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IM 1 > Vital signs exam 2 > Flashcards

Vital signs exam 2 Flashcards

1
Q

What makes up vital signs?

A

temp, pulse, BP,RR, and O2 saturation

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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

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3
Q

what is a normal temp range for an adult ?

A

96.8-100.4

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4
Q

what is a normal temp range for oral/tympanic/temporal?

A

97.6-99.6

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5
Q

what is a normal temp range for an adult rectally?

A

98.6-100.4

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6
Q

what is a normal temp range for an adult - Axilla

A

96.6-98.6

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7
Q

what is a normal pulse range for an adult?

A

60-100 BPM

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8
Q

what is a normal RR for an adult?

A

12-20 breaths per minute

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9
Q

what is a normal BP range for an adult

A

120/80 mmHg

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10
Q

Pre-hypertensive: systolic

A

120-139

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11
Q

Pre-hypertensive: Diastolic

A

80-89

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12
Q

hypertensive- systolic

A

> 140

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13
Q

hypertensive-Diastolic

A

> 90

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14
Q

body temperature

A

heat produced or heat loss

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15
Q

acceptable range for temperature?

A

96.8-100.4

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16
Q

examples of temperature sites?

A

oral, rectal, axillary, tympanic artery, esophageal, pulmonary artery, and urinary bladder

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17
Q

What helps control body temp?

A

hypothalamus

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18
Q

hypothalamus

A

located between the hemispheres, controls body temperature.

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19
Q

anterior hypothalamus

A

controls heat loss

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20
Q

posterior hypothalamus

A

controls heat production

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21
Q

what are mechanisms of heat loss

A

sweating, vasodilation, inhibition of heat production

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22
Q

neutral and vascular control?

A

anterior/posterior hypothalamus

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23
Q

heat production?

A

-BMR (basal metabolic rate)
- shivering

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24
Q

Heat loss?

A

radiation
conduction
convection

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25
Q

Radiation?

A

transfer of heat from surface of one object to surface of another without direct contact between the two

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26
Q

conduction?

A

transfer of heat from one object to another with direct contact

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27
Q

convection?

A

transfer of heat away by air movement

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28
Q

evaporation

A

transfer of heat energy when a liquid is changed

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29
Q

diaphoresis

A

visible perspiration, primarily occurring on the forehead and upper thorax

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30
Q

Factors that affect body temp?

A

age
hormonal level
environment
exercise
circadian rhythm-(normally does not change with age)
temperature alterations

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31
Q

exercise- factors affecting body temp

A

increases metabolism and heat production and thus the body temp. prolonged exercise increases body temp

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32
Q

hormone level- factors affecting body temp

A

women generally experience greater fluctuations in body temp than men

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33
Q

Fever (pyrexia)

A

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

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34
Q

hyperthermia

A

inability to promote heat loss or reduce production

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35
Q

heatstroke

A

dangerous heat emergency
high mortality rate
body temp 104+

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36
Q

signs/symptoms of heatstroke

A

confusion, excess thirst, muscle cramps
vitals: increased HR, decreased BP, no diaphoresis

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37
Q

heat exhaustion

A

diaphoresis results in excess water and electrolyte loss
symptoms: deficient fluid volume

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38
Q

hypothermia

A

prolonged exposure to cold decreases bodys ability to produce heat
temp: <86-96.8
classified into 3 sections: mild,moderate, and severe

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39
Q

conversion for C to F

A

C=(F-32)x5/9

can also substitute 5/9 for 1.8

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40
Q

conversion for F to C

A

F=(9/5xC) + 32

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41
Q

oral temperature

A

easily influenced by hot or cold foods
most common way to attain temp

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42
Q

rectal temperature placement for adult ?

A

insert 1 1/2 inch

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43
Q

rectal temperature placement for child?

A

insert 1 inch

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44
Q

rectal temperature placement for Infant?

A

insert 1/2 inch

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45
Q

what could give a rectal reading a inaccurate reading?

A

feces

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46
Q

axillary temperature

A

considered safest, must be left in place for 5-10mins, moisture in axillary area may reduce temp

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47
Q

tympanic temperature

A

most rapid means of measurement
must remember to remove hearing aids before using

48
Q

temporal temperature

A

most accurate compared to core temp
fast read 2-3seconds
ease of use
fewer errors that tympanic

49
Q

types of thermometers

A

tympanic, oral, disposable, temporal

50
Q

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?

A

wait 30 mins and take an oral temp

51
Q

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?

A

blankets off, cold wash cloth, meds to lower temp

52
Q

what do you do for a fever?

A

obtain blood cultures if ordered
monitor VS - assess skin color, temp,tugor, and lab work
maximize heat loss
extra fluids
dry bed linens

53
Q

Pulse

A

palpable or audible bounding of blood flow noted at various points of the body
an indirect measure of circulatory status

54
Q

radial pulse site

A

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
Q

apical pulse

A

fourth to fifth intercostal space at left midclavicular line
if pulse is abnormal
if taking meds that affect HR
if radial inaccessible

56
Q

carotid pulse

A

along medial edge of sternocleidomastoid muscle in neck
if pt condition suddenly worsens
Via doppler if unable to palpate
access bilaterally

57
Q

dorsalis pedis pulse

A

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
Q

what is a baseline rate (pulse)

A

60-100 BPM
- if abnormal, obtain apical

59
Q

Rhythm - pulse

A

regular, irregular, dysrhythmia

60
Q

Tachycardia

A

Elevated HR above 100 beats/min

61
Q

bradycardia

A

Slow rate 60 beats/min

62
Q

dysrhythmia

A

threatens ability of the heart to provide adequate cardiac output
identify by: palpating an interruption in successive pulse waves

63
Q

you notice that a teenage has an irregular radial pulse. what would be the best action for you to take?

