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NURSING FUNDAMENTALS > Vital Signs Ch 4 > Flashcards

Vital Signs Ch 4 Flashcards

0
Q

Vital signs and other physiologic measurements often provide what

A

The basis for problem-solving

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1
Q

Vital signs include what

A

Temperature, pulse, respirations, and blood pressure

They are called vital signs because of their importance

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2
Q

Many facilities have begun using the fifth vital sign witch is

A

Pain level or comfort level

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3
Q

Guidelines for obtaining vital signs (4)

A

Measure vital signs correctly.

Understand and interpret the values.

Communicate findings appropriately.

Begin interventions as needed

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4
Q

When do you access vital signs

A

When a patient is admitted to a facility, and then as prescribed by the physician or as policy dictates

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5
Q

Heart rate respiratory rate and blood pressure for a neonate

A

120-160

36-60

Systolic - 20-60

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6
Q

Heart rate respiratory rate and blood pressure for an infant

A

125-135

40-46

Systolic- 70-80

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7
Q

Heart rate respiratory rate and blood pressure for a toddler

A

90-120

20-30

Systolic 80-100

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8
Q

Heart rate respiratory rate and blood pressure for school-age 6 to 10 years

A

65-105

22-24

Systolic- 90-100
Diastolic- 60-64

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9
Q

Heart rate was between rate and blood pressure for Adolescent 10 to 18 years

A

65-100

16-22

Systolic 100-120
Diastolic 70-80

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10
Q

Heart rate respiratory rate blood pressure for an adult

A

60-100

12-20

Systolic- 100-120
Diastolic - 70-80

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11
Q

Heart rate respiratory rate blood pressure for an older adult

A

60-100

12-18

Systolic - 130-140
Diastolic - 90-95

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12
Q

Temperature

A

A relative measure of sensible hot or cold

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13
Q

What temperature is considered normal

What is acceptable variations

A

98.6 F (37 C)

97- 99.6 F (36.1 C - 37.5 C)

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14
Q

Factors that have the potential to cause body temperature variances

A

Environment, the time of day, the patient state of health and activity level, in the stage of the patients monthly menstrual cycle

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15
Q

Regulation of body temperature is the job of the what

And where is it located

A

Hypothalamus

Located in the brain, form in the floor and part of the lateral wall of the third ventricle.

The hypothalamus helps maintain a balance between heat loss and he produced by the body

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16
Q

What are the two categories temperature falls into

A

Core temperature and surface temperature

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17
Q

Core temperature

A

The temperature of the deep tissues in the body

Remains relatively constant unless a person is exposed to severe extremes in environmental temperature

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18
Q

Surface temperature

A

The temperature of the skin

Austin varies a great deal in response to the environment

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19
Q

What is usually the first sign of illness

A

Temperature elevations.

Pyrexia, febrile, and hypothermia all mean above normal body temp

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20
Q

What is fever and what is it do

A

It’s a body defense. Elevated body temperature will destroy invading bacteria

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21
Q

Intermittent fevers

A

Rise and fall

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22
Q

Remittent fevers

A

Similar to intermittent fevers except the temperature does not return to normal at all until the patient becomes well

