Vital signs exam 2 Flashcards
What makes up vital signs?
temp, pulse, BP,RR, and O2 saturation
when do you measure vital signs?
on admission
per physician order (routine, Q4h)
any changes in patients condition
before and after any major procedure
during blood transfusion
after medications or interventions that affect vital signs
what is a normal temp range for an adult ?
96.8-100.4
what is a normal temp range for oral/tympanic/temporal?
97.6-99.6
what is a normal temp range for an adult rectally?
98.6-100.4
what is a normal temp range for an adult - Axilla
96.6-98.6
what is a normal pulse range for an adult?
60-100 BPM
what is a normal RR for an adult?
12-20 breaths per minute
what is a normal BP range for an adult
120/80 mmHg
Pre-hypertensive: systolic
120-139
Pre-hypertensive: Diastolic
80-89
hypertensive- systolic
> 140
hypertensive-Diastolic
> 90
body temperature
heat produced or heat loss
acceptable range for temperature?
96.8-100.4
examples of temperature sites?
oral, rectal, axillary, tympanic artery, esophageal, pulmonary artery, and urinary bladder
What helps control body temp?
hypothalamus
hypothalamus
located between the hemispheres, controls body temperature.
anterior hypothalamus
controls heat loss
posterior hypothalamus
controls heat production
what are mechanisms of heat loss
sweating, vasodilation, inhibition of heat production
neutral and vascular control?
anterior/posterior hypothalamus
heat production?
-BMR (basal metabolic rate)
- shivering
Heat loss?
radiation
conduction
convection
Radiation?
transfer of heat from surface of one object to surface of another without direct contact between the two
conduction?
transfer of heat from one object to another with direct contact
convection?
transfer of heat away by air movement
evaporation
transfer of heat energy when a liquid is changed
diaphoresis
visible perspiration, primarily occurring on the forehead and upper thorax
Factors that affect body temp?
age
hormonal level
environment
exercise
circadian rhythm-(normally does not change with age)
temperature alterations
exercise- factors affecting body temp
increases metabolism and heat production and thus the body temp. prolonged exercise increases body temp
hormone level- factors affecting body temp
women generally experience greater fluctuations in body temp than men
Fever (pyrexia)
usually not harmful if below 102.2F
important defense mechanism
temp should be taken several times throughout the day
results from an alteration in the hypothalamic set point
causes increase in metabolism and oxygen consumption
increased HR and RR
hyperthermia
inability to promote heat loss or reduce production
heatstroke
dangerous heat emergency
high mortality rate
body temp 104+
signs/symptoms of heatstroke
confusion, excess thirst, muscle cramps
vitals: increased HR, decreased BP, no diaphoresis
heat exhaustion
diaphoresis results in excess water and electrolyte loss
symptoms: deficient fluid volume
hypothermia
prolonged exposure to cold decreases bodys ability to produce heat
temp: <86-96.8
classified into 3 sections: mild,moderate, and severe
conversion for C to F
C=(F-32)x5/9
can also substitute 5/9 for 1.8
conversion for F to C
F=(9/5xC) + 32
oral temperature
easily influenced by hot or cold foods
most common way to attain temp
rectal temperature placement for adult ?
insert 1 1/2 inch
rectal temperature placement for child?
insert 1 inch
rectal temperature placement for Infant?
insert 1/2 inch
what could give a rectal reading a inaccurate reading?
feces
axillary temperature
considered safest, must be left in place for 5-10mins, moisture in axillary area may reduce temp
tympanic temperature
most rapid means of measurement
must remember to remove hearing aids before using
temporal temperature
most accurate compared to core temp
fast read 2-3seconds
ease of use
fewer errors that tympanic
types of thermometers
tympanic, oral, disposable, temporal
you have delegated vital signs to the nursing assistant. She tells you that the patient has just finished a cup of hot coffee. the nurse most appropriate advice would be to?
wait 30 mins and take an oral temp
two hours later, the nurse aide reports your pts temp is 102.6F temporally. what are some interventions that would be appropriate for this patient?
blankets off, cold wash cloth, meds to lower temp
what do you do for a fever?
obtain blood cultures if ordered
monitor VS - assess skin color, temp,tugor, and lab work
maximize heat loss
extra fluids
dry bed linens
Pulse
palpable or audible bounding of blood flow noted at various points of the body
an indirect measure of circulatory status
radial pulse site
most common for routine VS
used for pt teaching
assesses circulation status to the hand
should be assessed together as well as once for pulse
apical pulse
fourth to fifth intercostal space at left midclavicular line
if pulse is abnormal
if taking meds that affect HR
if radial inaccessible
carotid pulse
along medial edge of sternocleidomastoid muscle in neck
if pt condition suddenly worsens
Via doppler if unable to palpate
access bilaterally
dorsalis pedis pulse
along top of foot, between extension tendons of great and first toe
assesses status of circulation of foot
via doppler if unable to palpate
assess bilaterally
what is a baseline rate (pulse)
60-100 BPM
- if abnormal, obtain apical
Rhythm - pulse
regular, irregular, dysrhythmia
Tachycardia
Elevated HR above 100 beats/min
bradycardia
Slow rate 60 beats/min
dysrhythmia
threatens ability of the heart to provide adequate cardiac output
identify by: palpating an interruption in successive pulse waves
you notice that a teenage has an irregular radial pulse. what would be the best action for you to take?
