Vital Signs Flashcards by Anndrealyn Ramos

_______ are the most frequent measurements taken by Health Care Providers as they reflect the function of three body processes that are essential for life.

Temperature, pulse, respiration and blood pressure (B/P)

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are important indicators of the body’s response to physical, environmental, and psychological stressors.

Vital signs

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TRUE or FALSE

Vital Signs may reveal sudden changes in a client’s condition in addition to changes that occur progressively over time.

True

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TRUE or FALSE

Vital signs are part of a routine physical assessment

True

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TRUE or FALSE

We should take VS before and after a SURGICAL or invasive diagnostic procedure

True

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This is the balance between heat produced by the body and the heat lost from body to the external environment.

Is the degree of warmth or coldness of a substance compared with a recognized standard.

Body temperature

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Types of temperature

Core temp
Surface temp

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This is temperature of deep body tissue which remain at a constant level of 37°C.

Core temp

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This is the temperature of the skin, subcutaneous tissue and it varies according to the environment.

Surface temp

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Normal body temperature

36.5 - 37.4

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Body temperature is controlled by the heat regulating centre which is the ____.

hypothalamus

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Heat is produced during the body’s metabolic processes and is lost through four processes:

Radiation
Conduction
Convection
Evaporation

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direct physical contact with an object

Conduction

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is the transfer of heat from the surface of one object to the surface of another without contact between two objects, mostly in form of infrared rays

Radiation

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perspiration that is removed from the body surface by change from a liquid to a vapor

Evaporation

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when body heat warms surrounding air which rises and is replaced by cooler air.

Convection

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Temperature is ___ in the morning (4am to 6am), ___ during the evening (4pm to 6pm)

lowest, highest

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Ovulation of a female also increases the temperature. In what range?

0.4 to 0.6

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• Environment
• Time of day
• Exercise
• Stress
• Hormones
• Drugs.
• Presence of illness

Factors affecting body temperature

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Also known as fever

It is an increase in the body temperature which is divided into high, moderate and low

Note: 37.5 Hindi pa lagnat yan

Pyrexia/Febrile/Hyperthermia

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Hyperpyrexia temp?

It is dangerous to functioning of the body cell

40.6

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High grade pyrexia temperature is above

39.4

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Moderate pyrexia temperature is between

3 to 39.3

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Low grade pyrexia is temperature is between

37.8 to 38.2

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This is a core body temperature of below the lower limit of the normal temperature (below 36 degree Celsius) Below 34 = DEATH

Hypothermia

Most accurate site in temperature

Rectal

Most safest site in temperature

Axilla

Most convenient site in temperature

Oral

mercury expands or contracts in response to heat. (just recently non mercury)

Glass mercury

heat sensitive probe, (reads in seconds) there is a probe for oral/axillary use (red) & a probe for rectal use (blue). There are disposable plastic cover for each use. Relies on battery power.

Electronic

sensor probe shaped like an otoscope in external opening of ear canal. Ear canal must be sealed & probe sensor aimed at tympanic membrane.

Infrared Tympanic (Ear)

easily accessible because it requires no position change provides accurate surface temperature readings Reflects rapid change in core temperature

Oral Body temperature Advantages

Inaccurate if the client has just swallowed a hot or cold fluid Glass thermometer can break if bitten - unsuitable for small children

Oral Body temperature Disadvantages

Safe Convenient Can be used in new born Inexpensive

Axillary Body temperature advantages

Long measurement time May require continuous positioning by the nurse Measurement lags behind the core temperature Affected by the environmental temperature

Axillary Body temperature disadvantages

it is said to be the most reliable and accurate

Rectal Body temperature Advantage

Most embarrassing due to the positioning It lags behind the core temperature Not for clients with diarrhoea or rectal surgery.

Rectal body temperature disadvantages

Defined as the pressure of the blood pushing against the wall of an artery as the heart beats and rests.

Pulse

PULSE Feel throbbing of the arteries caused by

contractions of the heart

Normal heart rate for Newborn

120 - 160 bpm

Normal heart rate for Adolescent 13+

60-100 bpm

Where would you assess the PR of a baby?

Brachial

Where would you assess the PR of an adult?

Carotid

What are the 9 pulses in the body

Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis pedis Posterior tibial

Point of maximal impulse

Apical pulse

You are assessing the ___ in the pulse

Rate Rhythm Strength of the tention

Is the number of beats per minute

Pulse rate

Normal ranges of pulse rate

60-100 bpm; 80bpm

Is a pulse rate that is greater than 100 bpm

Tachycardia

Is pulse rate that is less than 60 pm (except in children)

Bradycardia

TRUE or FALSE For athletes, they usually have lower heart rate.

True. Their heart gives off 1 huge pump to have more oxygen.

This refers to the pattern of the beats or the spacing of the beats. Which can be described as regular or irregular.

