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MTC NUR 134 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Name the vital signs in the order of which to take them.

A
  1. Temperature
  2. Pulse
  3. Respiration
  4. Blood Pressure
  5. Pain
  6. Oxygen saturation
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2
Q

Guidelines to use when taking vitals

A
  1. Make sure to have ALL the appropriate equipment BEFORE walking into the room.
  2. Make sure the equipment is working properly.
  3. Know the patient’s “normal” range.
  4. Know the patient’s hx, meds, and therapies.
  5. Control environmental effects.
  6. Communicate findings.
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3
Q

When should you measure vitals?

A
  1. Upon admission to ANY healthcare facility.
  2. ANYTIME there is a change in the patient’s condition.
  3. ANYTIME there is a loss of consciousness.
  4. Before and after surgical or invasive diagnostic procedures.
  5. Before and after activity that may increase risk.
  6. Before administrating medications that affect cardiovascular or respiratory function.
  7. Based on agency policies and procedures.
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4
Q

What is the most common rout to take temperature?

A

Oral

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5
Q

What is the most accurate rout to take temperature?

A

Rectal

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6
Q

What is the normal range for temperature?

A

97.0-99.5

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7
Q

What are the 2 ways to get the core temperature?

A
  1. Rectal

2. Tympanic

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8
Q

What are the 3 ways to get the surface temperature?

A
  1. Oral
  2. Axillary
  3. Skin surfaces
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9
Q

What are the normal temps for each rout?

A
  1. Oral - 98.6
  2. Rectal - 99.5
  3. Axillary - 97.7
  4. Tympanic - 99.5
    5 Temporal artery - 98.6
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10
Q

What part of the brain controls body temperature?

A

Hypothalamus

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11
Q

What is the definition of vasodilation?

A

The dilation (expanding; getting larger) of the vein which helps increase heat loss through the skin to cool off the body.

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12
Q

What is the definition of vasoconstriction?

A

The constriction (shrinking; getting smaller) of the vein which helps reduce heat loss through the skin to keep the body warm once it’s cooled off.

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13
Q

What is the primary source of heat production?

A

Metabolism

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14
Q

What are the sources of heat production?

A
  1. Metabolism
  2. Hormones
  3. Skeletal muscle activity
  4. Vasoconstriction
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15
Q

What are the 2 hormones that contribute to temperature?

A
  1. Epinephrine

2. Norepinephrine

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16
Q

What are the skeletal muscle activities that contribute to temperature?

A
  1. Exercise
  2. Shivering
  3. Piloerection
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17
Q

What are the 3 main sources of heat loss?

A
  1. Skin
  2. Sweat
  3. Elimination
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18
Q

What is the primary source of heat loss?

A

Skin

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19
Q

What are the 4 types of heat loss?

A
  1. Radiation
  2. Convection
  3. Evaporation
  4. Conduction
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20
Q

What is the definition of radiation?

A

A form of heat loss usually coming from the top of the head. The most common form of heat loss.

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21
Q

What is the definition of Convection?

A

The transfer of heat from one place to another.

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22
Q

What is the definition of evaporation?

A

The transfer of heat from the body through sweat.

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23
Q

What is the definition of conduction?

A

The process of losing heat through physical contact with another object or person.

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24
Q

What are the 5 factors that affect body temperature?

A
  1. Age and gender
  2. Circadian rhythm
  3. Exercise
  4. Endocrine
  5. Environment
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25
Q

What is the medical term for fever?

A

pyrexia

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26
Q

What are the main functions of a fever?

A
  1. Inhibit bacteria growth
  2. Increase WBC production
  3. Stimulates interferon (virus fighting substance)
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27
Q

Patterns of fever: Constant/Sustained

A

Remains above normal

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28
Q

Patterns of fever: Intermittent

A

Returns to normal at least once per 24 hours

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29
Q

Patterns of fever: Remittent

A

Does not return to normal, fluctuates up or down

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30
Q

Patterns of fever: Relapsing

A

Returns to normal for 1 or more days; episode of fever lasting several days

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31
Q

Why would a nurse change damp clothes and sheets?

A

To prevent bed sores, as well as, keep the patient cool and clean

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32
Q

Why would a nurse check vital signs every 4 hours if a patient has a fever?

A

To see if the vitals have either changed or contributed towards the temperature. Also, to see if there is a cause of the fever.

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33
Q

Why would a nurse cover a patient lightly if they have a fever?

A

To keep the patient from over heating while still giving them comfort, protection, and privacy.

34
Q

Why would a nurse encourage high fluid intake for a patient that has a fever?

A

To help prevent dehydration from sweat.

35
Q

Why would a nurse offer light foods frequently to a patient that has a fever?

A

So the patient has the nutrients to fight off whatever the fever is trying to get rid of. (Raise metabolism)

36
Q

Why would a nurse keep a patient with a fever on bed rest?

A

To prevent the fever from rising to dangerously high levels from movement or exercise.

