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Nancys Final > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Vital Signs Definition

A

Baseline Measurements of cardio-pulmonary

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2
Q

Vital Signs Include (4)

A
  1. Temperature
  2. Heart Rate (measured as pulse)
  3. Respiration
  4. Blood Pressure
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3
Q

Pt. Who Need Baseline Vital Signs (5)

A
  1. Elderly
  2. Very Young
  3. Debilitated pts.
  4. History of disease, trauma, or condition affecting cardiovascular disease (SCI, CVA, HTN, PVD, COPD, and any cardiac disease)
  5. According to facilities policy & procedure
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4
Q

Factors Affecting Vital Signs (8)

A
  1. Recent physical activity or physical conditioning.
  2. Environmental temp.
  3. Age, Gender
  4. Emotional Status
  5. Illness
  6. Medications
  7. Blood Volume
  8. Size, condition of arteries.
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5
Q

Adverse Responses to Physical Activity (11)

A
  1. Mental confusion
  2. Severe fatigue
  3. Decreased response/lethargy
  4. Nausea
  5. Syncope
  6. Shortness of Breath
  7. Chest Pain
  8. Vertigo
  9. Diaphoresis
  10. Change in appearance
  11. Pupil constriction/dilation
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6
Q

Factors Affecting Temperature

A

Normal Body temp. is 98.6
Some peoples normal is much lower (i.e. 97.2) ask the pt. so you dont mistakenly think they are hypothermic.
Lower: In the AM and as you age.
Higher: during physical activity, illness, and in response to stress, & during ovulation.

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7
Q

Auto Temp. Reading in Special Care Unit

A

Notice baseline:
If low: monitor closer and give more rest.
Temp drops during activity= abnormal response.

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8
Q

Hear Rate is Measured By

A

Heart Rate (beats per minute)
Measure by pulse of by listening to a stehtoscope.
Weak pulse may require a stethoscope to hear.

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9
Q

Normal Resting HR for an adult

A

60-100 bpm

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10
Q

Normal Resting HR for a child (1-7 years)

A

80-120 bpm

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11
Q

Normal Resting HR for a newborn

A

100-130 bpm

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12
Q

In an acute hospital a HR never wants to raise over ____ w/ therapy activity

A

Never raise more than 10-20 bpm

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13
Q

HR Documentation

A 
Strong & Regular 
Weak & Regular 
Irregular 
Thready 
Trachycardia 
Bradycardia
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14
Q

Pulse response to Activity: Begin or Increase Intensity

A

Normal Pulse Response: Increase then stabilize

Abnormal Pulse Response: Increase is very slow or does not increase

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15
Q

Pulse Response to Activity: Intensity Plateaus

A

Normal Pulse Response: Stable

Abnormal Pulse Response: Continues to increase or decrease

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16
Q

Pulse Response to Activity: Decrease Intensity or Stop

A

Normal Pulse Response: Slows & returns to resting rate within 5 min. of stopping.
Abnormal Pulse Response: Does not decline or return to resting rate.

17
Q

Steps to Measuring Pulse

A
  1. Wash Hands
  2. Place two fingers over artery (not thumb) : radial artery at wrist, or carotid artery at neck, femoral artery on infant.
  3. Count beats per minute felt for 30 seconds.
    - Multiply X2
    - Count for longer periods to prevent error
    - Need more time to check for irregular heart rhythm.
18
Q

Blood Pressure

A

In direct measure of pressure inside an artery

-Use a sphygmomanometer

19
Q

Normal BP for an Adult

A

120/80 = systolic/diastolic

20
Q

Systalic Normal

A

Between 90 & 135 mmhg

-Measurement during left ventricle contraction

21
Q

Diastolic Normal

A

between 60 & 80 mmhg

-Measurement between contractions during period of rest

22
Q

Hypertension

A

140/90 or greater

23
Q

Measuring BP (6 Steps)

A
  1. Ask normal BP (must know)
  2. Position so arm is relaxed (support or prop)
  3. Apply deflated cuff w/ center of bladder over medial aspect of arm (proximal to antecubital space)
  4. Pump to 180 mmHg unless known HP
  5. Known high BP or hospital pt. pump to 200mmHG
  6. Deflate cuff slowly at rate of 2-3 mmHG per second listen for Korotkoff’s sound.
    - note when sound begins and when it stops.
24
Q

Respiration

A

Measurement of breathing rate per minute.

One cycle = on inspiration and one expiration

25
Q

Normal respiration range for an Adult

A

12-22 bpm

26
Q

Normal respiration range for an infant

A

30-50 bpm

27
Q

Normal respiration range for a child (8-12)

A

15-20 bpm

28
Q

Othopenia, Apnea, Dyspena

A

All relate to shortness of breath (SOB)

29
Q

3 ways to Measure Respiration

A
  1. Visual
  2. Auditory w/ stethoscope
  3. Palpation: hand place lightly on thorax
    - Feel rise and fall of chest
30
Q

Oxygen Saturation

A

SAO2 + Percentage of Oxygen in the blood.

Oxygen molecules are attached (saturated) onto red blood cells that carry the oxygen to different parts of the body

31
Q

Oximeter

A

Measures using photoeletric technology.

  • device applied to the finger or earlobe/
  • apply so beam of light goes through nail-bed.
32
Q

Normal Oxygen Saturation

A

Normal is > 90%

33
Q

What do you for an oxygen saturation is < 90%

A

Defer Mobilization

Nancys Final (7 decks)

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