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NUR350 Midterm > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Why measure vital signs?

A
  • Provide information about the “effectiveness of circulatory, respiratory, neural and endocrine body functions”
  • Quick and efficient way of monitoring a patient’s condition, identifying problems, and evaluating responses to interventions
  • Evaluated in terms of norms and client’s baseline - look for trends
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2
Q

When to take vitals

A
  • Determined and driven by the patient’s needs and conditions
  • Medical order or policy; ordered vital signs are a MINIMUM
  • Before/after surgery/procedure
  • Before/after medication administration
  • Change in condition of client
  • Before/after nursing intervention
  • Non-specific symptoms
  • NOT routine or automatic - thoughtful and scientific
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3
Q

Body Temperature

A

(Heat Produced) - (Heat Loss) = (Body Temp)

  • Heat produces by body
  • Heat lost to environment
  • Body has mechanisms to control temperature; core temperature remains constant
  • Thermostat found in the hypothalamus (midbrain)
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4
Q

Core Temperature vs Surface Temperature

A

Core (deep tissues)

  • Rectum
  • Tympanic membrane
  • Temporal artery
  • Esophagus
  • Pulmonary artery (PA)
  • Urinary bladder
  • Constant 37C

Surface (temperature of skin, subcutaneous tissue and fat)

  • Skin
  • Mouth
  • Axillae
  • Rises and falls in response to the environment (36C - 38C)
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5
Q

Temperature Norms for Adults

A

Temperature range: 36-38C
Average oral or tympanic: 37.0C
Average rectal: 37.5C
Average axilla: 36.5C

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6
Q

Factors Affecting Temperature

A
  • Age: newborns and older adults are more susceptible to changes in environmental temperatures
  • Exercise: increases the head that the body produces and raises temperature
  • Hormones: progesterone in ovulation can cause decrease in body temperature
  • Circadian rhythm: normal sleeping pattern, 1-4Am lowest body temperature
  • Stress: makes us hot through anxiety inducing hormones and measures
  • Others; hyperthermia, hypothermia, heat stroke, fever
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7
Q

Types of Thermometers

A 
- Electric thermometers
IVAC/Sure temp with pencil like probe
TMT (tympanic membrane thermometer)
Temporal Artery
Invasive e.g. Swan Ganz (pulmonary artery) used in ICU
- Disposable (isolation or home use)
- Mercury-in-glass (unsafe)
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8
Q

Measuring Body Temperature

A
  • Electronic thermometer
  • Blue and Red probe
  • Oral and axillary (blue) or rectal (red)
  • Gloved mandatory for rectal
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9
Q

Oral Temperature

A

When to use:

  • Awake
  • Able to follow instructions
  • Over the age of 4

When not to use:

  • Unconscious
  • Unresponsive
  • Confused
  • Intubated
  • Unable to follow instructions
  • Oral surgery
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10
Q

Axillary Temperature

A

When to use:

  • Adults and children
  • Clients receiving oxygen via face mask

When not to use:
- Profuse sweating

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11
Q

Rectal Temperature

A

When to use:

  • When other methods are not available
  • Children under age of 2

When not to use:

  • Infants < 1 month
  • Premature newborns
  • Diarrhea
  • Rectal surgery
  • Rectal bleeding
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12
Q

Tympanic Temperature

A

When to use:

  • Adults and children
  • Clients receiving oxygen via face mask

When not to use:

  • Ear infection
  • Ear surgery
  • While wearing hearing aids
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13
Q

Temporal Artery Thermometer/”Temporal Scanner”

A
  • Core temperature scanner

- Idea is that is gets scanned across the facial forehead

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14
Q

Digital Thermometer

A
  • Same as for oral and axillary but does not have the probe
  • Often found in home use
  • Can be used for oral or axillary temperatures
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15
Q

Pulmonary Artery (PA) Temperature (Swan Ganz)

A
  • Tip placed in the heart
  • Very accurate reading but very invasive
  • Only in critical care areas
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16
Q

Disposable Single-Use Thermometers

A
  • Emergency triage setting; not used very often
  • High level screening; fever or no fever results
  • Placed on skin, dots indicate if patient has a fever
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17
Q

Mercury-in-glass Temperature

A
  • Hazardous substance
  • Don’t drop it
  • Have to be read at eye level to be read accurately
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18
Q

Recording Temperature

A
  • Recording: (PO or O); (R); (T or Tym)

