Vital signs exam 2 Flashcards
1
Q
What makes up vital signs?
A
temp, pulse, BP,RR, and O2 saturation
2
Q
when do you measure vital signs?
A
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
3
Q
what is a normal temp range for an adult ?
A
96.8-100.4
4
Q
what is a normal temp range for oral/tympanic/temporal?
A
97.6-99.6
5
Q
what is a normal temp range for an adult rectally?
A
98.6-100.4
6
Q
what is a normal temp range for an adult - Axilla
A
96.6-98.6
7
Q
what is a normal pulse range for an adult?
A
60-100 BPM
8
Q
what is a normal RR for an adult?
A
12-20 breaths per minute
9
Q
what is a normal BP range for an adult
A
120/80 mmHg
10
Q
Pre-hypertensive: systolic
A
120-139
11
Q
Pre-hypertensive: Diastolic
A
80-89
12
Q
hypertensive- systolic
A
> 140
13
Q
hypertensive-Diastolic
A
> 90
14
Q
body temperature
A
heat produced or heat loss
15
Q
acceptable range for temperature?
A
96.8-100.4
16
Q
examples of temperature sites?
A
oral, rectal, axillary, tympanic artery, esophageal, pulmonary artery, and urinary bladder
17
Q
What helps control body temp?
A
hypothalamus
18
Q
hypothalamus
A
located between the hemispheres, controls body temperature.
19
Q
anterior hypothalamus
A
controls heat loss
20
Q
posterior hypothalamus
A
controls heat production
21
Q
what are mechanisms of heat loss
A
sweating, vasodilation, inhibition of heat production
22
Q
neutral and vascular control?
A
anterior/posterior hypothalamus
23
Q
heat production?
A
-BMR (basal metabolic rate)
- shivering
24
Q
Heat loss?
A
radiation
conduction
convection
25
Radiation?
transfer of heat from surface of one object to surface of another without direct contact between the two
26
conduction?
transfer of heat from one object to another with direct contact
27
convection?
transfer of heat away by air movement
28
evaporation
transfer of heat energy when a liquid is changed
29
diaphoresis
visible perspiration, primarily occurring on the forehead and upper thorax
30
Factors that affect body temp?
age
hormonal level
environment
exercise
circadian rhythm-(normally does not change with age)
temperature alterations
31
exercise- factors affecting body temp
increases metabolism and heat production and thus the body temp. prolonged exercise increases body temp
32
hormone level- factors affecting body temp
women generally experience greater fluctuations in body temp than men
33
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
34
hyperthermia
inability to promote heat loss or reduce production
35
heatstroke
dangerous heat emergency
high mortality rate
body temp 104+
36
signs/symptoms of heatstroke
confusion, excess thirst, muscle cramps
vitals: increased HR, decreased BP, no diaphoresis
37
heat exhaustion
diaphoresis results in excess water and electrolyte loss
symptoms: deficient fluid volume
38
hypothermia
prolonged exposure to cold decreases bodys ability to produce heat
temp: <86-96.8
classified into 3 sections: mild,moderate, and severe
39
conversion for C to F
C=(F-32)x5/9
can also substitute 5/9 for 1.8
40
conversion for F to C
F=(9/5xC) + 32
41
oral temperature
easily influenced by hot or cold foods
most common way to attain temp
42
rectal temperature placement for adult ?
insert 1 1/2 inch
43
rectal temperature placement for child?
insert 1 inch
44
rectal temperature placement for Infant?
insert 1/2 inch
45
what could give a rectal reading a inaccurate reading?
feces
46
axillary temperature
considered safest, must be left in place for 5-10mins, moisture in axillary area may reduce temp
47
tympanic temperature
most rapid means of measurement
*must remember to remove hearing aids before using*
48
temporal temperature
most accurate compared to core temp
fast read 2-3seconds
ease of use
fewer errors that tympanic
49
types of thermometers
tympanic, oral, disposable, temporal
50
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
51
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
52
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
53
Pulse
palpable or audible bounding of blood flow noted at various points of the body
an indirect measure of circulatory status
54
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
55
apical pulse
fourth to fifth intercostal space at left midclavicular line
if pulse is abnormal
if taking meds that affect HR
if radial inaccessible
56
carotid pulse
along medial edge of sternocleidomastoid muscle in neck
if pt condition suddenly worsens
Via doppler if unable to palpate
access bilaterally
57
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
58
what is a baseline rate (pulse)
60-100 BPM
- if abnormal, obtain apical
59
Rhythm - pulse
regular, irregular, dysrhythmia
60
Tachycardia
Elevated HR above 100 beats/min
61
bradycardia
Slow rate 60 beats/min
62
dysrhythmia
threatens ability of the heart to provide adequate cardiac output
identify by: palpating an interruption in successive pulse waves
63
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
64
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
65
gas exchange
the process of transporting oxygen into cells
transport of carbon dioxide out of cells
66
ventilation
the movement of gases in and out of the lungs
67
Ischemia
insufficient O2 to tissues
68
Hypoxia
not enough 02 reaching the cells
69
hypoxemia
low levels of arterial 02
70
Process of gas exchange- 18 steps
1. Atmosphere (21% oxygen)
2. medulla
3. thorax intact, diaphragm contracts
4. nose
5. trachea
6. bronchi
7.alveoli
8. Pulmonary capillaries w/ hemoglobin to carry oxygen
9. perfusion to transport hemoglobin to cells
10. CELL METABOLISM
11. perfusion to transport hemoglobin from cells
12. pulmonary capillaries with hemoglobin carrying C02
13. alveoli
14. bronchi
15. trachea
16. nose
17. thorax intact, diaphragm relaxes
18. atmosphere
71
what impairs gas exchange?
