Vital Signs Flashcards
What are vital signs
Assessments nurses do that reflect the physiological status of body and it’s response to physical, environmental and psychological stressors
What are the 5 vital signs?
Temperature Pulse Respiration Blood Pressure Oxygen Saturation
When should vital signs be taken?
- Following doctors orders
- On admission to unit, or initial assessment
- When patent status changes
- Pre and post surgery/invasive procedures
- Pre, during and post infusions of blood/other meds
- Pre and post nursing interventions that may impact vs
What factors can affect vital signs?
- Medications
- Illness
- Exercise/stress
- Age
- Hemorrhage
- Environment
- PO intake
- Hormones
- Circadian Rhythm
What is the optimal core temperature
36.5-37.5
What happens when our thermoreceptors sense we are too hot
Notify hypothalamus, Vasodilation and sweating
What is hyperpyrexia?
A high fever
What is the difference between febrile and afebrile
Febrile: symptoms of a fever
Afebrile: non feverish
What are the normal temperature for: oral, axilla, tympanic, rectal and temporal artery
Oral: 37 Axilla: 36 Tympanic: 36.5 Rectal: 37.5 Temporal Artery: 35
How long do we have to wait to take oral temperature if they drank hot/cold fluids, chewed gum or smoked?
30 minutes
When would we not want to take oral temperature?
- Jaw surgery
- Facial trauma
- Children (might bite it)
- Unconscious, confused, disoriented
- Vomiting
What is the preferred site for taking temperature on children and infants?
Axillary
What can affect accuracy of axillary temperature
- Recent bathing
- Sepsis (vasodilation)
- Surgery (vasoconstriction)
- Sweating
How does a tympanic temperature work?
Detects heat radiation from TM using infrared sensor
What could cause error when taking tympanic temperature
Space, earwax, improper seal
What is a risk for taking rectal temperature
Puncture rectal tissue
What would be a reason not to take rectal temperature
- Cardiac conditions
- Spinal injury
- Uncooperative
- Feces
Where should we avoid when taking temporal temperature?
- Scar tissue
- Open abrasions
- Sores
What can temporal readings be affected by?
- Sweating
- Airflow
What is pulse?
The force of contraction that is felt as a pulse wave at a peripheral arterial site
How is cardiac output calculated
Heart Rate x Stroke Volume
What are the 4 assessments we take when taking pulse?
- Rate
- Rhythm
- Strength/Quality
- Equality
What is bpm for adults, children and infants
Adults: 60-100
Children: 90-140
Infants: 90- 180
What can cause tachycardia
Dehydration and anemia
When does a apical-radial pulse deficit occur?
When the pulse wave is not transmitted
What is an apical-radial pulse deficit?
When there is a difference between apical and radial pulse
What is ventilation?
Air entering and leaving the lungs
What part of the brain regulates breathing?
Medulla oblongata and Pons
What is eupnea? Apnea?
Eupnea: normal, good, unlabored breathing
Apnea: Shallowing breath, breathing pauses
What is tachypnea? Bradypnea
Tachypnea: abnormally rapid breathing
Bradypnea: abnormally slow breathing
What is the average respiratory rate for adults, children and infants
Adults: 2-20
Children: 20-26
Infants: 20-30
What is dyspnea? Orthopnea?
Dyspnea: Difficult, laboured breathing
Orthopnea: Shortness of breath that occurs when lying flat
What are the 4 things we assess when taking respirations
- Rate
- Depth/volume
- Rhythm/Pattern
- Quality
What is blood pressure
Pressure exerted on arterial walls by the force of the hearts contraction
What is the pulse pressure:
Difference between systole and diastole pressure (normally 30-50 mm hg)
If blood pressure is constantly high, what can it lead to?
- Arteriosclerosis
- Cranial Pressure
What is orthostatic hypotension?
Decrease in systolic by 20 mmHg OR decrease in diastolic by 10 mmHg
What are 6 sites to avoid when taking blood pressure
- Mastectomy
- Dialysis
- IV infusion
- Painful/swollen
- Cast
- Injury
What are korotoff sounds?
Series of sounds that occur as blood flow returns to previously occluded artery
What is phase I of korotkoff sounds? Phase V?
Phase I: appearance of sound is audible (systolic)
Phase V: Disappearance of sound (diastolic)
What is the ausculatory gap? What can it lead to?
Silent interval in middle of korotkoff sounds
May result in false low systolic reading
What does O2 saturation measure?
The approximate % of Hg binding sites that are occupied by O2
What is normal O2 saturation?
95-100%
What would be a life threatening O2 saturation level?
less than 70%
Where can the pulse oximeter be placed to measure O2 saturation?
- Finger
- Toe
- Nose
- Earlobe
Where do we place a pulse oximeter on a neonate?
Around hand or foot
What are 5 things to consider when using a oximeter
- Anything that interferes with light
- Impaired circulation
- Movement
- Hgb level
- Carbon monoxide
What temperature does death usually occur at?
34
What would you check in older adults before taking rectal temperature
Hemorrhoids present
What is the compliance of arteries
The distensibility of the arteries
What 8 factors may affect pulse? Explain each
- Age: decreases with age
- Sex: after puberty, male pulse rate lowers
- Exercise
- Fever: increases
- Medications: increase or decrease
- Hypovolemia/dehydration: increase
- Stress: increases
- Position
What are 3 lifespan considerations for older adults pertaining to heart
- Decreased cardiac output
- Sclerotic changes in heart valves
- Dysthymias
What is the normal amount of air that moves in and out of the lungs in a breath
500 mL
What does respiratory quality refer to?
The aspects of breathing that are different than normal breathing
What is tachypnea? Bradypnea?
Tach: quick shallow breaths
Brady: abnormally slow breathing (less than 10 per minute)
What is Cheyne-Stokes breathing
Rhythmic waxing and waning of respirations from very deep to very shallow
What is dyspnea?
difficult laboured breathing during which the individual has persistent unsatisfied need for air
What is stridor?
A shrill hard sound heard during inspiration with laryngeal obstruction
What is a stertor?
snoring respiration usually due to partial obstruction of the upper airway
When does a wheeze occur? During inspiration or expiration?
Usually during expiration sometimes inspiration
What is bubbling?
A gurgling sound heard as air passes through moist secretions in the respiration tract
Pertaining to chest movements, what are: intercostal, substernal and suprasternal retraction
Intercostal: indrawing between ribs
Substernal: indrawing beneath breast bone
Suprasternal: undraping above the clavicles
What is hemoptysis?
presence of blood in sputum
What is a productive cough?
a cough accompanied by expectorated secretions
What is a nonproductive cough?
a dry, harsh cough without secretions
Why can a nasal obstruction be lifethreatening for an infant?
Because they breath mainly out of their nose
What is the mean arterial pressure
the pressure actually delivered to the body organs
What is phase 2 of korotkoff sounds
The period when the sounds have muffled, whooshing or swishing quality
What is phase 3 of korotkoff sounds?
When blood flows freely through an increasingly open artery and sounds become more crisp and start thumping noise
What is phase 4 of korotkoff sounds?
When sound becomes muffled and have soft blowing quality
What is hemodynamic status?
cardiac output and blood vessel resistance
What is the average systolic pressure in infants/children
75 mmHg
What is hypoxemia?
under oxygenation
How can circulation affect O2 saturation
The oximeter will not give an accurate reading if there is poor circulation
How can carbon monoxide poisoning give a misreading in a oximeter
The oximeter cannot tell the difference between hemoglobin and carbon monoxide