37
Q

What is the normal range for pulse rate?

A

60-100BPM

38
Q

What is the range for bradycardia?

A

<60BPM

39
Q

What is the range for tachycardia?

A

> 100BPM

40
Q

What does the pulse rate assess?

A
  1. Heart function
  2. Tissue perfusion
  3. State of blood vessels
41
Q

What are the 9 pulse sites?

A
  1. Radial
  2. Temporal
  3. Carotid
  4. Apical
  5. Brachial
  6. Femoral
  7. Popliteal
  8. Dorsalis pedis
  9. Posterior tibial
42
Q

What is the location of the Apical Pulse?

A

Between the 5th and 6th rib; 5th intercostal; midline of the clavicle down.

43
Q

How long do you count the Apical Pulse?

A

1 full minute.

44
Q

What could be the reason be for a pulse deficit between the apical and radial pulses?

A

Atrial fibrillation

45
Q

Absent, not palpable pulse

A

0

46
Q

Diminished, weaker than expected pulse

A

+1

47
Q

Brisk, expected (normal) pulse

A

+2

48
Q

Bounding pulse

A

+3

49
Q

What is the definition of a regular rhythm when it comes to pulse?

A

Beats and pauses occur at regular intervals.

50
Q

What is the definition of irregular rhythm when it comes to pulse?

A

Beats and pauses occur at unequal intervals.

51
Q

What are the 4 pain things to check when assessing perfusion (circulation)?

A
  1. Color of the skin
  2. Warmth of the skin
  3. Blanching or capillary refill
  4. Pulses
52
Q

What factors influence pulse rates?

A
  1. Age and gender
  2. Physical activity
  3. Fever and stress
  4. Medications
  5. Disease
53
Q

What is the range for normal rate of respirations?

A

12-20BPM

54
Q

What are the 3 processes involved in respiration?

A
  1. Ventilation
  2. Diffusion
  3. Perfusion
55
Q

What is the definition of ventilation?

A

Movement of air in and out of the lungs

56
Q

What is the definition of hyperventilation?

A

Excessive (potentially dangerous) movement of air in and out of the lungs.

57
Q

What is the definition of hypoventilation?

A

Less than normal movement of air in and out of the lungs.

58
Q

What is diffusion?

A

CO2 and O2 exchange between lungs and blood

59
Q

What is perfusion?

A

CO2 and O2 exchange between blood and cells

60
Q

Why should you not tell the patient you are counting their respiration?

A

They may change their breathing patterns.

61
Q

What is the definition of eupnea?

A

Normal breathing

62
Q

What is the definition of bradypnea?

A

Slow breathing

63
Q

What is the definition of tachypnea?

A

Fast breathing

64
Q

What is the definition of apnea?

A

No breathing

65
Q

What is the definition of dyspnea?

A

Difficulty breathing

66
Q

What is the definition of orthopnea?

A

Difficulty breathing while laying down

67
Q

What are the 8 factors that influence respiration?

A
  1. Age
  2. Exercise/rest
  3. Anxiety/stress
  4. Fever
  5. Anemia
  6. Acute pain
  7. Medication/narcotics
  8. Body position
68
Q

What do you use to measure oxygen saturation?

A

Pulse oximeter

69
Q

What is the normal value for oxygen saturation?

A

> 93%

70
Q

What is the definition of blood pressure?

A

Force exerted on the walls of the artery created by the pulsing blood under pressure from the heart.

71
Q

What do the two numbers in blood pressure represent?

A

Systolic and diastolic

72
Q

What are the 9 factors that affect blood pressure?

A
  1. Age
  2. Exercise/rest
  3. Gender
  4. Race
  5. Stress/anxiety
  6. Medication
  7. Temperature
  8. Hemorrhage
  9. Postural changes
73
Q

What is a auscultatory gap?

A

It is a period of diminished or absent sounds during the manual measurement of blood pressure.

74
Q

What is the definition of hypotention?

A

Lower than normal blood pressure ( <100 systolic; <60 diastolic)

75
Q

What is the definition of prehypertension?

A

Slightly elevated blood pressure ( 120-139 systolic; 80-89 diastolic)

76
Q

What is the definition of hypertension?

A

Elevated or high blood pressure (>140/90 on several readings)

77
Q

What is orthostatic hypotension?

A

Occurs when a patient with a normal BP develops symptoms and a low BP when rising to an upright position.

78
Q

What are the symptoms of hypotension?

A

Dizziness, lightheadedness, and syncope

79
Q

How do we check for orthostatic hypotension?

A

Measure BP while lying, then sitting, then standing

80
Q

What can cause a false low blood pressure?

A
  1. Cuff is too big
  2. Defective equipment
  3. Deflating too quickly
  4. Not reading at eye level
81
Q

What can cause a false high blood pressure?

A
  1. Cuff too small
  2. Defective equipment
  3. Deflating too slowly
  4. Not reading at eye level
  5. Reinflation during auscultation

MTC NUR 134 (1 decks)

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