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Fundamentals of Nursing > Vital Signs/Cardinal Signs > Flashcards

Vital Signs/Cardinal Signs Flashcards

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1
Q

What are the 5 vital signs?

A 
Temperature
Pulse
Respirations
Blood Pressure
Pain
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2
Q

balance between heat produced by the body and heat loss from the body

A

Body Temperature

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3
Q

Types of body temperature

A

Surface and core temperature

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4
Q

Temperature of the deep tissues of the body such as abdominal and pelvic cavity.

A

Core temperature

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5
Q

Temperature of skin, SQ tissue and fat. Rises and falls in response to the environment.

A

Surface temperature

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6
Q

4 processes involved in heat loss

A
  • Radiation - transfer of heat from surface to surface of one object to surface of another w/o contact
  • Conduction - transfer of heat from one surface to another through direct contact
  • Convection - dispersion of heat by air currents
  • Evaporation - vaporization of moisture from the respiratory tract, mucosa of the mouth and skin
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7
Q

Body temperature is above the usual range

A

Pyrexia/Hyperthermia/Fever

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8
Q

Very high fever, 41°C (105.8°F) and above

A

Hyperpyrexia

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9
Q

Core body temperature is below the lower limit of normal

A

Hypothermia

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10
Q

What are the 5 types of fever?

A

Intermittent - alternates at regular intervals

Remittent - wide range of temp fluctuations more than 2°C for over 24 hrs

Relapsing - short febrile periods

Constant - fluctuates minimally but always remains above normal.

Fever spike (Staircase) - temperature rises to fever level rapidly following a normal temperature then
returns to normal within a few hours
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11
Q

What are the four ways of assessing body temperature?

A

Oral
Rectal
Axillary
Tympanic Membrane

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12
Q

Considered to be the most convenient and most accessible way of assessing body temperature

A

Oral

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13
Q

Considered to be a very accurate way of assessing body temperature

A

Rectal

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14
Q

Safest and non-invasive way of assessing body temperature

A

Axillary

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15
Q

Frequent site for estimating core body temperature

A

Tympanic Membrane

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16
Q

When will you start Tepid Sponge Bath (TSB)?

A

If there is 1°C to 2°C increase in body temperature

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17
Q

Wave of blood created by contraction of the left ventricle of the heart

A

Pulse

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18
Q

What are the 8 pulse sites?

A
  • Temporal
  • Carotid
  • Radial
  • Apical
  • Brachial
  • Femoral
  • Popliteal
  • Posterior tibia and Dorsal Pedal
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19
Q

excessively fast heart rate (over 100 beats/min)

A

Tachycardia

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20
Q

heart rate in adult that is less than 60 beats/min

A

Bradycardia

21
Q

The pattern of the beats and the intervals between beats.

A

Rhythm

22
Q

Irregular rhythm is referred to as

A

dysrhythmia or arrhythmia

23
Q

The three processes in the act of breathing

A

Ventilation, Diffusion, and Perfusion

24
Q

movement of air in and out of the lungs

A

ventilation

25
Q

exchange of gases from higher pressure to an area of lower pressure. It occurs at the alveolocapillary
membrane

A

diffusion

26
Q

availability and movement of the blood for transport of gases, nutrients and metabolic waste products

A

Perfusion

27
Q

Two types of breathing

A

Costal (thoracic) and Diaphragmatic (abdominal)

28
Q

primary respiratory center. CO2 is the primary chemical stimuli for breathing

A

Medulla oblongata

29
Q

contains pneumotaxic center that is responsible for rhythmic quality of breathing, and apneustic center that
is responsible for deep prolonged inspiration

A

Pons

30
Q

peripheral chemoreceptors that are sensitive to 02 and CO2 level in the blood

A

Carotid and Aortic Bodies

31
Q

cessation of breathing

A

Apnea

32
Q

quick, shallow breaths (>20cpm)

A

Tachypnea

33
Q

abnormally slow breathing (<12cpm)

A

Bradypnea

34
Q

very deep to very shallow breathing followed by temporary apnea

A

Cheyne-Stokes

35
Q

rapid, deep and labored breathing

A

Kussmaul’s

36
Q

difficult and labored breathing

A

Dyspnea

37
Q

ability to breathe only in upright sitting or standing position

A

Orthopnea

38
Q

shrill, harsh sound heard during inspiration

A

Stridor

39
Q

snoring or sonorous respiration

A

Stertor

40
Q

high-pitched musical squeak or whistling sound occurring on expiration

A

Wheeze

41
Q

gurgling sounds heard as air passes through moist secretions in the respiratory tract

A

Bubbling

42
Q

Shallow breaths interrupted by apnea

A

Biot’s (cluster) respirations

43
Q

Pressure exerted by blood as it flows through the arteries

A

Blood pressure (BP)

44
Q

blood pressure that falls when the client sits or stands

A

Orthostatic Hypotension

45
Q

What are the 5 Korotkoff’s Sound phases?

A

Phase 1: first faint, clear tapping or thumping sounds are heard

Phase 2: heard sounds have a muffled, whooshing or swishing sound quality

Phase 3: sounds become crisper and more intense, softer thumping sound

Phase 4: sound become muffled and have a soft, blowing quality

Phase 5: period of silence

46
Q

an unpleasant sensory and emotional experience associated with actual and potential tissue damage.

A

Pain

47
Q

What are the characteristics of Pain?

A

PQRST

Provoking factors
Quality
Radiation
Severity/Intensity
Time
48
Q

What are the 3 ways to assess pain?

A

Descriptive Pain Intensity Scale

Numeric Pain Scale

Visual Analogue Scales

Fundamentals of Nursing (26 decks)

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