assess the apical pulse rate for 1 full min
you are assessing your pts pedal pulses you are unable to palpate a pulse on the right foot. what should you do?
try the other foot, use a doppler
gas exchange
the process of transporting oxygen into cells
transport of carbon dioxide out of cells
ventilation
the movement of gases in and out of the lungs
Ischemia
insufficient O2 to tissues
Hypoxia
not enough 02 reaching the cells
hypoxemia
low levels of arterial 02
Process of gas exchange- 18 steps
- Atmosphere (21% oxygen)
- medulla
- thorax intact, diaphragm contracts
- nose
- trachea
- bronchi
7.alveoli - Pulmonary capillaries w/ hemoglobin to carry oxygen
- perfusion to transport hemoglobin to cells
- CELL METABOLISM
- perfusion to transport hemoglobin from cells
- pulmonary capillaries with hemoglobin carrying C02
- alveoli
- bronchi
- trachea
- nose
- thorax intact, diaphragm relaxes
- atmosphere
what impairs gas exchange?
-ineffective ventilation
- reduced capacity for gas transportation (reduced hemoglobin or RBCs)
-inadequate perfusion
diffusion
movement of O2 and Co2 between alveoli and RBCs
Perfusion
distribution of RBCs to and from the pulmonary capillaries
assessment of Respiration - rate
how many breaths/min
assessment of respiration - rhythm
regular/irregular
assessment of respiration- depth
- deep, normal, shallow
Eupnea
ventilation of normal rate and depth
“Eu” normal “pnea” lungs
normal breathing at 12-18b/min
factors influencing respiration - exercise
breathing more often
factors influencing respiration- acute pain
shallow breaths
factors influencing respiration-anxiety
breathing rapidly
factors influencing respiration-smoking
effects respirations
factors influencing respiration-body positions
position helps lung expand
Bradypnea
rate of breathing is regular but abnormally slow ( less than 12 b/min)
-shallow
tachypnea
rate of breathing is regular but abnormally rapid (greater than 20 b/min)
Apnea
respirations cease for several seconds
Cheyne-Stokes respiration
RR and depth are irregular
orthopnea
breathing that changes with position
dyspnea
difficulty breathing
diffusion
the movement of oxygen and CO2 between the alveoli and the RBCs
perfusion
the distribution of RBCs to and from the pulmonary capillaries
Factors affecting pulse ox reading
too loose/too tight
polish
temporal of extremity
movement
lighting
skin pigmentation
edema
peripheral vascular disease
you postop pt is breathing rapidly. what is the first thing you should do?
asses the o2 saturation
you measure the 02 saturation and it shows 77%. what is the FIRST thing you should do?
check the respirations
Blood Pressure
forced exerted against the blood vessels by the blood
measured in mmHg
systolic pressure
diastolic pressure
pulse pressure
obtaining a BP reading what equipment do you need?
cuff, sphygmomanometer, stethoscope
phase 1 of korotkoff sounds is
a sharp thump
phase 2 of korotkoff sound is
a blowing or whooshing sound
phase 3 of korotkoff sound is
a crisp intense tapping
phase 4 of korotkoff sound is
a softer blowing sound that fades
phase 5 of korotkoff sound is
silence
steps of obtaining a Blood pressure
- determine proper cuff size and site
- position arm at heart level, palm up
- wrap cuff around upper arm
- place stethoscope in ears and close valve
- inflate cuff to 30mmhg above basline
- slowly release pressure bulb
- note first clear sound
- note when sound dissappears
- record reading
ideal environment for getting a BP
quiet room, comfortable temp, sitting in preferred position, record in both arms initially, same are every reading if possible, avoid sites with IV, rest at least 5 mins before assessing, ask pt not to speak
factors that influence BP
age
stress
ethnicity
gender
daily variation
medications
activity weight
smoking
what happens to the BP after smoking?
smoking results in vasoconstriction, a narrowing of the blood vessels. BP raises when a person smokes and returns to baseline about 15 mins after smoking
hypertension
-major factor underlying stroke
- contributing factor to heart attacks
- frequently asymptomatic
hypotension symptoms
symptoms include skin mottling, clamminess, confusion, increased HR, or decreased urine output
symptoms of HYPERtension
more common
thickening of walls
loss of elasticity
family history
risk factors
symptoms of HYPOtension
SBP <90mmHg
dilaition of arteries
loss of blood volume
decrease of blood flow to vital organs
orthostatic/postural
automatic BP machines
used when frequent assessment needed
baseline BP manually first
more susceptible to error
unable to accurately detect low BP
do not talk with patient during reading- can cause increase in BP by 10-40%
alternate BP sites
thigh
- supine position have pt bend knee
-systolic pressure usually high by 10-40mmHg
- diastolic the same
arterial line
- catheter inserted in an artery
- reading monitored electronically
PQRST meaning
P-provoke/palliates
Q-quality
R- region/radiation
S severity/setting
T-timing
when to reassess pain?
every 30mins after pain medication has been given
when to assess for pain?
before procedures, activity, and medicate if available
Febrile
the hypothalamus set points drops, initiating heat loss responses. the skin becomes warm and flushed because of vasodilation
afebrile
when the fever “breaks”
