Vital Signs Flashcards
Afebrile
without fever
Febrile/Pyrexia
with fever
Hyperpyrexia
Very high fever
Hypothermia
body temperature below normal
Eupnea
normal breathing
Apnea
absence of breathing
Dyspea
difficulty/labored breathing
Orthopnea
difficulty breathing when laying down, but able to breathe better when standing
Tachypnea
increase respiratory rate
Bradypnea
decrease respiratory rate
Chynes-Stoke Respiration
(who is it usually seen in?)
- period of deep/rapid breathing, then period of apnea, and/or regular breathing
- seen in PTs with:
–> heart/kidney (renal) failure
–> increased cranial pressure
–> drug overdose
–> people living in high altitude
Kussmaul Respirations
(who is it seen in?)
- Increased respiratory rate and depth
- seen in PTs with:
-> Metabolic acidosis
-> Diabetic ketoacidosis
Intermittent Fever
body temperature fluctuates between normal and fever within 24hr period
Remittent Fever
temperature does NOT return to normal: may fluctuate, but remains high
Continous/Sustained Fever
temperature remains above normal; little/no temperature variations
Relapsing/Recurrent Fever
Series of fevers; normal for few days, the fever comes back
Sinus Bradycardia
generates slower pulse rate from SA node (pacemaker), but rhythm remains the same
- Common in athletes
Hypertension
high BP
Hypotension
low BP
Orthostatic hypotension
low BP when standing up
- decrease 20 systolic and decrease in 10 diastolic = orthostatic hypotension
- advise for pt to sit up slowly and “hang” from bed before standing
White Coat Hypertension
a condition where a person’s blood pressure is elevated only when they are in a healthcare setting, such as a doctor’s office
Assessing Blood Pressure:
Upper Arm & Special Considerations
Upper arm:
- Ask PT if they have smoked, exercised, or caffeine. If yes -> wait 30 minutes. Take blood pressure before eating
- Make sure PT back/legs straight and touch floor; remove any jackets
- Have PT rest for 5 minutes
- Choose the right cuff; width should be 40-50% circumference, and length should wrap 80-100%
Have PT arm rest on one side and arm tested should be on table equal to height of heart - Place cuff 1-2” above elbow bend and make sure it’s snug (2 finger in; snug)
- Make sure tubing is not touching each other
- Place two fingers on radial pulse, feel for pulse, inflate cuff until no longer able to feel pulse. This is your estimated systolic
- Add +30 to estimated systolic
- Place stethoscope on brachial artery and inflate to number. Slowly deflate at 2mmHg and measure systolic and diastolic pressure
Special Considerations
- Avoid extremity with IV or AV shunt
- Avoid arm on side of mastectomy/surgery/cast
Assessing Respiratory Rate:
Rate, Depth, Rhythm, Quality, Procedure
- Rate
- Depth
-> Deep vs shallow - Rhythm (pattern)
-> Regular
-> Irregular
–> Kussmal Respirations
–> Chynes-Stroke Respirations - Quality
-> Silent (normal) - Procedure
-> Look at chest fall/rise
Assessing O2 Saturations
(How do you do it? What are special considerations to take into account when taking O2 stat?)