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23
Q

Hypothermia

A

When body temperature is abnormally low

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24
Factors affecting body
Age- neonates 99.5 F, older adult- 95 F Exercise.- can raise as high as 103.2- 105.8 Hormonal influences.- woman have greater variations Diurnal daily variations.-change throughout day Stress.- Environment . Ingestion of hot and cold liquids. Smoking- plus or minus 0.2 F
25
Signs and symptoms of elevated body temperature (10)
``` Thirst anorexia flushed warm skin Irritability glassy eyes or photophobia headache elevated pules and respiratory rate restlessness or excessive sleepiness increased perspiration disorientation ```
26
Heat sensitive patches
To obtain your reading of surface temperature is a possible choice Place the patch on the area of the skin such as the four head the color change on the patch indicates the temperature
27
Electronic thermometer
Consist of rechargeable battery powered display unit, thin wire cord, and the temperature processing probe with the disposable cover Separate probes are available for oral temperature measurement (Bluetip )and rectal temperature measurement (red tip)
28
Normal body temperature is according to the measurements site
Oral 98.6 Rectal 99.5 Axillary 97.6 Tympanic 98.6 Make a telephone oral and tympanic 98.6 down the axillary minus one of the butt plus one
29
Oral temperature
Most assessable site comfortable for patient necessary no position change. Do not use for patients who are infants or small children, disoriented or unconscious patient
30
Rectal
Most accurate. Do not use a patient after rectal surgery or patients who have a rectal disorder
31
Axilla
Least accurate
32
Tympanic
Excessive your wax has a possibility to interfere with accurate reading
33
Temporal artery
Provides core temperature. | Diaphoresis and airflow across the face may affect the accuracy
34
Diaphragm
The circular flat surfaced portion of the chest piece covered with a thin plastic disc of the stethoscope it transmits the high pitch sound created by the hive velocity movement of air in blood
35
Auscultate
Listen for sounds within the body to evaluate the condition of heart lungs, pleura, intestines or other organs or to detect fetal heart tones
36
Pulse
A rhythmic beating or vibrating movement Signifies the regular, recurrent explanation and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts Adult pules rate is normally between 60-100 beats per minute
37
Tachycardia
>100 beats per min
38
Bradycardia
<60 beats per min
39
Dysrhythmia
If the amount of time between beats varies, there will be an irregular pulse Any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart
40
Which two arteries are easily palpated pules sites
Radial and carotid artery
41
Pulse volume variations
``` 0- absent pyulse 1+ thready pulse 2+ weak pulse 3+ normal pulse 4+ bounding pulse ```
42
Factors influencing pulse rates (10)
``` Age, exercise, fever/heat, acute pain and anxiety, unrelieved severe pain/chronic pain, medications, hemorrhage, postural changes, metabolism, pulmonary condition ```
43
Obtaining for radial pulse
Lightly place tips of first and second fingers in Groove formed along radial side of forearm lateral to flexor tendon of wrist
44
Obtaining for ulnar pulse
Place fingertips along ulnar side of forearm
45
Brachial pulse
Locate groove between biceps and triceps muscles above elbow at antecubital fossa
46
Femoral pulse
With patient supine, place first three fingers over inguinal area below inguinal ligament, midway between pubic symphysis and anterosuperior iliac
47
Popliteal pulse
Slightly flex knee with foot resting on table or bed
48
Dorsalis pedis pulse
Place fingertips between great and first toes and slowly move them along groove between extensor te done of great and first toe
49
Posterior tibial pulse
Slightly extend feel | Place fingertips behind and below medial malleolus (ankle bone
50
Apical
Apex | (The tip, the end, or the top of a structure) of the heart
51
Apical pulse
Represents the actual beating of the heart
52
Pulse deficit
The difference between the radial and apical rates. To confirm pulse deficit one nurse listens to the apical rate and the second palp area the radial pulse at the same time using same watch for 1 minute
53
Respiration
The taking in of oxygen, it's utilization in the tissues, and the giving off of carbon dioxide; the act of breathibg, I.e, inhaling and exhaling Both internal and external
54
Internal respiration
Refers to the exchange of gas at the tissue level caused by the process of cellular oxidation as well as the gas exchange that occurs in the alveoli of the lungs
55
Oxidation
Any process in which the oxygen content of a compound is increased
56
External respirations
The breathing movements of the patients that you will observe. The cycle of external respiration's has two parts: inspiration and expiration
57
Inspiration
Inhaling air with oxygen into the lungs
58
Expiration
Exhaling air with carbon dioxide out of the lungs
59
Factors intending respiration
``` Disease or illne STress Fever Age Sex Body position Medications Excercise Acute pain Smoking Brainstem injury Hemoglobin function ```
60
Tachypnea
Rapid respiratory rate
61
Bradypnea
Slow respiratory rate, blow 10 per minute
62
Cheyne stokes respirations
Abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing
63
Blood pressure
The pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart
64
Systolic
Pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries
65
Diastolic
The lower number of the blood pressure reading, the second pressure is the diastolic pressure
66
Pulse pressure
The different between systolic and diastolic
67
Cardiac output
The amount of blood discharged from the left or right ventricle per minute Blood pressure reflects cardiac output
68
Prehypertension
120-139/ 80-89
69
Hypertension
Occurs when elevated pressure is sustained above 140/90
70
Hypotension
Blood pressure below normal
71
Orthostatic hypotension
A drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from lying to a sitting position Occurs when a person rides too quickly usually from supine position
72
Sphygmomanometer
A device for measuring the arterial blood pressure . Consists of an inflatable cuff and a gauge Blood pressure readings are taken with sphygmomanometer and a stethoscope
73
Korotkoff
Pulsating sounds
74
Korotkoff phases
``` Phase 1 - a sharp thump Phase 2 - a blowing or whooshing sound Phase 3- a softer think then phase 1 Phase 4- a softer blowing sound that fades Phase 5- silence ```

NURSING FUNDAMENTALS (11 decks)

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