Vital Signs & Pain 121/ 110 Flashcards
1
Q
Older pt Temperature
A
Can be lower but make sure it’s consistent
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
3
Q
Temperature sites
A
Oral Rectal- most accurate, core temp Axillary Tympanic membrane Temporal artery Esophageal Pulmonary artery
4
Q
Bodies temperature
A
Neural and vascular control (hypothalamus)
5
Q
Heat Loss - RADIATION
A
Transfer heat from surface to surface without direct contact
6
Q
Heat Loss- CONDUCTION
A
Transfer heat from one object to another with direct contact
7
Q
Heat Loss- CONVECTION
A
Transfer heat by air movement
8
Q
Heat Loss- EVAPORATION
A
Sweating
9
Q
Factors affect body temperature
A
Exercise Pain Female Hormones Circadian rhythm Environment
10
Q
Circadian rhythm
A
Lowest temp between 1am-4am
Max temp 4pm
Takes 3 weeks to adjust if you have to change
11
Q
Inadequate oxygen in body causes radial pulse
A
To Beat faster (tachycardia)
12
Q
What would u assess for with irregular pulse rhythm
A
pulse deficit
Alteration in cardiac output
13
Q
Color of Rectal thermometer
A
RED
14
Q
Tympanic temperature
A
Gently tug the pinna backwards, up, and out before inserting probe into ear
15
Q
First action for irregular, weak peripheral pulse
A
Assess Apical pulse
For a full minute
16
Q
Cause tachycardia
A
High temp
Low oxygen
Loosing a lot of blood
17
Q
Vagal stimulation/ heart rate
A
Lowers heart rate
Bowel movement
Bearing down
18
Q
What is an irregular heartbeat pattern called
A
Dysthymia
Arrhythmia
19
Q
Best action if a pulse is 120 beats per minute
A
Ask about pain
20
Q
Pt with dizziness and fatigue w/ low pulse of 44
A
Assess apical pulse and evidence of pulse deficit
21
Q
Respirations
A
12-20
Regular/ irregular
Depth
22
Q
Effects respiration rate
A
Exercise Disease Smoking Fever Weight Medication
23
Q
Orthopnea
A
Difficulty breathing while Laying flat
24
Q
Apnea
A
Stop or delay in breathing for several seconds
Can cause respiration arrest
25
Dyspnea
Difficulty in breathing
26
Eupnea
Normal respiration
27
African Americans are high risk for
Hypertension
28
Morphine/ Respirations
Lower respiration
29
Bradypnea
Breathing lower than 12 breaths per minute
30
What do u do if pt
SOB due to anxiety
Respiration rate 22
Pulse ox 89%
Encourage deep breathing
31
Pulse oximetry
92-100%
SPO2
Measures arterial saturation
How much hemoglobin is bound to artery
32
When will the pulse ox alarm sound
Reading of 84%
33
What do u do first
| Post-op pt breathing rapidly
Oxygen saturation
34
Affects blood pressure
Food, activity, weight, medication, cuff size, stress, anxiety, smoking, ethnicity, age
35
Diastolic pressure
Lower number
36
Systolic
Larger number
37
What do u do
| Pt is dehydrated and wants to get out of bed for the first time
Have them dangle at the bedside before they stand up
38
Too wide blood pressure cuff
False low
39
Too narrow blood pressure cuff
False high
40
Temperature diagnosis
Risk for imbalanced body temp
Hyperthermia
Hypothermia
Ineffective thermoregulation
41
Cardiac output
Volume of blood pumped by the heart in 1 minute
42
Diaphragm of a stethoscope used for what type of sounds of the heart
High pitched
43
Bell of the stethoscope is used to hear what heart sounds
Low pitched
44
Pulse deficit
The difference between the radial and apical pulse rates
45
S1 heart sound
Low pitched dull LUB
| First heart sound
46
S2 heart sound
Higher pitched, shorter DUB
47
Pulse diagnosis
Activity intolerance, anxiety, fear, decrease cardio output, deficient/excess fluid volume, impaired gas exchange, hyperthermia, hypothermia, acute pain, ineffective peripheral tissue perfusion
48
Respiration - ventilation
Movement of gases into and out of the lungs
49
Respirations- diffusion
Movement of oxygen and carbon dioxide between alveoli and RBC
50
Respiration- perfusion
Distribution of RBC to and from the pulmonary capillaries
51
Hypoxemia
Low blood levels of oxygen
52
Respiration-exercise, anxiety, or cocaine
IncrEase rate and depth
53
Respiration- pain
Alters rate and rhythm
54
Respiration- smoking