- Find baseline
- Spot check
- Continous
- Special Considerations
-> Continuous monitoring for: Post-op, high risk, O2 therapy
-> Try to avoid wearing dark nail polish/artifical nails
Assessing Temperature:
Oral
Important Considerations: has PT consumed food/cold water
- if yes -> wait ~30 minutes
- Ask PT to open mouth and lift the tongue
- Cover the probe with disposable probe cover
- Place bulb on either side of frenulum and ask PT to close mouth
- Remove when beeps; throw away probe cover
**RED = RECTAL; BLUE = ORAL/AXILLARY
**
Assessing Temperature:
Rectal
- Apply disposable gloves
- Have PT in side lying position and instruct to take deep breaths
- Use lubricant and insert 1.5 inches (in adult) and wait for temp
**NEVER FORCE IF RESISTANCE
**
Assessing Temperature:
Axillary
- Pat axilla dry (if moist()
- Place bulb in middle and wait for temp
Assessing Temperature:
Tympanic
- Pull pinna slightly up and back
- Point probe slightly anteriorly (toward jaw)
- Insert probe slowly using circular motion
Assessing Heart Rate:
Sites, Rate (what type of pt may we see tachycardia in?), Rhythm, Quality/Strength, Important Considerations (equal?, where do you assess pulse in unconcious adult/infant)
Sites:
Count 60 seconds
- Apical
Count 30 seconds (unless abnormal):
- Carotid
- Brachial
- Radial
- Femoral
- Popliteal
- Dorsalis pedis
Rate:
- # ; BPM
- May see increase HR in those with: COPD, asthma, anemia
Rhythm:
- Lub-dub (normal)
- Regular: count 30 sec x 2
- Irregular: count 60 sec
Quality/strength:
- 0 - absent
- +1 - weak/thready/feeble
- +2 - normal
- +3 - bounding
Important Considerations:
- Make sure HR is Equal bilaterally
- Ask PT what their baseline/normal HR
- Unconcious adult = measure carotid
- Unconcious infant = measure brachial
Assessing Pain:
Scale, Quality, Characteristics
Scale:
- 0 - 10: 0 being no pain, 10 being the worst pain
Quality:
- Burning, Sharp, Dull
Characteristics:
- Radiating
- Localized
List the Situaitons When You Should Assess Vital Signs
- Admission/Discharge
- Pre and Post OP
- Change in condition
- Loss of consciousness
- Meds given that affect cardiac rate/rhythm
- Per MD order/hospital policy
Explain how disease/trauma to hypothalamus or spinal cord alters temperature control
Hypothalamus recieves messages from thermal receptors throughout the body, and compares that information with the set point, and initiates a response to either produce/conserve body heat. Damage to the hypothalamus can disrupt the set point and impair the bodys ability to regulate temperature corrcectly. (This could lead to neurogenic fever)
With damage to the spinal cord, information from thermal (sensory) receptors cannot be sent to the hypothalamus, damaging the bodys ability to regulate temperature
Body Temperature = __________ - _____________
- Amount of heat produced by body
- Amount of heat lost to environment
T/F: When documenting temperatures, you shouldn’t include sire where temp was taken
False, you should always include the site at where it was taken since each site has a different normal range for body temperature
T/F: Surface temperature is the most accurate for measuring temperature
False, Core temperature is the most accurate for measuring temperature
What areas are used to measure Core Temperature?
- Rectum
- Tympanic Membrane (ear)
- Temporal Artery (prope over forehead temporal artery)
-> Use high resolution infared image of PT temporal artery
-> Swipe thermometer probe across forehead and behind ear
What areas are use to measure Surface Temperature?
FAMS
- Forehead (disposable chemical strap)
- Axillae (armpit)
- Mouth (oral)
- Skin
________ is the most common way to take temperature in the hospital.
Mouth/Oral
List the different type of thermometers
ISTG EC
- Infrared (tympanic)
- Scanning Infrared (temporal artery)
- Temperature-sensitive tape
- Glass mercury
-> DO NOT USE; GLASS BREAKAGE - Electronic
- Chemical Disposal
List the ways body heat is lost:
- Skin
- Evaporation
- Conduction
- Convection
- Radiation
Describe the Mechanism of Action
Provide an example
-
Skin
-> BV at surface release heat (PRIMARY AREA WHERE HEAT IS LOST) -
Evaporation: Conversion of liquid to vapor
-> Sweating -
Conduction: Transfer heat to cooler object
-> ice pack, cooling blanket, water bath, tepid sponge -
Convection: blows cool air to warm body
-> fan -
Radiation: Diffusion of heat by electromagnetic waves (no hat)