A

assess the apical pulse rate for 1 full min

64
Q

you are assessing your pts pedal pulses you are unable to palpate a pulse on the right foot. what should you do?

A

try the other foot, use a doppler

65
Q

gas exchange

A

the process of transporting oxygen into cells
transport of carbon dioxide out of cells

66
Q

ventilation

A

the movement of gases in and out of the lungs

67
Q

Ischemia

A

insufficient O2 to tissues

68
Q

Hypoxia

A

not enough 02 reaching the cells

69
Q

hypoxemia

A

low levels of arterial 02

70
Q

Process of gas exchange- 18 steps

A
  1. Atmosphere (21% oxygen)
  2. medulla
  3. thorax intact, diaphragm contracts
  4. nose
  5. trachea
  6. bronchi
    7.alveoli
  7. Pulmonary capillaries w/ hemoglobin to carry oxygen
  8. perfusion to transport hemoglobin to cells
  9. CELL METABOLISM
  10. perfusion to transport hemoglobin from cells
  11. pulmonary capillaries with hemoglobin carrying C02
  12. alveoli
  13. bronchi
  14. trachea
  15. nose
  16. thorax intact, diaphragm relaxes
  17. atmosphere
71
Q

what impairs gas exchange?

A

-ineffective ventilation
- reduced capacity for gas transportation (reduced hemoglobin or RBCs)
-inadequate perfusion

72
Q

diffusion

A

movement of O2 and Co2 between alveoli and RBCs

73
Q

Perfusion

A

distribution of RBCs to and from the pulmonary capillaries

74
Q

assessment of Respiration - rate

A

how many breaths/min

75
Q

assessment of respiration - rhythm

A

regular/irregular

76
Q

assessment of respiration- depth

A
  • deep, normal, shallow
77
Q

Eupnea

A

ventilation of normal rate and depth
“Eu” normal “pnea” lungs
normal breathing at 12-18b/min

78
Q

factors influencing respiration - exercise

A

breathing more often

79
Q

factors influencing respiration- acute pain

A

shallow breaths

80
Q

factors influencing respiration-anxiety

A

breathing rapidly

81
Q

factors influencing respiration-smoking

A

effects respirations

82
Q

factors influencing respiration-body positions

A

position helps lung expand

83
Q

Bradypnea

A

rate of breathing is regular but abnormally slow ( less than 12 b/min)
-shallow

84
Q

tachypnea

A

rate of breathing is regular but abnormally rapid (greater than 20 b/min)

85
Q

Apnea

A

respirations cease for several seconds

86
Q

Cheyne-Stokes respiration

A

RR and depth are irregular

87
Q

orthopnea

A

breathing that changes with position

88
Q

dyspnea

A

difficulty breathing

89
Q

diffusion

A

the movement of oxygen and CO2 between the alveoli and the RBCs

90
Q

perfusion

A

the distribution of RBCs to and from the pulmonary capillaries

91
Q

Factors affecting pulse ox reading

A

too loose/too tight
polish
temporal of extremity
movement
lighting
skin pigmentation
edema
peripheral vascular disease

92
Q

you postop pt is breathing rapidly. what is the first thing you should do?

A

asses the o2 saturation

93
Q

you measure the 02 saturation and it shows 77%. what is the FIRST thing you should do?

A

check the respirations

94
Q

Blood Pressure

A

forced exerted against the blood vessels by the blood
measured in mmHg
systolic pressure
diastolic pressure
pulse pressure

95
Q

obtaining a BP reading what equipment do you need?

A

cuff, sphygmomanometer, stethoscope

96
Q

phase 1 of korotkoff sounds is

A

a sharp thump

97
Q

phase 2 of korotkoff sound is

A

a blowing or whooshing sound

98
Q

phase 3 of korotkoff sound is

A

a crisp intense tapping

99
Q

phase 4 of korotkoff sound is

A

a softer blowing sound that fades

100
Q

phase 5 of korotkoff sound is

A

silence

101
Q

steps of obtaining a Blood pressure

A
  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
Q

ideal environment for getting a BP

A

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
Q

factors that influence BP

A

age
stress
ethnicity
gender
daily variation
medications
activity weight
smoking

104
Q

what happens to the BP after smoking?

A

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
Q

hypertension

A

-major factor underlying stroke
- contributing factor to heart attacks
- frequently asymptomatic

106
Q

hypotension symptoms

A

symptoms include skin mottling, clamminess, confusion, increased HR, or decreased urine output

107
Q

symptoms of HYPERtension

A

more common
thickening of walls
loss of elasticity
family history
risk factors

108
Q

symptoms of HYPOtension

A

SBP <90mmHg
dilaition of arteries
loss of blood volume
decrease of blood flow to vital organs
orthostatic/postural

109
Q

automatic BP machines

A

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
Q

alternate BP sites

A

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
Q

PQRST meaning

A

P-provoke/palliates
Q-quality
R- region/radiation
S severity/setting
T-timing

112
Q

when to reassess pain?

A

every 30mins after pain medication has been given

113
Q

when to assess for pain?

A

before procedures, activity, and medicate if available

114
Q

Febrile

A

the hypothalamus set points drops, initiating heat loss responses. the skin becomes warm and flushed because of vasodilation

115
Q

afebrile

A

when the fever “breaks”

IM 1 (34 decks)

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