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CA Exam 5 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What type of patient is it important to establish a baseline

A
  1. Elderly
  2. Younger than 2 yrs
  3. Debilitated patients
  4. Limited activity
  5. History of cardio problems
  6. Recovering from recent trauma or surgery
  7. With HTN
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2
Q

What does temperature tell us

A

If there is an infection

Inflammatory Response

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3
Q

Normal Range for Temp

A

96.4 - 99.1

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4
Q

Which is most accurate way to measure temp

A

Rectal

  • oral is most common
  • Axillary will run lower than oral
  • Temporal
  • Tympanic
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5
Q

Factors that can effect patient temp

A
  1. Time of day (4-6pm = highest)
  2. Age (Age will dec temp)
  3. Environmental temp
  4. Infection (inc)
  5. Physical acitivty (inc)
  6. Emotional stress (inc)
  7. Ovulation (inc)
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6
Q

What is pulse measuring

A

Measure of HR - beats per minute - blood flow from contraction of LV

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7
Q

Norms for pulse

A 
Adult = 60-100 
Child = 80-100
Newborn = 100-120
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8
Q

Tachycardia

Bradycardia

A

Above 100

Below 60

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9
Q

Pulse Force

A 
4+ = bounding 
3+ = increased force
2+ = normal
1+ = weak
0 = unpalpable
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10
Q

Factors that affect pulse

A
  1. Age
  2. Gender (males lower)
  3. Environmental temp
  4. Infection (inc)
  5. Physical activity (inc)
  6. Emotional stress (inc)
  7. Medications
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11
Q

Where might you palpate pulse

A 
Temporal artery
Carotid Artery
Brachial artery
Radial artery
Femoral artery
Popliteal artery
Dorsal Pedal artery
Posterior tibial artery
Apex
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12
Q

Pulse abnormal responses to exercise

A

Pulse rate slowly increase
Pulse rate does not increase
Pulse rate continues to increase or decrease as intensity stops
Pulse rate declines before intensity does
Rhythm becomes irregular

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13
Q

What does BP tell us

A

Pressure on the arterial walls

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14
Q

What does SBP tell us

A

Pressure when heart is contracting

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15
Q

What does DBP tell us

A

Pressure when heart is relaxing

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16
Q

Korokoff Sounds

A 
Phase 1 = Tapping - systolic
Phase 2 = Swooshing
Phase 3 = Knocking
Phase 4 = Muffled 
Phase 5 = None - Diastolic
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17
Q

What is auscultatoy Gap

A

You hear phase 1 and then goes away for 30 mmHg and then comes back at phase 2
Noncompliant vessels

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18
Q

Infant birth - 3 months BP norm

A

85-90/35-65

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19
Q

Infant 3 months - 1 year BP

A

90-100/60-67

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20
Q

Children 1-4 years BP norm

A

100-108/60

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21
Q

Children 4-12 BP norm

A

add 2 mmHg per year to 100/ 60-70

22
Q

Adolescents BP

A

100-120/65-75

23
Q

Adults BP

A

below 120/80

24
Q

Elderly BP

A

120-140/80-90

25
Q

Prehypertension

A

120-139/80-89

26
Q

Stage 1

A

140-159/90-99

27
Q

Stage 2

A

160-179/100-109

28
Q

Stage 3

A

180-209/110-119

29
Q

Stage 4

A

Greater than 210/120

30
Q

What contributes to hypertension

A 
Obesity
Physical activity
Nicotine use
Alcohol
Salt
Arteriosclerosis
Diabetes Mellitus
Oral contraceptives
Advanced age
Kidney disease
Race
Diet
31
Q

What factors affect BP

A 
Age
Physical activity
Emotional status
Medications
Size of arteries
Arm position
Muscle contraction
Blood volume
Dehydration
Cardiac output
Site of measurement
32
Q

Technique for BP

A

Stethoscope
Sphygmomanometer
Cuff Bladder (40% of width of arm and 80% circumference)

33
Q

Errors in BP measurement

A 
White coat reaction
Pain
Talking 
Cuff size
Deflating
Arm unsupported
Paretic arm
Environmental noise
Cuff over clothing
Parallax view
Nicotine/Caffeine
34
Q

Abnormal BP responses with exercise

A

Sys inc rapidly
Sys does not increase
Sys continues to inc when activity stops
Dias inc more than 15 mmHg

35
Q

What is orthostatic hypotension

A

A drop in systolic BP more than 20 mmHg or a drop in diastolic BP more than 10 mmHg

36
Q

How do we define respirations

A

Breaths/minute

Taking in O2 and giving off Co2

37
Q

Ratio of inspiration to expiration

A

Ratio of expiration should be longer
Inhale 1-2 sec
Exhale twice as long

38
Q

Methods to measure RR

A

Visual
Auditory
Palpation

39
Q

How to describe RR

A

Rate
Rhythm
Depth
Character

40
Q

Norms for RR - Neonate

A

25-50/minute

41
Q

Norms RR Child

A

15-30/minute

42
Q

Norms RR Adult

A

12-20/minute

43
Q

What factors will affect RR

A 
Age
Physical activity
Emotional stress
Air quality
Altitude
Disease
44
Q

Technique RR

A

Need a stop watch

Differing intervals - 60 sec is best

45
Q

Abnormal responses RR

A

Slow or no inc with activity
RR inc as activity stops
Irregular rhythm
Excessive rate of inc

46
Q

Pain measure

A

scale 1-10
Fifth vital sign
Self report is most reliable indication
Pan management team consult

47
Q

What needs to be included in documentation of pain

A 
Onset
Pattern
Location
Position
Radiating
Patients description
Relieving factors
Aggravating factors
Rating
48
Q

What does oxygen saturation tell us

A

How much oxygen is bound to hemoglobin

49
Q

How is oxygen saturation measured

A

blood draw or pulse oximeter

50
Q

Norms for pulse Ox

A

90-100 = PaO2 (blood)
95-100% = SaO2 (blood)
Above 92% = SpO2 (pulse ox)

51
Q

What can impact level of O2

A 
Impaired production of RBCs
Decreased hgb
Sickle cell disease
Decreased blood volume
Pulmonary disease
Kidney failure
Chemotherapy

CA Exam 5 (1 decks)

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