-> body gives off waves of heat from uncovered surfaces
______ is the primary area where the body loses its heat.
Skin
List the ways heat is generated in the body:
Metabolism
Hormones
Exercise
Epinephrine/Norepinephrine
Tremors
Goosebumps
Describe the Mechanism of Action
Metabolism
- PRIMARY SOURCE FOR BODY HEAT
Hormones
- thyroid gland -> ↑ metabolism -> ↑ heat production
Exercise
- muscle contraction -> ↑ heat production
Epinephrine/Norepinephrine
- ↑ heat production
Tremors
- cold temp. -> hypothalamus -> cause tremors/shivering -> ↑ muscle contraction -> ↑ heat production
Goosebumps
- ↓ surface area -> ↑ heat retentioj
List the Expected Temperature Ranges for:
Oral Temperature
Rectal Temperature
Axillary Temperature
Temporal Temperature
- Oral Temperature: 96.8°F - 100.4° (Average 98.6)
- Rectal Temperature: 0.9°F higher than oral/tympanic
- Axillary Temperature: 0.9°F lower than oral/tympanic
- Temporal Temperature: 1° higher than oral, or 2° higher than axillary
List the S/SX of Fever
- Hot, Dry skin
- Flush
- General Malaise
- Increased HR
A PT has hot, dry skin, looks flush and is complaining of general discomfort. What nursing interventions should you do?
- VS
- I&O (see how much Fluid in/out, is PT Hydrated?)
- Fluids (IV, Oral)
- Meds (pain meds, antipyretic/fever reducing)
- Oral hygiene, dry clothing, linen
CNS
What systems are in the Central Nervous System?
CNS
- SNS (voluntary)
- ANS (involuntary)
-> SANS (increase HR)
-> PANS (decrease HR)
What system is responsible for the increasing heart rate and the fight/fight response?
Sympathetic Nervous System (SANS)
What system is responsible for the decreasing heart rate and the rest/digest response?
Parasympathetic Nervous System (PANS)
List the Pulse Assessment Sites:
Heart Areas
Other Pulse Sites (Arteries)
Heart Areas: APE To Man
- Aortic area
- Pulmonic Area
- Erb’s Point
- Tricuspid Area
- Mitral Area (apical pulse)
Other Pulse Sites: Arteries
- Carotid Artery
- Brachial Artery
- Radial Artery
- Femoral Artery
- Popliteal Artery
- Dorsalis Pedis
What is systolic pressure? What noise is systolic pressure responsible for?
- Highest pressure
- (Pressure on arteries) during ventricular contraction, Tricuspid/mitral (bicuspid) valve closes
What is diastolic pressure? What sound is diastolic pressure responsible for?
- Pressure in arteries when heart RELEAXES
- Pulmonic/aortic valve closes
-> as age ↑ -> ↓ in elasticity of arterial walls -> unable to stretch/dilate -> ↑ BP and poor blood flow
How do you calculate pulse deficit?
apical rate - radial rate
How long should you measure heart rate if youre measuring apical pulse? radial?
- Apical site MUST be for 60 seconds
- Radial pulse 30 seconds then mulitply by 2
How does pulse differ with age?
(Infant vs Teen vs Adult)
- Infants: 120-160/min
- Teen 12-14yo: 80-90
- Adults: 60-100
T/F: When measuring respirations, you need do it for a whole minute.
False; when getting respiration rate, measure for 30 seconds then mutliply by 2 (unless abnormal)
A ________ in CO2 is the most power respiratory stimulent and causing an increase in ____ and ______.
Increase; Respiratory Rate; Depth
What is diffusion?
- exchange of O2 and CO2 between alveoli of lungs and blood
What is perfusion?
exchange of O2 and CO2 between tissue cells and blood
When listening to blood manually, what is the first sound you hear? last sound? What are these sounds generally referred as?
- First sound: Systolic
- Last sound: Diastolic
- Sounds known as Korotkoff sounds
What areas are the most commonly used to assess blood pressure?
- Brachial artery
- Popliteal artery
What errors can affect the accuracy of blood pressure readings?
- Wrong size cuff - width ~ 40% arm circumference
- Not going high enough
- Distracting noises
- Position of PT
- Time between recheck
What does a pulse oximetry measure? What are other names for a pulse oxietry? Why are pulse oximeters so effective?
