Vital Signs/Cardinal Signs Flashcards
What are the 5 vital signs?
Temperature Pulse Respirations Blood Pressure Pain
balance between heat produced by the body and heat loss from the body
Body Temperature
Types of body temperature
Surface and core temperature
Temperature of the deep tissues of the body such as abdominal and pelvic cavity.
Core temperature
Temperature of skin, SQ tissue and fat. Rises and falls in response to the environment.
Surface temperature
4 processes involved in heat loss
- 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
Body temperature is above the usual range
Pyrexia/Hyperthermia/Fever
Very high fever, 41°C (105.8°F) and above
Hyperpyrexia
Core body temperature is below the lower limit of normal
Hypothermia
What are the 5 types of fever?
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
What are the four ways of assessing body temperature?
Oral
Rectal
Axillary
Tympanic Membrane
Considered to be the most convenient and most accessible way of assessing body temperature
Oral
Considered to be a very accurate way of assessing body temperature
Rectal
Safest and non-invasive way of assessing body temperature
Axillary
Frequent site for estimating core body temperature
Tympanic Membrane
When will you start Tepid Sponge Bath (TSB)?
If there is 1°C to 2°C increase in body temperature
Wave of blood created by contraction of the left ventricle of the heart
Pulse
What are the 8 pulse sites?
- Temporal
- Carotid
- Radial
- Apical
- Brachial
- Femoral
- Popliteal
- Posterior tibia and Dorsal Pedal
excessively fast heart rate (over 100 beats/min)
Tachycardia
heart rate in adult that is less than 60 beats/min
Bradycardia
The pattern of the beats and the intervals between beats.
Rhythm
Irregular rhythm is referred to as
dysrhythmia or arrhythmia
The three processes in the act of breathing
Ventilation, Diffusion, and Perfusion
movement of air in and out of the lungs
ventilation
exchange of gases from higher pressure to an area of lower pressure. It occurs at the alveolocapillary
membrane
diffusion
availability and movement of the blood for transport of gases, nutrients and metabolic waste products
Perfusion
Two types of breathing
Costal (thoracic) and Diaphragmatic (abdominal)
primary respiratory center. CO2 is the primary chemical stimuli for breathing
Medulla oblongata
contains pneumotaxic center that is responsible for rhythmic quality of breathing, and apneustic center that
is responsible for deep prolonged inspiration
Pons
peripheral chemoreceptors that are sensitive to 02 and CO2 level in the blood
Carotid and Aortic Bodies
cessation of breathing
Apnea
quick, shallow breaths (>20cpm)
Tachypnea
abnormally slow breathing (<12cpm)
Bradypnea
very deep to very shallow breathing followed by temporary apnea
Cheyne-Stokes
rapid, deep and labored breathing
Kussmaul’s
difficult and labored breathing
Dyspnea
ability to breathe only in upright sitting or standing position
Orthopnea
shrill, harsh sound heard during inspiration
Stridor
snoring or sonorous respiration
Stertor
high-pitched musical squeak or whistling sound occurring on expiration
Wheeze
gurgling sounds heard as air passes through moist secretions in the respiratory tract
Bubbling
Shallow breaths interrupted by apnea
Biot’s (cluster) respirations
Pressure exerted by blood as it flows through the arteries
Blood pressure (BP)
blood pressure that falls when the client sits or stands
Orthostatic Hypotension
What are the 5 Korotkoff’s Sound phases?
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
an unpleasant sensory and emotional experience associated with actual and potential tissue damage.
Pain
What are the characteristics of Pain?
PQRST
Provoking factors Quality Radiation Severity/Intensity Time
What are the 3 ways to assess pain?
Descriptive Pain Intensity Scale
Numeric Pain Scale
Visual Analogue Scales