- Ideally plotted on graph; easier to read and see whole bog picture

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19
Q

Advantages/Disadvantages of different Temperatures

A

Oral
- Non-invasive, inexpensive, easy to use, accurate
- Risk of infection (mucous membrane), if patient eat/drink can change reading, if patient is a smoker, limited population use, cannot us if patient on oxygen
Rectal
- Accurate, can use on most populations
- Uncomfortable, invasive
Axillary
- Familiar to patient, easy to perform, non-invasive
- Can’t use of patient sweating, time consuming, patient has to be able to keep arm down, most risk in terms of exposure to environment
Tympanic
- Familiar to patients, not many external factors, quick
- Technique for correct measurement, one size fits all (can be uncomfortable)
Temporal Artery
- Fast, non-invasive, reflect internal temperature, accurate
- Impacted by sweating, cannot be wearing head covering

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20
Q

Pulse

A
  • Palpable bounding of blood flow noted at various points on the body
  • Provides information on the status of the circulatory system
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21
Q

Pulse Sites

A
  • Temporal
  • Carotid: emergencies only
  • Apical: 4th-5th intercostal space at left mid-clavicular line
  • Brachial: groove between biceps and triceps muscles at antecubital fossa
  • Radial: radial or thumb side or forearm at wrist
  • Ulnar
  • Femoral
  • Popliteal
  • Posterior tibial
  • Dorsalis pedis
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22
Q

Pulse Norms

A
  • Infants: 120-160 bmp
  • Toddlers: 90-140 bmp
  • Preschoolers: 80-100 bmp
  • School-agers: 75-100 bmp
  • Adolescents: 60-90 bmp
  • Adults: 60-100 bmp
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23
Q

Factors Affecting Pulse Rates

A 
Exercise
- Increases pulse short term
- Decreases pulse long term
Temperature
- Fever and heat increase pulse
- Hypothermia decreases pulse 
Emotions
- Anxiety increases pulse 
- Relaxation decreases pulse
Pain
- Acute pain and occasionally chronic pain increases pulse
- Unrelieved ongoing serve pain decreases pulse
Medications 
- Epi increases pulse
- Digoxin, beta blockers, calcium channel blockers decrease pulse 
Hemorrhage
- Loss of blood increases pulse
Postural changes
- Standing or sitting increases pulse
- Lying down decreases pulse
Pulmonary conditions
- Poor oxygenation caused by asthma, COPD increases pulse
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24
Q

Assessing Radial and Apical Pulse

A

Assess:

  • Rhythm (regular or irregular)
  • Rate
  • Strength or force (full/bounding, normal/strong, weak/thready, absent/non-palpable)
  • Equality for radial pulse
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25
Q

Assessing Pulse Rate

A
  • Timing begins with one. Count of one is the first beat palpated after timing begins
  • If pulse regular; count for 30 seconds and multiply by 2
  • If pulse irregular; count 60 seconds and/or follow by checking apical pulse
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26
Q

Assessing Apical Pulse

A
  • Use stethoscope
  • Locate the PMI (point of maximal impulse) at the 5th intercostal space, left of the MCL
  • Most accurate way of determining pulse, but also the most invasive
  • Only in patients who have cardiac concerns, poor circulatory routes
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27
Q

Bradycardia

A

Pulse under our norm of <60bmp

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28
Q

Tachycardia

A

Pulse over our norm of >100bmp

29
Q

Dysrhythmia or Arrhythmia

A

Abnomral ryhthm

  • Regularly irregular (consistently irregular)
  • Irregularly irregular (no pattern)
30
Q

Sinus Arrhythmia

A

Variation with respiratory cycle

  • Can be a normal phenomenon; typical in younger adults and children
  • Heart rate speeds up when you inhale and decreases when you exhale
31
Q

Pulse Deficit

A

Difference between apical and radial pulses

- Heart is not contracting efficiently and failing to transmit its way to the radial pulse site

32
Q

Respiration

A
  • The mechanism that the body uses to exchange bases between the atmosphere and the blood between the blood and the cells
  • Rate, depth, and rhythm
33
Q

Ventilation - Resp.

A

Movement of gasses in/out of lungs

34
Q

Diffusion - Resp.

A

Movement of oxygen and carbon dioxide

35
Q

Perfusion - Resp.

A

Distribution of RBCs to and from the pulmonary capillaries

36
Q

Respiratory Rate Norms

A
  • Newborns: 30-60
  • Infants: 30-50
  • Children & Pre-Adolescents: 20-30
  • Adolescents: 16-19
  • Adults: 12-20
37
Q

Factors Affecting Respiration

A
  • Exercise: increases rate and depth
  • Acute pain: alters rate and rhythm (may becomes more shallow)
  • Anxiety: increases rate and depth
  • Smoking: increases rate
  • Medications: mixed effects on rate and depth depending on medication
  • Neurological injury: Decreases rate and alters rhythm
  • Hemoglobin functions: impairments can result in increased rate and depth
38
Q

