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Finals > Vital Signs & Pain 121/ 110 > Flashcards

Vital Signs & Pain 121/ 110 Flashcards

1
Q

Older pt Temperature

A

Can be lower but make sure it’s consistent

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2
Q

When are vitals taken

A

Every 4 hrs. For 24 hrs when admitted

Then every 8 hrs.

Nurses can decide how often if more frequent

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3
Q

Temperature sites

A 
Oral
Rectal- most accurate, core temp
Axillary
Tympanic membrane
Temporal artery
Esophageal
Pulmonary artery
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4
Q

Bodies temperature

A

Neural and vascular control (hypothalamus)

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5
Q

Heat Loss - RADIATION

A

Transfer heat from surface to surface without direct contact

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6
Q

Heat Loss- CONDUCTION

A

Transfer heat from one object to another with direct contact

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7
Q

Heat Loss- CONVECTION

A

Transfer heat by air movement

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8
Q

Heat Loss- EVAPORATION

A

Sweating

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9
Q

Factors affect body temperature

A 
Exercise
Pain
Female Hormones
Circadian rhythm 
Environment
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10
Q

Circadian rhythm

A

Lowest temp between 1am-4am
Max temp 4pm
Takes 3 weeks to adjust if you have to change

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11
Q

Inadequate oxygen in body causes radial pulse

A

To Beat faster (tachycardia)

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12
Q

What would u assess for with irregular pulse rhythm

A

pulse deficit

Alteration in cardiac output

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13
Q

Color of Rectal thermometer

A

RED

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14
Q

Tympanic temperature

A

Gently tug the pinna backwards, up, and out before inserting probe into ear

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15
Q

First action for irregular, weak peripheral pulse

A

Assess Apical pulse

For a full minute

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16
Q

Cause tachycardia

A

High temp
Low oxygen
Loosing a lot of blood

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17
Q

Vagal stimulation/ heart rate

A

Lowers heart rate

Bowel movement
Bearing down

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18
Q

What is an irregular heartbeat pattern called

A

Dysthymia

Arrhythmia

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19
Q

Best action if a pulse is 120 beats per minute

A

Ask about pain

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20
Q

Pt with dizziness and fatigue w/ low pulse of 44

A

Assess apical pulse and evidence of pulse deficit

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21
Q

Respirations

A

12-20
Regular/ irregular
Depth

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22
Q

Effects respiration rate

A 
Exercise
Disease
Smoking
Fever
Weight
Medication
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23
Q

Orthopnea

A

Difficulty breathing while Laying flat

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24
Q

Apnea

A

Stop or delay in breathing for several seconds

Can cause respiration arrest

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25
Q

Dyspnea

A

Difficulty in breathing

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26
Q

Eupnea

A

Normal respiration

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27
Q

African Americans are high risk for

A

Hypertension

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28
Q

Morphine/ Respirations

A

Lower respiration

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29
Q

Bradypnea

A

Breathing lower than 12 breaths per minute

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30
Q

What do u do if pt
SOB due to anxiety
Respiration rate 22
Pulse ox 89%

A

Encourage deep breathing

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31
Q

Pulse oximetry

A

92-100%
SPO2
Measures arterial saturation
How much hemoglobin is bound to artery

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32
Q

When will the pulse ox alarm sound

A

Reading of 84%

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33
Q

What do u do first

Post-op pt breathing rapidly

A

Oxygen saturation

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34
Q

Affects blood pressure

A

Food, activity, weight, medication, cuff size, stress, anxiety, smoking, ethnicity, age

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35
Q

Diastolic pressure

A

Lower number

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36
Q

Systolic

A

Larger number

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37
Q

What do u do

Pt is dehydrated and wants to get out of bed for the first time

A

Have them dangle at the bedside before they stand up

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38
Q

Too wide blood pressure cuff

A

False low

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39
Q

Too narrow blood pressure cuff

A

False high

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40
Q

Temperature diagnosis

A

Risk for imbalanced body temp
Hyperthermia
Hypothermia
Ineffective thermoregulation

41
Q

Cardiac output

A

Volume of blood pumped by the heart in 1 minute

42
Q

Diaphragm of a stethoscope used for what type of sounds of the heart

A

High pitched

43
Q

Bell of the stethoscope is used to hear what heart sounds

A

Low pitched

44
Q

Pulse deficit

A

The difference between the radial and apical pulse rates

45
Q

S1 heart sound

A

Low pitched dull LUB

First heart sound

46
Q

S2 heart sound

A

Higher pitched, shorter DUB

47
Q

Pulse diagnosis

A

Activity intolerance, anxiety, fear, decrease cardio output, deficient/excess fluid volume, impaired gas exchange, hyperthermia, hypothermia, acute pain, ineffective peripheral tissue perfusion

48
Q

Respiration - ventilation

A

Movement of gases into and out of the lungs

49
Q

Respirations- diffusion

A

Movement of oxygen and carbon dioxide between alveoli and RBC

50
Q

Respiration- perfusion

A

Distribution of RBC to and from the pulmonary capillaries

51
Q

Hypoxemia

A

Low blood levels of oxygen

52
Q

Respiration-exercise, anxiety, or cocaine

A

IncrEase rate and depth

53
Q

Respiration- pain

A

Alters rate and rhythm

54
Q

Respiration- smoking

A

Increased rate when NOT smoking

55
Q

Respiration- neurological injury

A

Inhibits rate and rhythm

56
Q

Respiration- hemoglobin function

A

Increase rate

57
Q

Tachypnea

A

Abnormally rapid Respirations above 20

58
Q

Hyperpnea

A

Respiration are labored, increase depth and rate

Usually after exercise

59
Q

Hyperventilation

A

Rate and depth increase

Loose a lot of carbon dioxide

60
Q

Hypoventilation

A

RR rate is abnormally low and depth is depressed

Caused by having too much carbon dioxide(hypercardia)

