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Nursing 134 fundamentals > Vital Signs > Flashcards

Vital Signs Flashcards

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1
Q

When to measure vitals

A

Upon admission to any healthcare agency
Based on agency policy and procedure
Anytime there’s a change in the patient’s condition
Anytime there’s a loss of consciousness
Before and after surgical procedures
Before and after activity that may increase risk
Before administering medication that affects cardiovascular or respiratory function

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2
Q

Guidelines

A

Ensure equipment is working properly and select appropriate equipment
Know patience usual range
Know patient’s history

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3
Q

Body temp

A 
Normal range 97-99.5 
Core temp:
- rectal
- tympanic
Surface temp: 
- oral
- axillary 
- skin surface
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4
Q

Normal temps

A

Oral: 98.6
Rectal: 99.5
Axillary: 97.5
Temporal artery: 98.6

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5
Q

Rectal temp

A

Adult: 1.5 in
Child: 1 in

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6
Q

Primary source of heat in body

A

Metabolism with heat produced as a byproduct of metabolic activities that generate energy for cellular function

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7
Q

Temp regulation

A

Neural and vascular control

  • hypothalamus = thermoregulatory center
  • vasodilation
  • vasoconstriction
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8
Q

Afebrile

A

Normal body temperature

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9
Q

Heat production

A

Metabolism
Hormones
Skeletal muscle activity
Vasoconstriction

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10
Q

Heat loss

A

Skin is primary source
Sweat
Elimination

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11
Q

Hypothermia

A

Shivering

Constriction of blood vessels

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12
Q

Radiation

A

Heat transfer via infrared radiation

Diffusion of heat by electromagnetic waves

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13
Q

Convection

A

Air / water

Heat by motion between areas of unequal density

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14
Q

Evaporation

A

Transfer heat as water

Conversion of liquid to a vapor

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15
Q

Conduction

A

Transfer heat from one object to another through physical contact

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16
Q

Pyrexia

A

Fever

Heat loss mechanism unable to keep pace with excess heat production

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17
Q

Function of fever

A

Inhibit bacteria growth
Increase WBC production
Stimulates interferons (virus fighting substances)

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18
Q

Constant / sustained fever

A

Remain above normal

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19
Q

Intermittent fever

A

Returns to normal at least once per 24 hours

20
Q

Remittent fever

A

Does not return to normal, fluctuates up or down

21
Q

Relapsing

A

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

22
Q

Syncopal

A

Fainting or sudden temporary loss of consciousness

23
Q

Pulse

A

Normal: 60-100
Bradycardia: < 60
Tachycardia: > 100

24
Q

Pulse deficit

A

Difference in apocalyptic and radial rates

25
Q

Pulse amplitude

A 
0= absent not palpable 
\+1= diminished, weaker than expected 
\+2= brisk, expected (normal)
\+3= bounding
26
Q

Pulse rhythm

A

Pattern of the beats and phases between them
Regular= beasts and pauses occur at regular intervals
Irregular= beats and pauses occur at unequal intervals

27
Q

Pulse pressure

A

Systolic - diastolic

28
Q

Cardiac output

A

Volumes of blood pumped by heart

- heart rate x stroke volume

29
Q

Stroke volume

A

Amount of blood pumped by the left ventricle

30
Q

Respiration rate

A

12-20

31
Q

Eupnea

A

Normal, unlabored breathing

32
Q

Apnea

A

Periods there is no breathing

33
Q

Orthopnea

A

Breathing better upright

34
Q

Normal pulse oximeter

A

> 93% (95 % for class)

35
Q

Blood pressure

A

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

36
Q

Peripheral resistance

A

Elasticity of the arteries
Lumen size
Smaller lumen= higher BP
Larger lumen= lower BP

37
Q

Orthostatic hypotension

A

Form of low BP that happens when standing up from sitting down

38
Q

Orthostatic hypotension signs

A 
Dizziness 
Fainting 
Weakness 
Lightheadedness
Pillar 
Syncope- temporary loss of consciousness cause by fall in BP
39
Q

Blood volume

A

Increased volume = increase BP
- iv fluid overload
Decreased volume = decreased BP
- hemorrhage

40
Q

Blood viscosity

A

Increased viscosity = increase BP
- heart has to work harder
Decreased viscosity = decreased BP

41
Q

Auscultatory gap

A

Where sound completely disappears then return at a lower level
The true systolic BP is the higher reading the 4th diastolic sound is the distinct muffling sound

42
Q

Hypotension

A

< 100 systolic

< 60 diastolic

43
Q

Prehypertension

A

Systolic 120-139

Diastolic 80-89

44
Q

Hypertension

A

> 140/90 on several readings

45
Q

Guidelines for measuring orthostatic hypotension

A

Measure BP lying, sitting and standing

Nursing 134 fundamentals (31 decks)

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