- Measures % of O2 carried by available Hb
- Arterial Oxyhemoglobin saturation
-> SaO2 or SpO2, “pulse ox” - Non-invasive, almost instantaneous
Describe the parameters for the following vital sign:
Blood Pressure
(Normal, Abnormal)
Normal:
- 120/80 mmHg
Abnormal:
- Stage II Hypertension: ≥140 / ≥ 90
- Stage 1 Hypertension: 130-139 / 80-89 mmHg
- Elevated: 120 - 129 / <80 mmHg
- Hypotension: <90 / 60 mmHg
Describe the parameters for the following vital sign:
Respiration Rate
(Normal, Abnormal)
Normal:
- 12 - 20 breaths/min
Abnormal:
- Tachypnea: > 20 breaths
- Bradypnea: < 10 breaths
Describe the parameters for the following vital sign:
Oxygen Saturation
(Normal, Abnormal)
Normal:
- 95 - 100%
Abnormal:
- ≤ 90%
- < 85% indicates inadequate
oxygenation
Describe the parameters for the following vital sign:
Temperature
(Normal, Abnormal)
Normal:
Oh, RAT!
- Orally: 96.8°F - 100.4°F
- Rectal: +0.9°F than oral/tympanic
- Axillary: -0.9°F than oral/tympanic
- Tympanic: +1°F than oral, and +2°F axillary
Abnormal:
- Hyperpyrexia: ≥106°F (extremly high fever)
- Hyperthermia: >104°F
- Hypothermia: <95°F
Describe the parameters for the following vital sign:
Heart Rate
(Normal, Abnormal)
Normal:
- 60 - 100 BPM
Abnormal:
- Tachycardia > 100 BPM
- Bradycardia < 60 BPM
Describe the parameters for the following vital sign:
Pain
(Normal)
Normal:
- Assess pain based on scale, quality, characteristics on a scale of 0 - 10
-> 0 = no pain
-> 10 = worst pain
Abnormal:
- X
Describe factors that affect the following vital sign:
Blood Pressure
(Identify, Describe)
Identify:
- Age
- Circadian rhythm
- Sex
- Eating food
- Weight
- Emotion
- Body position
- Race
- Medications
Describe:
- ↑age = ↓elasticity = ↑BP
- BP↑ day, BP↓ during night
- Women ↓BP vs. Men
- ↑Weight = ↑BP
- Strong emotions (fear, pain, anger) = ↑BP
- ↓BP Prone/Supine vs Sitting/Standing
- ↑BP prevalent in African American men and woman
- Oral contraceptives can cause ↑BP
Describe factors that affect the following vital sign:
Respiration Rate/Rhythm
(Identify, Describe)
Identify:
- Age
- Acid-base balance
- C-V disease
- Pain
- Emotions
- Opioid-narcotics
- Anesthesia
- CNS injury
Describe:
- ↑age = ↓RR
- ↑acid = ↑RR
- Acute pain = ↑RR
- Opiod-narcotics/Anesthesia = ↓RR
Describe factors that affect the following vital sign:
Oxygen Saturation
(Identify, Describe)
Identify:
- Respiratory Conditions (chronic bronchitis, emphysema)
- Low hemoglobin (anemia)
- Heart conditions/BP
- Skin pigmentation
Describe:
- Impair lungs ability to exchange oxygen from the air to bloodstream = ↓spO2
- ↓ hemoglobin= ↓ blood’s capacity to carry O2 = ↓spO2
- impairs the heart’s ability to pump blood effectively = ↓ oxygen-rich blood is delivered to the body’s tissues =↓ oxygen saturation levels
- Deeply pigmented skin can interfere with the passage of light waves used by pulse oximeters, potentially leading to inaccurate reading
Describe factors that affect the following vital sign:
Temperature
(Identify, Describe)
Identify:
CABIE
- Circadian Rhythms
- Age
- Biological Sex
- Illness
- Environment
Describe:
- Circadian rhythm = peak temperature in afternoon/evening 3-6pm (lowest at 4am)
- ↑ age = ↓temp (lose thermoregulatory control)
-> very old/young sensitive to temp change - Women ↑fluctuations in temp vs men
-> increase in progesterone during ovulation - Illness = ↑/↓temp (ex: fever)
Describe factors that affect the following vital sign:
