • Later symptoms:
    • confusion
    • poor concentration
    • dilated pupils
    • loss of consciousness (LOC)
34
Q

nursing interventions for hypothermia

A
  • Warming mats/blankets
    • Bair Hugger
  • Increase room temperature
  • Layers of clothing/blankets
  • Warmed IV fluids
35
Q

respiratory rate

A
  • Respiration consists of inspiration and expiration.
    • Inspiration is the intake of air by the
      lungs in order to oxygenate body
      tissues and support cellular function.
    • Expiration expels carbon dioxide from
      the lungs.
  • Expected reference range is 12 to
    20 breaths per minute for adults.
36
Q

eupnea

A

normal breathing

37
Q

tachypnea

A

faster than normal

38
Q

bradypnea

A

slower than normal

39
Q

cheyne-stokes

A

end of life
- rapid and shallow, deep breaths, apnea and repeat

40
Q

kussmual

A

deep and rapid

41
Q

apnea

A

absence of breathing

42
Q

what is tachypnea

A
  • Respiratory rate above the expected reference range (greater than
    20 breaths per minute).
  • Possible causes
    • Physical activity
    • Anxiety
    • Pain
    • Health conditions (e.g., asthma)
  • Common symptoms
    • Dizziness
    • Tingling in the hands
43
Q

what is bradypnea

A
  • Respiratory rate that is below the expected reference range (less than 12
    breaths per minute).
  • Possible causes
    • Health conditions
    • Medications: opioids, sedatives
  • Common symptoms
    • Dizziness
    • Fatigue
    • Weakness
    • Confusion
    • Impaired coordination
44
Q

oxygen saturation

A
  • Oxygenation saturation is the
    estimated amount of oxygen bound
    to the hemoglobin.
    • Expressed as a percentage
    • Direct reflection of a client’s
      respiratory status
  • Expected reference range is 95%
    to 100%
45
Q

alterations in oxygenation

A
  • Decreased oxygen saturation is a
    level below 95%.
  • Possible causes
    • Health condition (e.g., pneumonia,
      chronic lung disease, pulmonary
      edema, poor cardiac output).
  • Common symptoms
    • Decrease in mental alertness
    • Confusion
46
Q

nursing interventions for hypoxia

A

Depends on underlying cause or etiology. Some routine interventions to increase
oxygen saturation include:
* Sitting client in upright position
* Take deep breaths/cough
* Apply oxygen as prescribed
* Flow rate depends on severity of hypoxia
* Give medications as prescribed
Impending respiratory arrest = notify doctor and prepare for intubation.

Healthcare Fundamentals 2 (12 decks)

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