Vital signs Flashcards
Acceptable temp range:
96.8-100.4 F
Most accurate temp reading:
Rectal because measures core
Body temp regulations: (4)
Neuro and vascular control (hypothalamus)
Heat production (post. pituitary)
Heat loss (ant. pituitary)
Skin temperature
Convection:
Transfer of heat away from the body by air movement
Ex- Fan or cool breeze
Conduction:
Transfer of heat from one object to another with direct contact
Ex- Application of ice pack to cool temp
Radiation:
Transfer of heat from the surface of one object to the surface of another without direct contact between the two
Ex- environment is warmer than the skin, the skin absorbs the heat
Evaporation:
Transfer of heat energy when a liquid is changed to a gas
Ex- sweating
The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take?
Place the patient on oxygen.
Fastest measurement time for temp:
Tympanic
Best sites for assessing an infant or young child’s pulse:
Brachial or apical
Why must you use oxygen cautiously in patients with chronic lung disease?
Hypoxemia controls ventilation by providing stimulus that allows a patient to breathe
Normal capnography value:
What does it measure?
35-45 mm Hg
Exhaled CO2
The nurse is caring for a patient who has a pulse rate of 48. His blood pressure is within normal limits. Which finding will help the nurse determine the cause of the patient’s low heart rate?
The patient has calcium channel blockers or digitalis medication prescriptions.
Normal hemoglobin level:
14-18 g/100 mL in males
12-16 g/100 mL in females
What to assess prior to obtaining an oxygen saturation reading:
Latex allergy
If pulse is irregular, what should the nurse do?
Do an apical/radial pulse assessment to detect a pulse deficit
A nurse is working in the intensive care unit and must obtain core temperatures on patients. Which sites can be used to obtain a core temperature?
Tympanic, esophagus, and pulmonary artery
How to take a radial pulse:
Place tips of the first two fingers over the groove along the thumb side of the patient’s wrist
Normal pulse/ HR:
60-100 BPM
Normal SpO2:
95-100%
Normal respiration rate:
12-20 breaths/min
Pulse pressure value:
How to find?
30-50 mmHg (systolic-diastolic)
How to rate strength of pulse:
4- Bounding 3- Full or strong 2- Normal and expected 1- Barely palpable or diminished 0- Absent
For a regular pulse-
Count rate for 30 secs and multiply by 2
For irregular pulse-
Count for full 60 secs
How to locate PMI/apical impulse:
Over the apex of the heart in the 5th intercostal space at the left midclavicular line
Which action would take priority if a patient’s apical pulse has an irregular rhythm?
Reassess for 1 full min
How to find a pulse deficit:
2 nurses- one measures apical, one measures radial pulse. Subtract the radial rate from the apical rate. If the difference is more than 2 BPM, a pulse deficit exists.
F/u care for a pt with a pulse deficit:
Signs or sxs of decreased cardiac output, such as edema, cyanosis or pallor of the skin, and dizziness or syncope.
Normal BP in patients with elevated BP:
Systolic: 120-129 mm Hg
Diastolic: less than 80 mm Hg
Normal BP in patients with stage 1 HTN:
Systolic: 130-139 mm Hg
Diastolic: 80-89 mm Hg
Normal BP in patients with stage 2 HTN:
Systolic: 140 mm Hg
Diastolic: 90 mm Hg
Using a blood pressure cuff that is too wide would cause:
Low BP
Using a blood pressure cuff that is too loose would cause:
High BP
Vasoconstriction effect on temp:
Decreased temp -> blood vessels constrict-> less blood reaches the skin to promote heat production
Vasodilation effect on temp:
Increased temp -> blood vessels dilate-> more blood reaches the skin to promote heat loss
Why does fever cause increased HR and respiratory rate
Increased metabolism to replenish energy stores from fighting fever requires additional oxygen/heat
For every 1° C rise in temp, the body’s chemical reactions increase 10% (WBC production, decrease in iron concentration, stimulation of interferons)
Hyperthermia:
When the body cannot reduce heat production or promote heat loss
Heatstroke:
Prolonged exposure to sun overwhelms heat-loss mechanisms
Heat exhaustion:
Excess sweating that causes dehydration
Hypothermia:
Heat loss through prolonged exposure to cold, decreased heat production
Cardiac output=
SV x HR
Diaphragm of stethoscope:
Detects high pitched sounds
Bell of stethoscope:
Detects low pitched sounds
S1 sound:
Low pitched “lub”
S2 sound:
High pitched “dub”
How to measure rhythm of strength:
Can be regularly irregular or irregularly irregular
Ventilation:
Movement of gases in/out of the lungs
Diffusion:
Movement of oxygen and carbon dioxide between alveoli and RBC
Perfusion:
Distribution of RBC to and from pulmonary capillaries
Ventilatory depth (breathing depth):
Shallow, deep, normal, or labored
Factors affecting SpO2:
- Outside light sources
- Carbon monoxide elevates SpO2
- Patient movement
- Jaundice
- Nails
- Intravascular dyes
- Dark skin
Hyperpnea:
Respirations are labored, increased rate, increased depth
Hyperventilation:
Increased rate, increased depth
Hypoventilation:
Deceased rate, decreased depth
Hypovolemia:
Shock and severe dehydration causes extracellular fluid loss and reduced circulating blood volume
