Vital Signs Flashcards
What is the purpose of measuring vital signs anyways?
Quick and efficient way to monitor patient condition, identify problems, or evaluate responses to interventions
Which of the following are times when you should measure vital signs? Select all that apply.
a) medically ordered
b) upon admission to hospital for non specific symptoms
c) unit policy requires it
d) before surgery
e) after surgery
f) before medication administration
Surprise! Its all of them.
What are the four main vital signs we care about?
Temperature, pulse, resp rate, blood pressure
What are the two main types of temperatures we take? How are they different?
- Core (deep tissue)
- constantly 37 - Surface (skin, subQ tissue, fat)
- effected by envir. between 36-38
Which of the following are core temperature locations?
a) rectum
b) mouth
c) tympanic
d) urinary bladder
e) axillae
f) temporal artery
Core temperature includes: PRETTU Pulmonary artery Rectum Esophagus Tympanic membrane Temporal artery Urinary bladder
A client comes in running late and mentions how stressed they are about not being there on time and how much they have to do later that day. What will you take into account when measuring their vital signs?
Stress can lead to an increased body temperature so if she measures slightly higher than expected this could be a contributing factor.
Other factors that effect temp include:
- disease state
- exercise
- environment
- hormone levels
- circadian rhythm
- age
If you are pulling the ear back and down are you measuring tympanic temperature for adults or paeds?
Paeds!
For adults pull the ear up, back, and away
When would you recommend a rectal temp?
- patient is under 2 years and over 1 month
- patient has other indications that prevent oral, tympanic, or axillae
What is the normal temperature range for adults?
36-38C
Tympanic: 37
Rectal: 37.5
Axillae: 36.5
When would you recommend and axillary temp?
Infants and paeds, client able to follow instructions, oral cannot otherwise be measured (just consumed a hot beverage), patient NOT profusely sweating)
What are the 6 types of thermometers?
- IVAC/sure temp, temp probe for oral, axillae, and rectal use
- TMT - typanic membrane thermometer
- Temporal artery
- Swan Ganz
- Disposable (used in emerg or triage settings, solely indicates presence or absence of temp)
- Mercury
How does a fever act as a defense mechanism?
Up to 38:
- enhances the body’s immune system
- during febrile episode white blood cell production is stimulated
- reduction in conc. of iron in the blood plasma, suppresses growth of bacteria
- stimulates production of interferon, fights viruses
List some advantages and disadvantages of taking an oral temperature.
Advantages:
non invasive, inexpensive, accurate, easy
Disadvantages:
at the whim of the temp of food/drink they’ve consumed, limited population (ability to follow instruction), if they smoke could be effected, not core
What is a pulse?
The palpable bounding of blood flow noted at various points on the body.
Informs on the status of the circulatory system.
Quick! There’s been an emergency! Which pulse do you choose to measure?
Carotid
What are they types of pulses?
Carotid (side of neck)
Apical (4-5th intercostal space at mid clavicular - PMI)
Brachial (groove beween bicep and tricep)
Radial (thumb side of forearm at wrist)
Femoral (crotch groove)
Dorsalis pedis (top of foot)
Posterior tibial (back of ankle?)
What is the expected pulse in adults?
a) 120-160bpm
b) 60-100bpm
c) 80-120pm
d) 100-200bpm
b) 60-100bpm! Though variation is accepted in athletes etc.
120-160bpm is accepted in infants
Name 5 factors that effect pulse.
- Exercise
- Temperature
- Emotion
- Pain
- Medications (increase with epinepherine, decrease with beta blockers)
- postural changes
What is a nurse looking for when assessing pulse?
- Rhythm
- Rate
- Strength
- Symmetry
What is Bradycardia?
<60bpm
What is Tachycardia?
> 100bpm
What is Dysrhythmia/Arrhythmia?
abnormal rhythm
What is sinus arrhythmia?
variation with the respiratory cycle (heart speeds up when you inhale and slows down when you exhale)
-normal in children and young adults
What is a pulse deficit?
The difference between apical and radial pulse.
What is respiration?
the mechanism used by the body to exchange gases between the atmosphere, blood, and the cells
Your measuring a newborn resp. rate in the obstetrical unit and get a rate of 28 breaths/min. Should you be concerned?
Yes! Measure again for accuracy. Expected resp rate for newborns is 30-60.
12-20 is expected in adults
Name 4 factors that could increase resp rate.
- exercise
- acute pain
- anxiety
- smoking
Your client was practicing for baseball try outs and was clocked in the head, how may this effect resp rate? Select all that apply.
a) decreased rate
b) alters rhythm
c) increases depth
d) shallower/quicker
Both a and b
What are you assess when assessing resp. rate.
- rate
- depth (deep, normal, shallow)
- rhythm (regular or irregular)
- sound (digression from normal or effortless)
What is Bradypnea?
<12 breaths/min
What is Tachypnea?
> 20 breaths/min
What is Hyperpnea?
laboured, increased depth and rate
What is Apnea?
pauses in breathing
What is Dyspnea?
difficulty breathing or breathless
Accurate measurement of respirations requires _________________________ and _____________________ of the chest wall movement.
Observation, palpation
What is blood pressure?
The force of blood pushing against the side of the vessel wall. Indicator of cardiovascular health.
What is systolic pressure?
The max pressure felt in an artery during ventricular contraction
What is diastolic pressure?
Elastic recoil, resting pressure that blood exerts between each contraction
Your client, George, a moderately active accountant, measures in with a blood pressure of 90/70. What would you refer to this as?
Optimal: <120/<80 mmHg Normal: <135/<85 mmHg Hypotension: <90/anything? Hypertension: >140/90
Name 5 factors that effect BP
Cardiac output (volume of blood that flows from the heart to the ventricles) Peripheral vascular resistance (contraction/dilation of vessels) Elasticity of vessel walls Blood Volume Age Stress Viscosity of blood Ethnicity Smoking Medications Daily variation
What are some ways to assess BP?
BP devices (manual or automatic)
Arterial lines
Auscultation with stethoscope and sphygmomanometer
How should you size a blood pressure cuff?
40% of the width of the arm
2/3 of arm covered
An auscultatory gap is when sounds disappear during BP auscultation for _____mmHg
10-40 at any point during auscultation
What is pain?… other than studying for this course
Pain is an unpleasent sensory and emotional experience associated with actual or potential damage
How to assess for pain?
History of current pain (subjective, PQRSTU-AAA) P- provocative/precipitating factors Q- quality R- region/radiation S- severity T- timing A- aggravating factors A- associated symptoms A- alleviating factors
What are the two types of sphygamomanometers?
- Aneroid- subject to drift, must be recalibrated once a year to rest at zero, inexpensive and lightweight
- Mercury- must be read at eye level, doesn’t require readjustment, but mercury is bulky and dangerous
What are the Korotkoff sounds?
The sounds auscultated during blood pressure measurement.
I- soft, clear tapping, increasing in intensity
II- swooshing, soft murmur that follows tapping
III- knocking, crisp, high pitched sounds
IV- abrupt muffling, muting of sounds to a low-pitched, cushioned murmur, blowing
V- SILENCE
Your older nurse mentor says that automatic BP cuffs are the best way to go, but you in all your student wisdom know that manual BP cuff do have their virtues. What are some pros and cons to automatic BP cuffs?
Advantages: fast, accurate, non-invasive
Disadvantages: Cannot sense vibrations of low BP or rapidly irregular pulses, as in atrial fibrillation, must be properly calibrated for accurate readings