61
Q

Cheyenne - strokes respiration

Death rattle

A

Rate and depth are irregular
Alternating periods of apnea and hyperventilation.
Begins w/ slow and shallow breaths that gradually increase to abnormal rate and depth the patter reverses breathing slows and become shallow climaxing in apnea before Respirations resume

62
Q

Kussmaul’s respiration

A

Abnormally deep, regular rhythm, increase rate

63
Q

Boits respiration

A

Shallow for 2-3 breaths followed by an irregular period or apnea

64
Q

Placement of SPO2

A

Digital probes-not accurate less than 70 draw labs
Earlobe probe- greater accuracy at lower rates and least affected by peripheral vasoconstriction
Disposable probes- bridge of nose, sole of infant feet

65
Q

What alters digital SPO2 digital probes

A

Cold hands or toes

66
Q

Respiration diagnosis

A 
Activity intolerance
Ineffective airway clearance 
Anxiety 
Ineffective breathing pattern 
Impaired gas exchange
Acute pain
Ineffective peripheral tissue perfusion
Dysfunctional ventilators weaning response
67
Q

What do u do

Post-op pt breathing rapidly

A

Immediately asses the oxygen saturation rate

68
Q

Pulse pressure

A

The difference between systolic and diastolic pressures

Example: BP 120/80 pulse pressure is 40. 120-80

69
Q

Hemorrhage or dehydration does what to blood pressure

A

Drops

70
Q

Factors influencing BP

A

Age, stress, ethnicity, gender, daily variation, medications, activities, weight, smoking

71
Q

BP factors of age and gender

A
  • no difference in boys or girls however after puberty males tend to have higher BP
  • after menopause woman tend to have higher BP then men of the same age.
72
Q

Hypertension greater than 140/ 90

A

Asymptomatic

73
Q

Hypotension symptoms

A

Skin mottling, clamminess, confusion, increased HR, decreased urine output

74
Q

Besides arm where can u take BP

A

Thigh

75
Q

When not to electric BP

A

Irregular HR
Peripheral vascular obstruction (clots narrowed vessels)
Shivering
Seizures
Excessive tremors
Inability to cooperate
Blood pressure systolic reading less than 90

76
Q

What else to asses if pt w/diabetes has pneumonia and T- 100.8

A

HR
Presence of diaphoresis
RR
Pt normal temp Hx

77
Q

High temp will have what kind of HR

A

High

78
Q

Pt returned from Cardiac Cath placement into the Rt femoral artery.. What position is best for this pt

A

Supine w/HOB no higher than 30 degrees

These pt need to be on bedrest and nearly flat for 6 Hrs.

79
Q

Some cultures view pain as

A

Punishment for past wrongs

80
Q

Joint Commission standards for Pain

A 
Initial and regular assessments 
Don't just medicate and ignore
Consider pt culture, spiritual,ethical beliefs
Assess all things in OLDCARTS
Don't ignore pain complaints ever
81
Q

Acute Pain

A

Less than 6 months

82
Q

Chronic pain

A

Last more than 6 months

83
Q

Nociceptive pain

A

Pain in tissues, organs, bones

84
Q

Neuropathic pain

A

Nerve pain

85
Q

Referred pain

A

Originates in injured or diseased organ
Has no pain receptors
Example: gallbladder pain

86
Q

Phantom Pain

A

Felt in amputated extremity after stump has HEALED

87
Q

Pain Threshold

A

Point at which stimulus is perceived as pain

Doesn’t vary much among people or w/in same person over time

88
Q

Pain Tolerance

A

Duration or intensity of pain
To can endure before outwardly responding
Can vary based on factors

89
Q

Quality of pain ask

A

What word best describes the pain u are experiencing

90
Q

How does electric heating pad relieve pain

A

It’s dry heat

By promoting muscle relaxation

91
Q

Excessive exposure to cold packs can…

A

Damage skin by reflex vasodilation occurs following the initial vasoconstricting effects

92
Q

TENS

A

Transcutaneous electrical nerve stimulator
Pain relief provided by delivery of small electrical currents to the skin
ALWAYS use conducting gel or pads and clean skin

93
Q

Biofeedback

A

A treatment technique where people are trained to improve their health by using signals from their own body

94
Q

Ventrogluteal

A

Best injection site for pain medication

Place palm of hand on the greater trochanter to locate

95
Q

What do do when you have Muscle tension

A

Tense the muscle fully, then relax it completely

96
Q

Signs of heat exhaustion

A

Tachycardia

Profuse diaphoresis

97
Q

Vascular sounds w/ abdominal assessment

A

Aorta
Rt & Lt Renal
Rt & Lt iliac
Rt & Lt Femoral Pubic

98
Q

Order of vitals for adult

A 
Blood pressure 120/80
Temperature 96.8- 100.4
Radial pulse 60-100
Respirations 12-20
SPO2 % 92-100

Finals (10 decks)

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