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Techniques > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are vital signs

A

Assessments nurses do that reflect the physiological status of body and it’s response to physical, environmental and psychological stressors

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2
Q

What are the 5 vital signs?

A 
Temperature 
Pulse
Respiration 
Blood Pressure 
Oxygen Saturation
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3
Q

When should vital signs be taken?

A
  • 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
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4
Q

What factors can affect vital signs?

A
  • Medications
  • Illness
  • Exercise/stress
  • Age
  • Hemorrhage
  • Environment
  • PO intake
  • Hormones
  • Circadian Rhythm
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5
Q

What is the optimal core temperature

A

36.5-37.5

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6
Q

What happens when our thermoreceptors sense we are too hot

A

Notify hypothalamus, Vasodilation and sweating

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7
Q

What is hyperpyrexia?

A

A high fever

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8
Q

What is the difference between febrile and afebrile

A

Febrile: symptoms of a fever
Afebrile: non feverish

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9
Q

What are the normal temperature for: oral, axilla, tympanic, rectal and temporal artery

A 
Oral: 37
Axilla: 36 
Tympanic: 36.5 
Rectal: 37.5 
Temporal Artery: 35
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10
Q

How long do we have to wait to take oral temperature if they drank hot/cold fluids, chewed gum or smoked?

A

30 minutes

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11
Q

When would we not want to take oral temperature?

A
  • Jaw surgery
  • Facial trauma
  • Children (might bite it)
  • Unconscious, confused, disoriented
  • Vomiting
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12
Q

What is the preferred site for taking temperature on children and infants?

A

Axillary

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13
Q

What can affect accuracy of axillary temperature

A
  • Recent bathing
  • Sepsis (vasodilation)
  • Surgery (vasoconstriction)
  • Sweating
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14
Q

How does a tympanic temperature work?

A

Detects heat radiation from TM using infrared sensor

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15
Q

What could cause error when taking tympanic temperature

A

Space, earwax, improper seal

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16
Q

What is a risk for taking rectal temperature

A

Puncture rectal tissue

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17
Q

What would be a reason not to take rectal temperature

A
  • Cardiac conditions
  • Spinal injury
  • Uncooperative
  • Feces
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18
Q

Where should we avoid when taking temporal temperature?

A
  • Scar tissue
  • Open abrasions
  • Sores
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19
Q

What can temporal readings be affected by?

A
  • Sweating

- Airflow

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20
Q

What is pulse?

A

The force of contraction that is felt as a pulse wave at a peripheral arterial site

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21
Q

How is cardiac output calculated

A

Heart Rate x Stroke Volume

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22
Q

What are the 4 assessments we take when taking pulse?

A
  • Rate
  • Rhythm
  • Strength/Quality
  • Equality
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23
Q

What is bpm for adults, children and infants

A

Adults: 60-100
Children: 90-140
Infants: 90- 180

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24
Q

What can cause tachycardia

A

Dehydration and anemia

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25
Q

When does a apical-radial pulse deficit occur?

A

When the pulse wave is not transmitted

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26
Q

What is an apical-radial pulse deficit?

A

When there is a difference between apical and radial pulse

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27
Q

What is ventilation?

A

Air entering and leaving the lungs

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28
Q

What part of the brain regulates breathing?

A

Medulla oblongata and Pons

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29
Q

What is eupnea? Apnea?

A

Eupnea: normal, good, unlabored breathing
Apnea: Shallowing breath, breathing pauses

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30
Q

What is tachypnea? Bradypnea

A

Tachypnea: abnormally rapid breathing
Bradypnea: abnormally slow breathing

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31
Q

What is the average respiratory rate for adults, children and infants

A

Adults: 2-20
Children: 20-26
Infants: 20-30

32
Q

What is dyspnea? Orthopnea?

A

Dyspnea: Difficult, laboured breathing
Orthopnea: Shortness of breath that occurs when lying flat

33
Q

What are the 4 things we assess when taking respirations

A
  • Rate
  • Depth/volume
  • Rhythm/Pattern
  • Quality
34
Q

What is blood pressure

A

Pressure exerted on arterial walls by the force of the hearts contraction

35
Q

What is the pulse pressure:

A

Difference between systole and diastole pressure (normally 30-50 mm hg)

36
Q

If blood pressure is constantly high, what can it lead to?

A
  • Arteriosclerosis

- Cranial Pressure

37
Q

What is orthostatic hypotension?