Increased rate when NOT smoking
55
Respiration- neurological injury
Inhibits rate and rhythm
56
Respiration- hemoglobin function
Increase rate
57
Tachypnea
Abnormally rapid Respirations above 20
58
Hyperpnea
Respiration are labored, increase depth and rate
| Usually after exercise
59
Hyperventilation
Rate and depth increase
| Loose a lot of carbon dioxide
60
Hypoventilation
RR rate is abnormally low and depth is depressed
| Caused by having too much carbon dioxide(hypercardia)
61
Cheyenne - strokes respiration
| Death rattle
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
Kussmaul's respiration
Abnormally deep, regular rhythm, increase rate
63
Boits respiration
Shallow for 2-3 breaths followed by an irregular period or apnea
64
Placement of SPO2
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
What alters digital SPO2 digital probes
Cold hands or toes
66
Respiration diagnosis
```
Activity intolerance
Ineffective airway clearance
Anxiety
Ineffective breathing pattern
Impaired gas exchange
Acute pain
Ineffective peripheral tissue perfusion
Dysfunctional ventilators weaning response
```
67
What do u do
| Post-op pt breathing rapidly
Immediately asses the oxygen saturation rate
68
Pulse pressure
The difference between systolic and diastolic pressures
| Example: BP 120/80 pulse pressure is 40. 120-80
69
Hemorrhage or dehydration does what to blood pressure
Drops
70
Factors influencing BP
Age, stress, ethnicity, gender, daily variation, medications, activities, weight, smoking
71
BP factors of age and gender
- 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
Hypertension greater than 140/ 90
Asymptomatic
73
Hypotension symptoms
Skin mottling, clamminess, confusion, increased HR, decreased urine output
74
Besides arm where can u take BP
Thigh
75
When not to electric BP
Irregular HR
Peripheral vascular obstruction (clots narrowed vessels)
Shivering
Seizures
Excessive tremors
Inability to cooperate
Blood pressure systolic reading less than 90
76
What else to asses if pt w/diabetes has pneumonia and T- 100.8
HR
Presence of diaphoresis
RR
Pt normal temp Hx
77
High temp will have what kind of HR
High
78
Pt returned from Cardiac Cath placement into the Rt femoral artery.. What position is best for this pt
Supine w/HOB no higher than 30 degrees
| These pt need to be on bedrest and nearly flat for 6 Hrs.
79
Some cultures view pain as
Punishment for past wrongs
80
Joint Commission standards for Pain
```
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
Acute Pain
Less than 6 months
82
Chronic pain
Last more than 6 months
83
Nociceptive pain
Pain in tissues, organs, bones
84
Neuropathic pain
Nerve pain
85
Referred pain
Originates in injured or diseased organ
Has no pain receptors
Example: gallbladder pain
86
Phantom Pain
Felt in amputated extremity after stump has HEALED
87
Pain Threshold
Point at which stimulus is perceived as pain
| Doesn't vary much among people or w/in same person over time
88
Pain Tolerance
Duration or intensity of pain
To can endure before outwardly responding
Can vary based on factors
89
Quality of pain ask
What word best describes the pain u are experiencing
90
How does electric heating pad relieve pain
It's dry heat
| By promoting muscle relaxation
91
Excessive exposure to cold packs can...
Damage skin by reflex vasodilation occurs following the initial vasoconstricting effects
92
TENS
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
Biofeedback
A treatment technique where people are trained to improve their health by using signals from their own body
94
Ventrogluteal
Best injection site for pain medication
| Place palm of hand on the greater trochanter to locate
95
What do do when you have Muscle tension
Tense the muscle fully, then relax it completely
96
Signs of heat exhaustion
Tachycardia
| Profuse diaphoresis
97
Vascular sounds w/ abdominal assessment
Aorta
Rt & Lt Renal
Rt & Lt iliac
Rt & Lt Femoral Pubic
98
Order of vitals for adult
```
Blood pressure 120/80
Temperature 96.8- 100.4
Radial pulse 60-100
Respirations 12-20
SPO2 % 92-100
```