Assessing Respiration

A
  • Rate
  • Depth: deep, normal, shallow
  • Rhythm: regular or irregular
  • Sound: audible digression from normal or effortless breathing
  • Observe one respiratory cycle: inspiration/expiration
  • Timing begins with count of one
  • If regular count for 30 seconds and multiply by 2
  • If irregular count for 1 full minute
39
Q

Bradypena

A

Slow breathing or less than <12 breaths per minute

40
Q

Tachypena

A

Fast breathing or more than >20 breaths per minute

41
Q

Hyperpnea

A

Laboured, increased depth and rate

- Normal in exercise situations but otherwise abnormal

42
Q

Apena

A

Pauses in breathing

- If goes on for prolonged period of time patient will go into respiratory distress

43
Q

Dyspnea

A

Difficulty breathing or breathlessness

44
Q

Blood Pressure

A
  • The force of blood pushing against the side of the vessel wall
  • Indicator or cardiovascular health
  • Reported in mmHg (millimeters of mercury)
    Influenced by:
  • Cardiac output (volume of blood that flows from the heart into the ventricles, usually mL/min)
  • Peripheral vascular resistance (constricted or dilated)
  • Volume of circulating blood
  • Viscosity/thickness of blood
  • Elasticity of vessel walls
45
Q

Systolic Pressure

A

Maximum pressure felt in the artery during left ventricular contraction, or systole

46
Q

Diastolic Pressure

A

Elastic recoil, or the resting pressure that the blood exerts constantly between each contraction

47
Q

Blood Pressure Norms for Adults

A
  • Optimal: <120/<80
  • Normal: <135/<85
  • Hypotension: <90/
  • Hypertension: >140/90
  • Usually more attention paid to systolic number
48
Q

Factors Affecting Blood Pressure

A
  • Age: increase in BP value
  • Stress: fear, pain, anxiety increase BP
  • Ethnicity: BP higher in certain groups; South Asian, Indigenous, African descent
  • Daily variation: rises in late afternoon, declines in late night/early morning; lowest in early morning
  • Medication: can lower or raise BP
  • Activity, weight & smoking
49
Q

Measuring Blood Pressure - Different types

A

1) Arterial lines (invasive)
- Line places directly into artery and used to measure BP
- Usually only found in critical care situations
- Continuous reading of BP

2) Automatic BP devices or VS monitor
- Found in many situations, very common
- Want to use when possible; more accurate provided they’re calibrated correctly
- AOBP; automatic office blood pressure machine; six measurements, discards first and averages remaining five

3) Auscultation
- With stethoscope and sphygmomanometer (aneroid or mercury)

50
Q

How to measure BP

A
  • Baseline data; verify BP in both arms initially
  • Difference of 5-10mmHg is a normal finding
  • Restrictions to measuring BP such as;
    IV in arm
    Underarm or breast surgery
    Arms that have been traumatized, undergone surgery, etc.
  • Lower extremities can be used if arms not accessible
  • Choose cuff size carefully
    If too big, reading lower than normal; if too small, reading higher than normal
  • Ideally, client is seated with both feet flat on ground
51
Q

Proper BP Cuff Size

A
  • Cuff size width is 40% circumference of the arm

- 2/3 length of arm

52
Q

Korotkoff Sounds

A
  • The sound auscultated during blood pressure measurement
  • Can be differentiated into the five Korotkoff phases;
  • Focus on the 1st and 5th sound
  • 1st; sharp thump followed by clear rhythmical tapping
  • Corresponds to the onset of the systolic (top) BP
  • 2nd; A blowing of whooshing sound
  • 3rd; A softer thumb than phase 1
  • 4th; A softer blowing sound that fades
  • 5th; disappearance of sound
  • Corresponds to the diastolic (bottom) BP
53
Q

Two Step Method

A

Step 1: Take palpable BP

  • Palpate radial or brachial pulse after BP cuff is in position (arrow/dot on cuff aligns with brachial artery)
  • Inflate cuff until 30mmHg above where palpable pulse disappears
  • Deflate cuff and note where pulse reappears - that is systolic BP (guide for BP auscultation)

Step 2: Auscultate BP

  • Inflate cuff 30mmHg above palpated systolic
  • Have stethoscope listening and letting air out
  • Deflate cuff 2-3mmHg/second
  • Listen for absence of sound; diastolic BP
54
Q

One Step Method

A
  • Measuring BP by auscultation alone
  • Common practice but not always the best practice
  • Useful of you already know the baseline BP
55
Q

Auscultatory Gap

A
  • Reasoning of occurrence unknown
  • A period when sounds disappear during auscultation of BP
  • Usually for 10-40mmHg and then returns
  • Can cause underestimation of systolic BP or overestimation of diastolic BP
  • Occurs in 5% of people with hypertension
56
Q

