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NS205 Nursing Fundamentals > Vital Signs > Flashcards

Vital Signs Flashcards

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1
Q

How do you locate the apical impulse? (point over the apex of the heart where the apical pulse can be most clearly heard)

A
  1. Palpate the angle of Louis
  2. Slide finger just left of the sternum, palpate 2nd intercostal space
  3. Palpate downward until locate 5th intercostal space
  4. Move finger laterally along 5th intercostal space to midclavicular line (MCL)
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2
Q

Angle of Louis

A

The angle between the manubrium, the top of the sternum, and the body of the sternum. Palpated just below the suprasternal notch and is felt as a prominence

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3
Q

Normal HR for newborns

A

100-170bpm

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4
Q

Normal HR for Infants to 2 years

A

80-130bpm

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5
Q

Normal HR for 2-6 years

A

70-120bpm

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6
Q

Normal HR for 6-10 years

A

70-110bpm

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7
Q

Normal HR for 10-16 years

A

60-100bpm

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8
Q

Normal HR for 17 years to adult

A

60-100bpm

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9
Q

What causes the S1 heart sound (lub)?

A

The atrioventricular valves closing after the ventricles have been sufficiently filled

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10
Q

What causes the S2 heart sound (dub)?

A

The semilunar valves closing after the ventricles empty

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11
Q

What is a normal rhythm and strength of a heartbeat?

A

Normal pulse has equal time periods between beats

Normal beats are equal in strength

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12
Q

Periodic breathing in newborns

A

some newborns pause for a few seconds between respirations. This condition can be normal, but parents should be alert to prolonged or frequent pauses (apnea) that require medical attention

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13
Q

Why would an infants’ respiratory rate and effort of breathing increase with respiratory infections?

A

Compared to adults, infants have fewer alveoli and their airways have a smaller diameter

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14
Q

Normal respiratory rate for newborns

A

30-80 pm

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15
Q

Normal respiratory rate for 1 year

A

20-40pm

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16
Q

Normal respiratory rate for 3 years

A

20-30pm

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17
Q

Normal respiratory rate for 6 years

A

16-22pm

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18
Q

Normal respiratory rate for 10 years

A

16-20pm

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19
Q

Normal respiratory rate for 17 and older

A

12-20pm

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20
Q

Tachypnea (Rate)

A

quick, shallow breaths

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21
Q

Bradypnea (Rate)

A

abnormally slow breathing

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22
Q

Apnea (Rate)

A

cessation of breathing

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23
Q

Hyperventilating (Volume)

A

overexpansion of the lungs characterized by rapid and deep breaths

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24
Q

Hypoventilation (Volume)

A

Underexpansion of the lungs, characterized by shallow respirations.

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25
Q

Cheyne-Stokes breathing (Rhythm)

A

Rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea

26
Q

Dyspnea (Effort)

A

Difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed.

27
Q

Orthopnea (Effort)

A

Ability to breathe only in upright sitting or standing positions

28
Q

Stridor

A

A shrill, harsh sound heard during inspiration with laryngeal obstruction

29
Q

Stertor

A

Snoring or sonorous respiration, usually due to a partial obstruction of the upper airway

30
Q

Wheeze

A

Continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

31
Q

Bubbling

A

gurgling sounds heard as air passes through moist secretions in the respiratory tract

32
Q

Intercostal retraction (chest movements)

A

Indrawing between the ribs

33
Q

Substernal retraction (chest movements)

A

Indrawing beneath the breastbone

34
Q

Suprasternal retraction (chest movements)

A

Indrawing above the clavicles

35
Q

Hemoptysis (Secretions & coughing)

A

The presence of blood in the sputum

36
Q

Productive cough (Secretions & coughing)

A

A cough accompanied by expectorated secretions

37
Q

Nonproductive cough (Secretions & coughing)

A

A dry, harsh cough without secretions

38
Q

The patient sitting with legs crossed while taking BP can cause what?

A

Elevated systolic and diastolic blood pressures

39
Q

Blood pressure is what kind of sound (Pitch)?

A

Low frequency, best heard with bell (or light pressure)

40
Q

Errors in Blood Pressure Assessment and Effect

Bladder cuff too narrow

A

Erroneously high

41
Q

Errors in Blood Pressure Assessment and Effect

Bladder cuff too wide

A

Erroneously low

42
Q

Errors in Blood Pressure Assessment and Effect

Arm unsupported

A

Erroneously high

43
Q

Errors in Blood Pressure Assessment and Effect

Insufficient rest before the assessment

A

Erroneously high

44
Q

Errors in Blood Pressure Assessment and Effect

Repeating assessment too quickly

A

Erroneously high systolic or low diastolic readings

45
Q

Errors in Blood Pressure Assessment and Effect

Cuff wrapped too loosely or unevenly

A

Erroneously high

46
Q

Errors in Blood Pressure Assessment and Effect

Deflating cuff too quickly

A

Erroneously low systolic and high diastolic readings

47
Q

Errors in Blood Pressure Assessment and Effect

Deflating cuff too slowly

A

Erroneously high diastolic reading

48
Q

Errors in Blood Pressure Assessment and Effect

Failure to use the same arm consistently

A

Inconsistent measurements

49
Q

Errors in Blood Pressure Assessment and Effect

Arm above level of the heart

A

Erroneously low

50
Q

Errors in Blood Pressure Assessment and Effect

Arm below heart level

A

Erroneously high

51
Q

Errors in Blood Pressure Assessment and Effect

Assessing immediately after a meal or while client smokes or has pain

A

Erroneously high

52
Q

Errors in Blood Pressure Assessment and Effect

Failure to identify auscultatory gap

A

Erroneously low systolic pressure and erroneously low diastolic pressure

53
Q

Secondary skin lesions

Atrophy

A

A translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin

54
Q

Secondary skin lesions

Erosion

A

Wearing away of the superficial epidermis causing a moist, shallow depression.
Because erosions do not extend into the dermis, they heal without scarring

55
Q

Secondary skin lesions

Ulcer

A

Deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. May bleed. May leave scar

56
Q

Secondary skin lesions

Fissure

A

Linear crack with sharp edges, extending into the dermis

57
Q

Secondary skin lesions

Lichenification

A

Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing

58
Q

Secondary skin lesions

Scales

A

Shedding flakes of greasy, keratinized skin tissue.
Color may be white, gray, or silver.
Texture may vary from fine to thick.

59
Q

Secondary skin lesions

Crust

A

Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst.
Can be red-brown, orange, or yellow.
Large crusts that adhere to the skin surface are called scabs.

60
Q

Secondary skin lesions

Scar

A

Flat, irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple; older scars may be silvery or white.

61
Q

Secondary skin lesions

Keloid

A

Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. Extends beyond the site of the original injury.
Higher incidence in people of African descent

62
Q

Secondary skin lesions

Excoriation

A

Linear erosion

i.e. Scratches, some chemical burns

NS205 Nursing Fundamentals (6 decks)

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