Vital Signs Flashcards
Heat produced - heat lost
Body temperature
Acceptable temp for Fahrenheit
96.8° F to 100.4° F
Acceptable temp for Celsius
36° C to 38° C
What controls body temp like a thermostat?
Hypothalamus
What 5 things regulate body temperature?
Neural and vascular control Heat production Heat loss (radiation, conduction, convection, evaporation) Skin temperature regulation Behavioral control
7 Factors that affect body temperature
Age Exercise Hormone level Circadian rhythm Stress Environment Temperature alterations
Heat-loss mechanisms are unable to keep pace with excessive heat production
Fever (pyrexia)
Have fever
Do not have fever
Febrile
Afebrile
hypothalamus isn’t working correctly
Hyperthermia
Acceptable pulse rate
60-100bpm
Acceptable respirations
12-20bpm
Acceptable blood pressure
120/80 mm Hg
Risk for Imbalanced Body Temperature
Hyperthermia
Hypothermia
Ineffective Thermoregulation
Examples of nursing diagnosis for pt with body temperature alterations
How to reduce fever (6)
Antipyretics (meds) obtain blood cultures minimize heat production Maximize heat loss increase metabolic rate (oxygen levels) pt comfort
When do you want to draw a culture?
Before starting antibiotics
Palpable bounding of blood flow noted at various points on the body
The indicator of circulatory status
Pulse
HR (same thing as pulse)
Number of pulsing sensations in 1 minute
Pulse rate
Electrical impulses
originate from the sinoatrial (SA) node
Characteristics of Pulse (4 things)
Rate (# per minute)
Rhythm (intervals)
Strength (0-4) volume of blood ejected
Equality (compare sides)
Factors that affect pulse (7 things)
Exercise Temperature Emotions Medications Hemorrhage Postural changes Pulmonary conditions
difference b/w peripheral & apical pulses
pulse deficit
0 1 2 3 4 strength of pulse is recorded as
0= absent 1= weak or thready 2=normal 3 =full or strong 4= bounding
Sites for pulse (10 sites)
Temporal Carotid Apical Brachial Radial Ulnar Femoral Popliteal Post. tib Dorsal pedis
7 things that determine what the pulse will be like
Activity intolerance
Anxiety
Acute Pain
Decreased cardiac output
Deficient/excess fluid volume
Impaired gas exchange
Ineffective peripheral tissue perfusion
Movement of gases into and out of the lung.
Ventilation
Movement of oxygen and carbon dioxide between alveoli and red blood cells.
Diffusion
Distribution of red blood cells to and from the pulmonary capillaries.
Perfusion
What is involved with respiration?
Ventilation, Diffusion, Perfusion
During the mechanics of inspiration what happens?
abdomen moves downward & forward
Chest wall moves up
During the mechanics of expiration what happens?
diaphragm relaxes
abdomen returns to normal position
chest wall relaxed position
When assessing respiration you need to assess
diffusion & perfusion
Assessing ventilation
Respiratory Rate: breaths/minute
Depth: deep, normal, shallow
Rhythm: regular/irregular
Assessment of diffusion & perfusion
Measure: oxygen saturation of blood & arterial oxygen saturation
8 Factors affecting respiration
exercise acute p! anxiety smoking body position medications neurological injury Hemoglobin function
Force exerted on the walls of an artery by pulsing blood under pressure from the heart
BP
Maximum peak pressure during ventricular contraction, squeezing ventricle to get blood out
Systolic
Minimal pressure during ventricular relaxation
Diastolic
Difference between systolic and diastolic pressures
pulse pressure
Physiology of Arterial BP
Cardiac output Peripheral resistance Blood volume Viscosity Elasticity
is the resistance to blood flow determined by the tone of the vascular musculature and diameter of the blood vessels
Peripheral Resistance (PVR)
8 factors influencing BP
Age Stress Ethnicity Gender Daily Variation Meds Activity, weight Smoking
Thickening of walls
Loss of elasticity-makes it ridged
Family history
Hypertension
6 Risk factors for hypertension
obesity cigarette smoking heavy alcohol consumption high sodium intake sedentary life-style stress
Systolic <90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs
Hypotension
Korortkoff phase 1
sharp thump
Korortkoff phase 2
blowing or whooshing sound
Korortkoff phase 3
crisp, intense tapping
Korortkoff phase 4
softer blowing sound that fades
Korortkoff phase 5
silence
when do we need to do BP manually? (7 things)
Hyper & hypotensive pt irregular HR Peripheral vascular obstructions (clots) Shivering Seizures Excessive tremors Inability to cooperate
Characteristics of pain
Quality
Aggravating and precipitating factors
Relief measures
Effects of pain on the patient
Behavioral effects
Influence on activities of daily living (ADLs)
Concomitant (secondary) symptoms
Usually increases pain severity
ABCDE of P! assessment
Ask Believe Choose Deliver Empower
Type of pain scales
Wong-Baker Faces
Oucher
Cuff is too small, release to slow
will cause a high reading
If the arm is low
high reading
Cuff is too big, above the heart
low reading
Systolic <90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow to vital organs
Hypotension
The measure of HR & rhythm
Pulse
Bodys mechanism for exchanging oxygen & carbon dioxide
Respiration
Core temp sites
rectum tympanic membrane temporal artery pulmonary artery esophagus urinary bladder
Pulses for infants toddler preschooler school age child adolescent adult
Infants 120-160 toddler- 90-140 Preschooler- 80-110 School age child- 75-100 Adolescent- 60-90 Adult - 60-100
