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NURS125 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

what are the main vital signs?

A
  • temperature
  • heart rate
  • respiratory rate
  • blood pressure
  • pain
  • oxygen saturation
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2
Q

when do we take vital signs?

A
  • during a health visit
  • upon admission
  • before & after surgery
  • before, during & after medication administration
  • routine orders from NP, physician
  • based on critical thinking
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3
Q

why do we take vital signs?

A
  • obtain a baseline
  • screening
  • response to treatment
  • change in health status
  • monitor for complications
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4
Q

what is the expected temperature from an oral reading?

A

36.5-37.5ºC

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5
Q

what methods can we use to take a temperature?

A
  • oral
  • tympanic
  • axillary
  • rectal
  • temporal
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6
Q

how does an axillary temperature differ from an oral reading?

A

typically 0.5ºC lower

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7
Q

how does a tympanic temperature differ from an oral reading?

A

typically 0.5ºC higher

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8
Q

how does a rectal temperature differ from an oral reading?

A

typically 0.5ºC higher

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9
Q

when is an oral temperature reading not appropriate to use?

A
  • on newborns/children
  • if pt can’t close their mouth
  • if pt is unconscious
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10
Q

what do we assess when examining a pulse?

A
  • rate
  • rhythm
  • strength/amplitude
  • elasticity of vessel
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11
Q

what is the normal range of heart rate in adults?

A

60-100 bpm

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12
Q

define tachycardia

A

heart rate >100bpm

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13
Q

define bradycardia

A

heart rate <60 bpm

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14
Q

what is a normal amplitude for an adult pulse?

A

2+ (strong)

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15
Q

define pulse deficit

A

apical pulse - radial pulse

evaluation of heart contractions

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16
Q

where do we take the apical heart rate?

A

bottom left of the heart at the fifth intercostal space at the midclavicular line

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17
Q

what sites can we take a pulse measurement at?

A
  • radial
  • brachial
  • carotid
  • femoral
  • apical
  • dorsal
  • ulnar
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18
Q

what do we assess when examining respiration?

A
  • rate
  • rhythm
  • depth
  • quality
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19
Q

what two phases make up one breath count?

A

one inhalation one exhalation

20
Q

what is the normal range of respiratory rate in adults?

A

12-20 breaths per minute

21
Q

define tachypnea

A

> 20/minute

22
Q

define bradypnea

A

<12 breaths/minute

23
Q

define apnea

A

no breaths

24
Q

define hyperventilation

A

shallow & rapid

25
define hypoventilation
deep & slow OR shallow & slow
26
define eupnea
normal breathing, expected rate, regular, moderate depth, and easy
27
define oxygen saturation
tests percentage of oxygen saturated hemoglobin
28
what is the expected range of oxygen saturation?
>92%
29
define blood pressure
force exerted on arterial walls
30
define systolic
highest pressure as the ventricle contracts at the beginning of systole
31
define diastolic
lowest pressure as ventricle relaxes
32
define pulse pressure
difference between systolic and diastolic pressure
33
what is the expected range of pulse pressure?
40-60 mmHg
34
define mean arterial pressure
measures delivery of oxygen to the periphery | i.e. perfusion
35
define CPP
a measurement typically assessed in patients with head injury or in neurology to measure oxygen being delivered to the brain
36
define multi-limb reading
blood pressure readings are taken at multiple sites (limbs) in the body to assess perfusion in multiple areas | e.g. take BP at right arm and left leg
37
what is Korotkoff sound 1?
the initial sound marking systole
38
what is Korotkoff sound 5?
the complete disappearance of sound marking diastole
39
what is the expected range of blood pressure in healthy adults?
* SBP: between 120 and 80 * DBP: <80 * 120/80
40
what is the criteria of hypotension?
<90 SBP or a 30mmHg drop in BP
41
what is the critical range of BP in diabetic patients?
≤130/80
42
when is taking a BP contrainted or need to be taken elsewhere?
* when there is an open wound or fistula * when IV that cannot be stopped is administered * when pt has lymphedema * when pt is post surger (e.g. mastectomy)
43
what are emergency red flags?
* acute changes * agitation, restlessness * new/unresponsive chest pain * ranges of concern
44
what is a range of concern of respiration?
* shortness of breath * RR < 10 or > 32/min * O2 saturation <92%
45
what is a range of concern of heart rate?
HR < 55 or >120 bpm
46
what is a range of concern of BP?
* SBP < 100 or > 170 mmHg * drop of ≥30mmHg
47
what is a range of concern of temperature?
< 35ºC or > 39.5ºC

NURS125 (12 decks)

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