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P&A midterm > Vital signs > Flashcards

Vital signs Flashcards

1
Q

What are the vital signs?

A 
Temperature
Pulse
Respirations
Blood Pressure
Pain
Pulse ox
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2
Q

When do you measure vital signs?

A 
Inpatient settings
Upon admission
Evaluation of treatment
Establish baseline
Monitor trends
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3
Q

What is the average temp range for adults?

A

36.5-37.5

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4
Q

What is the average oral temp?

A

98.6

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5
Q

Rectal temps may be …

A

1 degree higher

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6
Q

Axillary temps may be …

A

1 degree lower

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7
Q

What routes can you take a temp?

A

Mouth, rectum, ear, forehead, axilla

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8
Q

Elderly generally have …

A

Lower temps

36-36.8

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9
Q

How does the body respond to decreased temperature?

A

Vasoconstriction

Shivering is vasoconstriction is ineffective

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10
Q

How does the temp respond to increased body temp?

A

Vasodilation

Sweating

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11
Q

Factors affecting body temp

A 
Age
Exercise
Hormones
Circadian rhythm
Stress
Environment
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12
Q

Pyrexia

A

Fever
Defense mechanism
Results when heat-loss mechanisms are unable to keep pace with excessive heat production

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13
Q

Methods of heat loss

A

Radiation
Conduction
Convection
Evaporation

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14
Q

Radiation

A

Transfer of heat from one surface to another without actual contact

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15
Q

Conduction

A

Transfer of heat from the body to another surface

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16
Q

Convection

A

Dispersion of heat by air currents (wind blowing across exposed skin - fan)

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17
Q

Evaporation

A

Heat loss through water vapor (diaphoresis)

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18
Q

At what point does the body hit an abnormally elevated body temp?

A

102.2/39

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19
Q

How to deal with pyrexia

A

Antipyretics (no Aspirin for kids - causes Rye syndrome in kids)
Cooling blanket
Encourage liquids

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20
Q

Hypothermia

A

Temp <95/35

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21
Q

Nursing interventions for hypothermia

A 
Remove wet clothes
Blankets
Warm liquids
Increase room temp
Warmed IV fluids
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22
Q

What is pulse an indirect measure of?

A

Cardio output

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23
Q

How to measure pulse?

A

Count for 30 second then multiply by 2

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24
Q

When giving a beta blocker, how should one take a HR?

A

Apically

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25
Q

What is a bounding pulse?

A

Fingers bounce when feeling for pulse

Hypervolemic

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26
Q

What is a normal pulse?

A

60-100/min

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27
Q

What is tachycardia?

What is bradycardia?

A

> 100/min in adults

<60/min in adults

28
Q

What is the average BPM for infants?

A

120-160, decreases as child ages

29
Q

What is the average BPM for a 14 year old?

30
Q

Grades of pulse

A 
4+ bounding
3+ full or strong
2+ normal and expected
1+ diminished or barely palpable
0 absent
31
Q

What factors affect HR?

A 
Conditioning
Medications
Fever increases; hypothermia decreases
Acute pain and anxiety
Severe pain decreases rate
Deficient fluid increases rate
32
Q

What is HR a compensatory mechanism for?

33
Q

What is the sex difference in breathing character?

A

Women tend to be chest breathers

Men tend to be diaphragmatic breathers

34
Q

What is the average respiratory rate for newborns?

35
Q

What is the average respiratory rate for infants?

36
Q

What is the average respiratory rate for school age children?

37
Q

What is the average respiratory rate for adolescents?

38
Q

What is the average respiratory rate for adults?

39
Q

What is bradypnea?

A

RR <12/min

40
Q

What is tachypnea?

A

RR >20/min

41
Q

What is hyperpnea?

A

RR >20/min and deep, labored

42
Q

What is apnea?

A

No breathing

43
Q

What is hyperventilation?

A

Breathing fast and blowing off all CO2

44
Q

What is hypoventilation?

A

Breathing slowly and holding on to CO2

45
Q

What is Cheyne-Strokes breathing?

A

Rate and depth are irregular, alternating apnea/hyperventilation

46
Q

What is Kussmaul breathing?

A

Abnormal deep, regular, increased rate

Seen in people with DKA

47
Q

What is dyspnea?

A

Difficulty breathing

48
Q

What is pulse oximetry?

A

Measurement of O2 sat in blood

49
Q

What is the normal pulse ox value?
What is the acceptable range of values?
What range indicates an emergency?

A

95-100%
>93%
<90%

50
Q

What is systolic BP

A

Heart at work

51
Q

What is diastolic BP

A

Heart at rest

52
Q

What is a Karotkoff sound?

A

Sounds during BP

53
Q

What are the characteristics of BP for adults?

A

<120/<80 - normal
120-139 or 80-89 - preHTN
140-159 or 90-99 stage 1 HTN
>160 or >100 stage 2 HTN

54
Q

What is the average optimal BP for a 1 month old?

55
Q

What is the average optimal BP for a 1 year old?

56
Q

What is the average optimal BP for a 6 year old?

57
Q

What is the average optimal BP for a 10-13 year old?

58
Q

What is the average optimal BP for a 14-17 year old?

59
Q

What factors affect BP?

A 
Age
Stress/anxiety/pain
Ethnicity
Time of day (higher at night)
Medications
Activity and weight
Smoke/caffeine
60
Q

What happens to BP as one ages?

A

Vessels harden and lose elasticity, so pressure increases

61
Q

What is hypotension?

A

BP below normal (systolic <90)

62
Q

Hypertension vs. Hypotension

A

Thickening of walls
Loss of elasticity
Family history
Risk factors (envmt, stress, diet)

<90
dilation of arteries
loss of blood volume
decrease of blood flow to vital organs
orthostatic
63
Q

What are risk factors for HTN?

A 
Family history
Excessive sodium intake
Physical inactivity
Obesity
Heavy alcohol consumption
African American
Hyperlipidemia
Stress
64
Q

If arm contains ___, do not take

A 
IV
AV fistula
Post mastectomy
Cast
Hand trauma
65
Q

What is orthostatic hypotension and what are associated symptoms?

A

Lowering of BP when a pt rises to an upright position
Dizziness
Syncope

66
Q

Who get orthostatic hypotension?

A

Anemic, dehydrated, elderly, medication side effects, fluid depletion

67
Q

What is the 5th vital sign?

A

Pain

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P&A midterm (10 decks)

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