Rhythm

Irregular or abnormal rhythm of puise is called ___, it is usually caused by a defect in the electrical conduction pattern of the heart.

arrhythmia

PULSE (strength/size) You assess the volume of blood pushed against the wall of an artery during the ____, i.e its strength or intensity.

ventricular contraction

Strength size (pulse) When it lacks fullness

Weak or thready

Strength size (pulse) When volume is higher than normal

Full, bounding

Strength size (pulse) When the pulse cannot be felt or heard

Imperceptible

Age Sex Position i.e sitting or standing Drugs Illness Emotions Activity level Temperature Physical training

Factors affecting pulse rate

Increased rates can be caused by

Exercise Stimulant drugs Excitement Fever Shock Anxiety

Decreased rates can be caused by

Sleep Depressant drugs Heart disease Coma

What should always be 0. It is the difference between the apical pulse and periphery pulses Periphery pulse = pulses away from the heart >> They should always be the same, otherwise there’s a blockage

Pulse deficit

TRUE or FALSE If a person has fever, he has a higher pulse rate

True. It is the body response to the abnormality

Severe dehydration/blood loss

Hypovolemic shock

is the process of taking in oxygen and expelling carbon dioxide from the lungs and respiratory tract.

Respiration

Inspiration and Expiration is automatic & controlled by the ____ which is the respiratory.

medulla oblongata (center of brain)

Age Activity level Position Drugs Sex Illness Emotions Temperature

Factors affecting respiratory rate

Normal respiratory rate

12-20 cpm

Qualities of normal respiration

Quiet Effortless Regular

When assessing respirations you look at;

• Rate • Rhythm and depth • Quality: Usually automatic, quiet, and effortless

___ is the number of breathing cycles/minute (inhale/exhale- 1 cycle).

Respiration rate

Normal respiratory rate for infants

30-60 cpm

Gagawin if hindi makahinga patient To elevate/expansion of lungs

Fowler’s position

normal rate & depth breathing

Eupnea

rapid respiratory rate above 20 cpm

Tachypnea

slow respiratory rate, usually below 12 cpm

Bradypnea

Absence of respirations.

Apnea

severe dyspnea in which breathing is very difficult in any position other than sitting erect or standing.

Orthopnea:

bubbling or noisy sounds caused by fluids of mucus in the air passages.

Rales

TRUE or FALSE The character of respirations is described by words such as deep, shallow, labored, moist, difficult, stertorous (abnormal sounds like snoring).

True

difficult or labored breathing

Dyspnea

alternating periods of apnea and hyperventilation, gradual increase & decrease in rate & depth of respirations with period of apnea at the end of each cycle.

Cheyne-stokes

What should be the normal oxygen saturation

95 - 100%

refers to the regularity or equal spacing between breaths.

Rhytm

Refers to the amount of air inhaled/exhaled (deep & even movements of chest)

Normal

Refers to the amount of air inhaled/exhaled (rise & fall of chest is minimal)

Shallow

Refers to the amount of air inhaled/exhaled (shallow & rapid)

Shortness of breath

Measurement of the pressure that the blood exerts on the walls of the arteries as the heart contracts or relaxes.

Blood pressure

BLOOD PRESSURE Measured in millimeters of mercury on an instrument called a ___

sphygmomanometer

Blood pressure is measured in 2 points

Systolic Diastolic

is the force exerted against the arterial wall as left ventricle contracts & pumps blood into the aorta - (max. pressure exerted on vessel wall).

Systolic pressure

is the arteria! pressure during ventricular relaxation, when the heart is filling, ( minimum pressure in arteries).

Diastolic pressure

Blood pressure is measured in

MmHg (millimeters of mercury)

Korotkoff sounds can be heard with a stethoscope placed over the artery

Auscultation

When Korotkoff sounds are inaudible, blood pressure may be estimated by palpation

Palpation

Normal systolic reading is 120 mm of Hg Normal range is 100 - 140 mm of Hg Noted as the reading on the sphygmomanometer gauge when the first sound is heard

Systolic pressure

Constant pressure that is in the walls of the arteries when the heart is at rest or between contractions Blood has moved into the capillaries and veins, so the volume of blood in the arteries has decreased • Normal diastolic reading is 80 mm of Hg • Normal range is 60 - less than 90 mm of Hg

Diastolic pressure

High blood pressure Indicated when pressures are greater than 140 mm Hg systolic and 90 mm Hg diastolic

Hypertension

Low blood pressure Indicated when pressures are less than 100 mm Hg systolic and 60 mm Hg diastolic

Hypotension

Factors influencing blood pressure readings

Force of heartbeat Resistance of the arterial system Elasticity of the arteries Volume of blood in the arteries

Factors that may increase blood pressure

Excitement, anxiety, nervous tension Stimulant drugs Exercise and eating

Factors that may decrease blood pressure

Rest or sleep Depressant drugs Shock Excessive blood loss

Age Circulating volume e.g Lower with blood loss Medications Activity Position changes B/P Weight Sleep Emotions Sex Viscosity of blood Illness/ Disease

Factors affecting B/P

Difference between systolic and diastolic pressure Normal: 30 - 40 mmHg

Pulse pressure

Plem with blood

Hemoptysis

also known as postural hypotension, is a medical condition wherein a person's blood pressure drops when they are standing up or sitting down

Orthostatic hypotension

If pressure of the blood pumps is enough to be distributed to different parts of body

Mean arterial pressure