A

Decrease in systolic by 20 mmHg OR decrease in diastolic by 10 mmHg

38
Q

What are 6 sites to avoid when taking blood pressure

A
  • Mastectomy
  • Dialysis
  • IV infusion
  • Painful/swollen
  • Cast
  • Injury
39
Q

What are korotoff sounds?

A

Series of sounds that occur as blood flow returns to previously occluded artery

40
Q

What is phase I of korotkoff sounds? Phase V?

A

Phase I: appearance of sound is audible (systolic)

Phase V: Disappearance of sound (diastolic)

41
Q

What is the ausculatory gap? What can it lead to?

A

Silent interval in middle of korotkoff sounds

May result in false low systolic reading

42
Q

What does O2 saturation measure?

A

The approximate % of Hg binding sites that are occupied by O2

43
Q

What is normal O2 saturation?

A

95-100%

44
Q

What would be a life threatening O2 saturation level?

A

less than 70%

45
Q

Where can the pulse oximeter be placed to measure O2 saturation?

A
  • Finger
  • Toe
  • Nose
  • Earlobe
46
Q

Where do we place a pulse oximeter on a neonate?

A

Around hand or foot

47
Q

What are 5 things to consider when using a oximeter

A
  • Anything that interferes with light
  • Impaired circulation
  • Movement
  • Hgb level
  • Carbon monoxide
48
Q

What temperature does death usually occur at?

A

34

49
Q

What would you check in older adults before taking rectal temperature

A

Hemorrhoids present

50
Q

What is the compliance of arteries

A

The distensibility of the arteries

51
Q

What 8 factors may affect pulse? Explain each

A
  • Age: decreases with age
  • Sex: after puberty, male pulse rate lowers
  • Exercise
  • Fever: increases
  • Medications: increase or decrease
  • Hypovolemia/dehydration: increase
  • Stress: increases
  • Position
52
Q

What are 3 lifespan considerations for older adults pertaining to heart

A
  • Decreased cardiac output
  • Sclerotic changes in heart valves
  • Dysthymias
53
Q

What is the normal amount of air that moves in and out of the lungs in a breath

A

500 mL

54
Q

What does respiratory quality refer to?

A

The aspects of breathing that are different than normal breathing

55
Q

What is tachypnea? Bradypnea?

A

Tach: quick shallow breaths
Brady: abnormally slow breathing (less than 10 per minute)

56
Q

What is Cheyne-Stokes breathing

A

Rhythmic waxing and waning of respirations from very deep to very shallow

57
Q

What is dyspnea?

A

difficult laboured breathing during which the individual has persistent unsatisfied need for air

58
Q

What is stridor?

A

A shrill hard sound heard during inspiration with laryngeal obstruction

59
Q

What is a stertor?

A

snoring respiration usually due to partial obstruction of the upper airway

60
Q

When does a wheeze occur? During inspiration or expiration?

A

Usually during expiration sometimes inspiration

61
Q

What is bubbling?

A

A gurgling sound heard as air passes through moist secretions in the respiration tract

62
Q

Pertaining to chest movements, what are: intercostal, substernal and suprasternal retraction

A

Intercostal: indrawing between ribs
Substernal: indrawing beneath breast bone
Suprasternal: undraping above the clavicles

63
Q

What is hemoptysis?

A

presence of blood in sputum

64
Q

What is a productive cough?

A

a cough accompanied by expectorated secretions

65
Q

What is a nonproductive cough?

A

a dry, harsh cough without secretions

66
Q

Why can a nasal obstruction be lifethreatening for an infant?

A

Because they breath mainly out of their nose

67
Q

What is the mean arterial pressure

A

the pressure actually delivered to the body organs

68
Q

What is phase 2 of korotkoff sounds

A

The period when the sounds have muffled, whooshing or swishing quality

69
Q

What is phase 3 of korotkoff sounds?

A

When blood flows freely through an increasingly open artery and sounds become more crisp and start thumping noise

70
Q

What is phase 4 of korotkoff sounds?

A

When sound becomes muffled and have soft blowing quality

71
Q

What is hemodynamic status?

A

cardiac output and blood vessel resistance

72
Q

What is the average systolic pressure in infants/children

A

75 mmHg

73
Q

What is hypoxemia?

A

under oxygenation

74
Q

How can circulation affect O2 saturation

A

The oximeter will not give an accurate reading if there is poor circulation

75
Q

How can carbon monoxide poisoning give a misreading in a oximeter

A

The oximeter cannot tell the difference between hemoglobin and carbon monoxide

Techniques (7 decks)

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