-ineffective ventilation
- reduced capacity for gas transportation (reduced hemoglobin or RBCs)
-inadequate perfusion
72
diffusion
movement of O2 and Co2 between alveoli and RBCs
73
Perfusion
distribution of RBCs to and from the pulmonary capillaries
74
assessment of Respiration - rate
how many breaths/min
75
assessment of respiration - rhythm
regular/irregular
76
assessment of respiration- depth
- deep, normal, shallow
77
Eupnea
ventilation of normal rate and depth
"Eu" normal "pnea" lungs
normal breathing at 12-18b/min
78
factors influencing respiration - exercise
breathing more often
79
factors influencing respiration- acute pain
shallow breaths
80
factors influencing respiration-anxiety
breathing rapidly
81
factors influencing respiration-smoking
effects respirations
82
factors influencing respiration-body positions
position helps lung expand
83
Bradypnea
rate of breathing is regular but abnormally slow ( less than 12 b/min)
-shallow
84
tachypnea
rate of breathing is regular but abnormally rapid (greater than 20 b/min)
85
Apnea
respirations cease for several seconds
86
Cheyne-Stokes respiration
RR and depth are irregular
87
orthopnea
breathing that changes with position
88
dyspnea
difficulty breathing
89
diffusion
the movement of oxygen and CO2 between the alveoli and the RBCs
90
perfusion
the distribution of RBCs to and from the pulmonary capillaries
91
Factors affecting pulse ox reading
too loose/too tight
polish
temporal of extremity
movement
lighting
skin pigmentation
edema
peripheral vascular disease
92
you postop pt is breathing rapidly. what is the first thing you should do?
asses the o2 saturation
93
you measure the 02 saturation and it shows 77%. what is the FIRST thing you should do?
check the respirations
94
Blood Pressure
forced exerted against the blood vessels by the blood
measured in mmHg
systolic pressure
diastolic pressure
pulse pressure
95
obtaining a BP reading what equipment do you need?
cuff, sphygmomanometer, stethoscope
96
phase 1 of korotkoff sounds is
a sharp thump
97
phase 2 of korotkoff sound is
a blowing or whooshing sound
98
phase 3 of korotkoff sound is
a crisp intense tapping
99
phase 4 of korotkoff sound is
a softer blowing sound that fades
100
phase 5 of korotkoff sound is
silence
101
steps of obtaining a Blood pressure
1. determine proper cuff size and site
2. position arm at heart level, palm up
3. wrap cuff around upper arm
4. place stethoscope in ears and close valve
5. inflate cuff to 30mmhg above basline
6. slowly release pressure bulb
7. note first clear sound
8. note when sound dissappears
9. record reading
102
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
103
factors that influence BP
age
stress
ethnicity
gender
daily variation
medications
activity weight
smoking
104
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
105
hypertension
-major factor underlying stroke
- contributing factor to heart attacks
- frequently asymptomatic
106
hypotension symptoms
symptoms include skin mottling, clamminess, confusion, increased HR, or decreased urine output
107
symptoms of HYPERtension
more common
thickening of walls
loss of elasticity
family history
risk factors
108
symptoms of HYPOtension
SBP <90mmHg
dilaition of arteries
loss of blood volume
decrease of blood flow to vital organs
orthostatic/postural
109
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%
110
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
111
PQRST meaning
P-provoke/palliates
Q-quality
R- region/radiation
S severity/setting
T-timing
112
when to reassess pain?
every 30mins after pain medication has been given
113
when to assess for pain?
before procedures, activity, and medicate if available
114
Febrile
the hypothalamus set points drops, initiating heat loss responses. the skin becomes warm and flushed because of vasodilation
115
afebrile
when the fever "breaks"
