Vital Signs Chapter 19 Flashcards
These allow the nurse to detect changes in the health status of the patient, identify early warning signs of life-threatening health conditions, and evaluate effectiveness of interventions.
Vital signs
Vital signs consist of what 5 things?
Temperature, pulse, respirations, blood pressure, and pulse oximetry
Vital sign: measurable heat of the human body. What is the normal range?
Temperature; 97.6-99.6
Vital sign: detectable rhythmic expansion of an artery that occurs with the pumping action. What is the normal range?
Pulse; 60-100 BPM
Vital sign: act of breathing measured in beats per minute. What is the normal range?
Respiration; 12-20 BPM
Vital sign; the measurable pressure of blood within the systemic arteries. What is the normal range?
Blood pressure; systolic 90-120, diastolic 60-80.
Vital sign; measures the amount of oxygen available to tissues. What is the normal range?
Pulse oximetry; 95%-100%
Infection, physical environment, emotional state of patient, medications, fluid and food intake, activity level and tolerance are all factors that influence what?
Factors that influence vital signs.
Age, exercise, hormone fluctuations, circadian rhythms, stress, environment, and smoking are all factors that influence what?
Factors that influence temperature.
Condition of low body temperature. signs and symptoms include respirations, pale, cool skin, and decreased blood pressure.
Hypothermia
Condition of high body temperature.
Hyperthermia
This condition occurs when prolonged exposure to the sun or high environmental temperatures overwhelms the body’s heat loss mechanisms.
Heat stroke
This condition occurs when extreme or prolonged environmental heat exposure leads to profuse sweating with consequent excessive water and electrolyte loss.
Heat exhaustion.
What are the 5 common sites used to measure temperature?
Mouth, ear, rectum, forehead, axilla
This selection is affected by patient’s age, state of consciousness, amount of pain the patient is suffering, and treatment the patient is undergoing.
Site selection of temperature
Pulse is measured through which 9 areas? TCABRFPPtD
Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior tibial, Dorsalis pedis
This pulse site is located at neck area and both should not be palpated at the same time because it could limit blood flow to the brain.
Carotid site
This pulse site is located at the apex of the heart, at the fifth intercostal space midclavicular line. AKA Point of maximal impulse.
Apical pulse
This pulse site is located at the inner aspect of the arm and used to assess pulse in pediatric emergencies
Brachial pulse
This pulse site is located at femoral artery and used in cases of cardiac arrest and for assessing circulation to the leg.
Femoral pulse
This pulse site is at medial surface of the ankle and used to determine circulation of the foot.
Posterior tibial pulse.
This pulse site is used to determine circulation of the foot.
Dorsalis pedis pulse
Listening with a stethoscope is considered what?
Auscultation
An excessively fast heart rate of greater than 100 bpm
Tachycardia
A slow heart rate of less than 60 bpm is called what?
Bradycardia
Present when the patient’s radial pulse rate is slower than the apical pulse because of cardiac contractions that are ineffective at pumping blood to the peripheral extremities.
Pulse deficit
An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat.
Dysrhythmia or arrhythmia
Normal respiration with a normal rate and depth for the patient’s age
Eupnea
An increase in respiratory rate of more than 24 BPM in the adult.
Tachypnea
A decrease in respiratory rate to less than 10 BPM. Can be caused by medications, opioids, metabolic disorders, or brain injury.
Bradypnea
Characterized by shallow respirations; associated with drug overdose and obesity, cervical spine injury, and COPD (chronic obstructive pulmonary disease).
Hypoventilation
Characterized by deep, rapid respirations. Often caused by stress and anxiety.
Hyperventilation
The absence of breathing; brain damage can occur after 4-6 minutes of this.
Apnea
Shortness of breath or difficult, labored breathing with rapid shallow pattern.
Dyspnea
Difficulty breathing when lying flat that is relieved by sitting or standing
Orthopnea
The peak of blood pressure wave is called what? Where the heart contracts.
Systolic pressure
The lowest pressure on arterial walls, which occurs when the heart rests is called what? Where the heart dilates.
Diastolic pressure
Blood pressure is measured in what?
Millimeters of mercury (mm Hg)
This condition is when systolic blood pressure is less than 90 mm Hg. Or 20-30 mm Hg below the patient’s normal blood pressure.
Hypotension
A sudden drop of 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from lying to sitting to standing.
Orthostatic hypotension
Elevated blood pressure that can lead to myocardial infarction, stroke, renal failure, and death.
Hypertension.
The sounds in which the nurse listens to when assessing blood pressure.
Korotkoff sounds
The absence of Korotkoff sounds noted in some patients after the initial systolic pressure. Failure to recognize this can cause major errors in measuring blood pressure.
Auscultatory gap
Landmark for heart auscultation: located in 2nd intercostal space right of the sternal border.
Aortic valve
Landmark for heart auscultation: located in 2nd intercostal space left of the sternal border.
Pulmonic valve
Landmark for heart auscultation: located at 5th intercostal space left of the sternal border.
Tricuspid valve
Landmark for heart auscultation: located at 3rd intercostal space, left of the sternal border.
Erb’s point
Landmark for heart auscultation: located at 5th intercostal space, mid clavicular line (apical pulse)
Mitral valve
A condition that causes an increased lumbar curvature just above the buttocks area.
Lordosis
An outward curvature of the thoracic spine.
Kyphosis
A sideways or s-shaped curvature of the spine and is always abnormal.
Scoliosis
