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Block 1 Nursing SCC > Vital Signs > Flashcards

Vital Signs Flashcards

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1
Q

Facility Standards for Monitoring in:

  • Hospital
  • Home Health Setting
  • Clinic
  • Skilled Nursing Facilities (SNF)
A
  • Hospital: every 4-8 hours
  • Home Health Setting: each visit
  • Clinic: each visit
  • Skilled Nursing Facilities: weekly to monthly
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2
Q

When to assess Vital Signs?

A
  • admission to any healthcare agency
  • institutional policy and procedure
  • per orders of healthcare provider
  • anytime a change in patient’s condition
  • before and after surgical or invasive procedures
  • before and after activity that may increase risk
  • medications
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3
Q

What are the main Vital Signs?

A 
Temperature 
 Pulse
 Respirations 
 Blood Pressure 
 Pain
 Pulse Oximetry 
* always ask for allergies!!!
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4
Q

Define Body Temperature

A

Degree of heat maintained by the body.

  • thermoregulatory center is located in the hypothalamus
  • center initiates responses to produce or conserve body heat or increase heat loss
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5
Q

Sites to measure Body Temperature are…

A 
Oral
Tympanic Membrane
Rectal
Urinary Catheter
Axillary or Groin 
Temporal Artery
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6
Q

Variables that Affect Body Temperature

A
  • Circadian Rhythms
  • Hormones
  • Age
  • Exercise
  • Stress
  • Food/Beverage Consumption
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7
Q

What is Hyperthermia?

A

An increase in body temp above normal

Ex: an extreme form = heat stroke

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8
Q

What is Hypothermia?

A

A decrease in body temp below normal

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9
Q

What is the Average Oral Temp and the Range? Advantages and Disadvantages?

A

-average: 37C or 98.6F
-range: 36-38C or 96.8-100.4F
Advantages: convenient, easily assessable, minimally invasive
Disadvantages: safety, physical abilities, accuracy

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10
Q

Contraindications to Oral Temp

A
  • Infant or child under 6 years
  • Unconscious, confused or disoriented person
  • Someone who had surgery or injury to the face, neck, nose or mouth
  • Receiving oxygen (>6 L/min)
  • Paralysis on one side of body
  • Seizure disorder
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11
Q

What is the Average Rectal Temp and Range? Advantages and Disadvantages?

A

-average: 37.5C or 99.5F
-range: 36.7-38.5C or 98.0-101.6F
Advantages: most accurate
Disadvantages: safety, invasive, uncomfortable

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12
Q

When should you take a Rectal Temperature?

A

Taken when oral or other routes cannot be used.

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13
Q

Contraindications to Rectal Temp

A
  • Diarrhea
  • Rectal disorder or injury
  • Hemorrhoids
  • Heart disease
  • Rectal surgery
  • Patient who is confused or agitated
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14
Q

What is the Average Axillary Temperature and Range? Advantages and Disadvantages.

A

-average: 36.5C or 97.6F
-range: 35.4-37.4C or 95.6-99.4F
Advantages: safe, noninvasive
Disadvantages: questionable accuracy, length of time to obtain measurement

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15
Q

When should an Axillary Temperature be used?

A

Used one other sites cannot be used.

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16
Q

What is the Average Tympanic Membrane Temperature and Range? Advantages and disadvantages.

A

-average: same as oral and rectal
-range: same as oral and rectal
Advantages: convenient, fast, safe, reduced risk of spreading infection
Disadvantages: questionable accuracy, technique effects reading

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17
Q

Define Pulse

A

The beat of the heart felt as a wave as blood passes through an artery

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18
Q

What is the Average Pulse Rate and Normal Range for Adults?

A
  • average: 70-80 bpm

- range: 60-100 bpm

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19
Q

Define Tachycardia

A

Pulse rate greater than 100 bpm

20
Q

Define Bradycardia

A

Pulse rate less than 60 bpm

21
Q

Determine Pulse Volume

A 
0 = absent
1 = thready
2 = weak
3 = normal
4 = bounding
22
Q

Where are the Pulse Sites?

A

Peripheral Sites

Apical Pulse- over apex of heart

23
Q

Where is the Apical Pulse?

A

Over Apex of Heart

  • 5th intercostal space, left midclavicular line
  • most accurate
24
Q

What are the Peripheral Pulse Sites?

A 
Carotid
Temporal 
Brachial 
Radial
Femoral
Popliteal
Posterior Tibialis
Dorsalis Pedis
25
Q

What are some Factors affecting Heart Rate?

A 
Age
Gender
Activity/Exercise 
Metabolism
Fever
Emotional Status
Pain
Stimulants 
Medications
Sympathetic Stimulation- increases heart rate
Parasympathetic Stimulation- decreases heart rate
26
Q

What is a Pulse Deficit?

A

The difference between the Apical-Radial Pulse.

27
Q

What is the Normal Respiration Rate for an adult?

A

-rate: 12-20 per min

28
Q

Define Apnea

A

Not breathing

29
Q

Define Tachypnea

A

Fast or rapid breathing

30
Q

Define Bradypnea

A

Slow breathing

31
Q

Define Dyspnea

A

Difficult or labored breathing

32
Q

Define Orthopnea

A

Difficulty breathing when laying down

33
Q

Factors Affecting Respirations

A 
Exercise
Respiratory and Cardiovascular Disease
Alterations in fluid, electrolytes, and acid balances
Medications
Trauma 
Infection 
Pain
Anxiety
34
Q

What is the Normal Range for Oxygen Saturation (Pulse Ox, SpO2)?

A
  • range: 90%-100%

- report

35
Q

Define Blood Pressure

A
  • The force of blood against arterial walls

- Pressure rises as ventricle contracts and falls as heart relaxes

36
Q

What are Korotkoff Sounds?

A

The sounds you hear when measuring blood pressure.

  • The 1st sound occurs during systole
  • The 5th sound is silence corresponding with diastole
37
Q

What is the typical Adult Blood Pressure reading? What is the range for BP?

A

Typical Adult BP- 118/78

-Range: 90-140/60-90

38
Q

Pre-hypertension BP Reading

A

120-139/80-89

39
Q

Hypertension BP Reading

A

> 140/90

40
Q

Hypotension BP Reading

A
41
Q

Define Orthostatic or Postural Hypotension

A

A sudden drop in BP on moving from a lying to a sitting or standing position.

42
Q

Define Systole

A

The period of heart contraction

-force needed to pump blood out of heart into arterial circulation.

43
Q

Define Diastole

A

Period of heart muscle relaxation

-pressure in the arteries when the heart is at rest

44
Q

What is a Pulse Pressure?

A

Systolic pressure minus the Diastolic pressure

- around 40mmHg in healthy adults

45
Q

What is BP Regulation influenced by?

A

Cardiac function
Peripheral vascular resistance
Blood volume

46
Q

What are the Factors Affecting BP?

A 
Age
Gender
Race
Diet
Circadian Rhythm
Exercise
Weight
Blood Volume
     -hypovolemia    -hypervolemia
47
Q

Why do we take Vital Signs?

A

To provide an understanding of how the body’s ‘big three’ organ systems are functioning:

  • heart
  • lungs
  • brain

Block 1 Nursing SCC (11 decks)

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