Common Errors in BP Measurement

A
  • Faulty arm position or arm not supported
  • Wrong cuff size
  • Not inflating high enough; auscultatory gap
  • Too much pressure on brachial artery with diaphragm of stethoscope
  • Deflation of cuff too fast
  • Not accounting for dysrhythmias or very slow pulse
  • Observer error;
    Subconscious bias
    Haste, poor hearing, poor equipment, digit preference
    Eye not level with mercury
57
Q

Pain: the 5th Vital Sign

A
  • Unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage
  • Multi-dimensional complex phenomenon
  • Requires comprehensive and ongoing assessment
  • Make sure to do a thorough pain assessment; nurses interact with patients the most
58
Q

Comprehensive Pain Assessment

A

1) History of the client’s current pain experience (subjective data)
2) Direct observation of the behavioural and physiological responses of the client (objective data)

59
Q

PQRST-AAA

A 
P - provocative/precipitating factors
Q - quality of pain
R - region/radiation 
S - severity
T - timing 
A- Associated symptoms
A - Aggravating factors
A - Alleviating factors
60
Q

How does a fever work?

A

A true fever results from an alteration in the hypothalamic set point. Pyrogens such as bacteria and viruses cause a rise in body temperature. Pyrogens act as antigens, triggering immune system responses. The hypothalamus reacts to raise the set point, and the body responds by producing and conserving heat.

  • Phase one: the chill phase
  • Phase two: the plateau
  • Phase three: febrile episode

Fever is an important defence mechanism. Temperature elevations up to 38 degrees Celsius enhance the body’s immune system. During a febrile episode, white blood cell production is stimulated. Increased temperature reduces the concentration of iron on the blood plasma, suppressing the growth of bacteria. Fever also fights viral infections y stimulating production of interferon, the body’s natural virus-fighting substance.

61
Q

How do you treat a fever

A

The objective of therapy is to increase heat loss, reduce heat production, and prevent complications. Methods to treat fever are ones that increase heat loss by evaporation, conduction, convection or radiation.

62
Q

PMI

A
  • The apex beat, also called the apical impulse, is the pulse felt at the point of maximum impulse (PMI)
  • Which is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.
63
Q

How to locate the PMI in an adult

A
  • The PMI is located by anatomical landmarks.
  • The heart is located behind and left to the sternum with base at top and apex at bottom.
  • Find angle of Louis just below suprasternal notch between sternal body and manubrium; it can be palpated as a bony prominence.
  • Slip fingers down each side of angle to fins second intercostal space.
  • Carefully move fingers down left side of sternum to fifth ICS and laterally to the left midclavicular line.
  • A light tap in an area within 1-2cm of PMI is reflected from the apex of the heart.
64
Q

What does accurate measurement of respirations require

A

Observation and palpation of the chest wall movement

65
Q

Cardiac output

A
  • As cardiac output increases, more blood is pumped against arterial walls, causing the blood pressure to rise.
  • Cardiac output increases as a result of an increase in heart rate, greater heart muscle contractility, or an increase in blood volume.
  • A rapid or significant increase in heart rate decreases the heart’s ability to fill, resulting in blood pressure decreasing.
66
Q

Peripheral vascular resistance

A
  • Peripheral vascular resistance is the resistance to blood flow determined by the tone of the vascular musculature and diameter of blood vessels.
  • The smaller the lumen of a vessel, the greater the resistance to blood flow.
  • As resistance rises, arterial blood pressure rises.
  • As vessels dilate and resistance falls, blood pressure subsequently decreases.
67
Q

Blood volume

A
  • Most adults have a circulating blood volume of approximately 5000mL.
  • If volume increases, more pressure is exerted against arterial walls, meaning blood pressure increases.
  • When circulating blood volume decreases (as with hemorrhage or dehydration) blood pressure would subsequently decrease.
68
Q

Blood viscosity

A
  • The hematocrit, or percentage of red blood cells in the blood, determines blood viscosity.
  • When the hematocrit rises and blood flow slows, the heart must contract more forcefully to move the viscous blood through the circulatory system.
  • This results in arterial blood pressure increasing.
69
Q

Arterial elasticity

A
  • As pressure within the arteries increase, the diameter of the vessel walls increase to accommodate the rising pressure change.
  • With reduced elasticity, resistance to blood flow is greater. As a result, when the left ventricle ejects its stroke volume, the vessels no longer yield to pressure.
  • Instead, a given volume of blood is forced through the rigid arterial walls, and systemic pressure rises.
  • Systolic pressure is more significantly elevated that diastolic pressure as a result of reduced arterial elasticity.

NUR350 Midterm (11 decks)

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