Heart Rate
(Identify, Describe)
Identify:
FISH PEA
- Fever
- Illness
- Stress
- Hemorrhage
- Pain
- Exercise
- Age
Describe:
- Fever = ↑HR bc ↑metabolic demands
- ↑stress = ↑HR
- Hemmorhage = ↓BV = ↓BP = ↓SV = ↓CO = ↑HR
- Pain = stressor = ↑HR
- ↑Age = ↓HR
Describe factors that affect the following vital sign:
Pain
(Identify)
Identify:
- -algia
Describe:
- X
Describe Basic Nursing Responsibilities:
Role of Nurse
- Assess
-> Assess upon admission to healthcare setting, meds that affect VS, before/after invasive diagnostic/surgical procedure, emergency situations - Evaluate
- Normal v abnormal
- Recognize trends
- Supervise
Describe Basic Nursing Responsibilities:
Documentation
- Timely
- Accurate
- Comapre/Trend
- Note significant changes & report
Describe Basic Nursing Responsibilities:
Communication/Teamwork
- Communicate findings to other nursing/healthcare professionals through written and spoken words
-> Written actual/potential health problem/need IS NOW permanent part of patients health record
Describe Basic Nursing Responsibilites:
Safety
- PPE, sanitizating devices
- PT education on use adn rationale
Describe Methods to Maintain Adequate Oxygenation:
Positioning
(Technique, Who uses it?, Misc)
Technique:
- Raise HOB (Head of Bed)
- Use pillows
- Leaning over bedside table (orthopneic)
Who uses it?
- Dyspnea
- Orthopnea
Misc:
- refer to notes for visual of orthopneic position
Describe Methods Maintain Adequate Oxygenation:
Deep Breathing
(Technique, Who uses it?)
Technique:
- Breathe slowly
Who uses it?
- Hypoventilation
Misc:
- X
Describe Methods Maintain Adequate Oxygenation:
Incentive Spirometry
(Technique, Who uses it?, Misc)
Technique:
- Direct teh pt to inhale to lift light balls/disks
Who uses it?
- Post op (pvt atelectasis)
- Dyspnea
- Secretions
Misc:
- refer to notes for visual of incentive spirometry
Describe Methods Maintain Adequate Oxygenation:
Pursed Lip Breathing
(Technique, Who uses it?)
Technique:
- Inhale slowly through nose, hold, and slowly exhale through pursed lips
Who uses it?
- Dyspnea/panic
- COPD
Misc:
- X
Describe Methods Maintain Adequate Oxygenation:
Diaphragmatic Breathing
(Technique, Who uses it?)
Technique:
- PT sits upright with knees bent.
- One hand placed on the stomach, and the other on the middle of the chest.
- PT breathes in slowly through the nose to allow the abdomen to fill, while keeping the chest as still as possible.
- PT breathes out through pursed lips while contracting the abdominal muscle, while keeping hand on chest as still as possible
Who uses it?
- Asthma
- COPD
Misc:
- X
Describe Methods Maintain Adequate Oxygenation:
Splinting with Pillow
(Technique, Who uses it?)
Technique:
- Split pillow and place pressure on painful area (to reduce pain)
Who uses it?
- Post-op pt who have pain when breathing
Misc:
- X
Describe Methods Maintain Adequate Oxygenation:
Nasal Cannula
(Technique, Misc)
Technique:
- Place nasal cannula prongs into the PT nose and wrap around the ears. Check ear for skin breakdown
Who uses it?
- X
Misc:
- Supplemental O2 on doctor order only
Describe Methods Maintain Adequate Oxygenation:
Mask
(Technique, Misc)
Technique:
- Place mask snugly around PT mouth/nose
- Assess for pressure injuries/skin breakdown
Who uses it?
- X
Misc:
- Supplemental O2 on doctor order only
Describe Methods Maintain Adequate Oxygenation:
Oxygen Tent
(Technique, Who uses it?, Misc)
