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461-Foundations > Vital Signs Power Point > Flashcards

Vital Signs Power Point Flashcards

1
Q

As indicators of health status, vital sign measurements indicate the _______ of circulatory, respiratory, neural, and endocrine body functions. Because of the importance of these functions, these measurements are referred to as vital signs.

A

effectiveness

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2
Q

Vital Signs

A 
Temperature
Pulse
Respiration
Blood Pressure
Pain Assessment
Pulse Oximetry
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3
Q

______ reflects the balance between heat the body produces and loses

A

temperature

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4
Q

_____ is the measurement of heart rate and rhythm. ____ corresponds to the bounding of blood flowing through various points in the circulatory system.

A

pulse

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5
Q

______ is the body’s mechanism for exchanging oxygen and carbon dioxide between the atmosphere and the cells of the body, which is accomplished through breathing and recorded as the number of breaths per minute.

A

respiration

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6
Q

_______ reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart.

A

blood pressure (BP)

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7
Q

______ occurs during ventricular systole of the heart, when the ventricles force blood into the aorta, and represents the maximal amount of pressure exerted on the arteries.

A

Systolic BP (SBP)

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8
Q

_______occurs during ventricular diastole of the heart, when the ventricles relax and exert minimal pressure against arterial walls, and represents the minimum amount of pressure exerted on the arteries.

A

Diastolic BP (DBP)

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9
Q

Vital Sgns - Key Steps

A
  1. Obtaining Vital Signs- accuracy
  2. Interpretation of data- evaluate results and consider environmental factors
  3. Recording Data- in chart, documentation (or it did not happen)
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10
Q

The _____ writing the orders on this patient will decide the minimum frequency of VS for each patient; this will be in your order set in the EMR. This could be less frequently in a stable patient, or very frequently in a recent post-surgical patient or a patient with a recent change in condition. You can always assess ______ as a nurse if you feel it’s necessary.

A

provider

more frequently

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11
Q

Despite extremes in environmental conditions and physical activity, temperature control mechanisms of humans keep body core temperature (temperature of the deep tissues) relatively _____

A

constant

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12
Q

Core temperature

A

98.6F or 37C

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13
Q

Acceptable Temperature range

A

98.6 - 100.4 F

36 - 38 C

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14
Q

_____ has a great effect on body temperature. Newborns’ temperature control mechanisms are immature. They can lose up to ____ of heat through their heads. Until a child reaches puberty, temperature regulation is unstable. Also, note that it is not unusual for older adults to reach temperatures no higher than 96.8° F.

A

Age

30%

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15
Q

______ stimulates muscle activity and requires an increased blood supply and increased carbohydrate and fat breakdown. _____ will increase heat production and body temperature.

A

Exercise

Exercise

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16
Q

____experience greater fluctuations in body temperature than men. Hormonal variations occur during the menstrual cycle and menopause. Women may experience hot flashes caused by an inability to control vasodilation and vasoconstriction.

A

Women

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17
Q

______ changes the body temperature over the 24-hour period. The lowest body temperature occurs between 0100 and 0400 hours. The body reaches maximum temperature at 1800 hours. The circadian rhythm does not change with age but will change for those who work the night shift. This usually takes up to 3 weeks.

A

Circadian rhythm

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18
Q

The ______ influences body temperature. When entering a warm room, a person’s body heat will rise. If outside without warm clothing, a person’s body temperature may be low owing to radiant and conductive heat loss.

A

environment

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19
Q

Temperature alterations are related to _________, excessive heat loss, minimal heat production, minimal heat loss, or any combination of these. [These are discussed on a subsequent slide.]

A

excessive heat production

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20
Q

______ occurs with exposure to cold. The core body temperature drops, and the body is unable to compensate.

A

Hypothermia

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21
Q

_____ hypothermia ranges from 93.2 -96.8.

A

mild

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22
Q

_____ hypothermia ranges from 86-93.2.

A

moderate

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23
Q

____ hypothermia ranges less than 86.

A

severe

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24
Q

Hypothermia causes a decrease in metabolism, mental functioning, pulse, respiration, BP and can cause _____ if untreated.

A

cardiac arrest

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25
Q

Treatment for hypothermia includes _____.

A

gradual warming

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26
Q

Hypothermia can be used in a ______ way.

A

therapeutic

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27
Q

_____ occurs when the body is exposed to subnormal temperatures. Ice crystals form inside the cell, and permanent circulatory and tissue damage occurs. The patient suffers uncontrolled shivering, loss of memory, depression, poor judgment, ______. )Can demonstrate clinical signs of death).

A

frostbite

becomes cyanotic

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28
Q

_____ thermometers are—not used in hospitals 2° mercury hazards

A

glass

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29
Q

____ thermometers are rapid, must have correct technique to be accuracy, not affected by eating/smoking, less sensitive in detecting fevers in small children

A

tympanic

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30
Q

____ thermometers are safe, non invasive, and offer easy access.

A

temporal

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31
Q

Quick, accurate assessment for emergencies use _____ because body preserves brain flow, peripheral pulses weaken, hard to find.

A

carotid

32
Q

_____ pulse for accuracy-on certain medications like digoxin, use stethoscope

A

Apical

33
Q

When auscultating an apical pulse, assess rate and ___ only.

A

rhythm

34
Q

When assessing the pulse, consider the variety of ____ that influence the pulse rate. A single factor or a combination of these factors often causes significant changes. If you detect an abnormal rate while palpating a peripheral pulse, the next step is to assess the apical rate.

A

factors

35
Q

_______ of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit, you and a colleague assess radial and apical rates simultaneously and then compare rates. The difference between apical and radial pulse rates is the pulse deficit. Pulse deficits are often associated with abnormal rhythms.

A

Inefficient contraction

36
Q

Factors that affect pulse

A 
Exercise
Fever or excess temperature
Acute pain and anxiety
Unrelieved chronic pain
Medications
Age
Metabolism
Hemorrhage
Postural changes
Pregnancy
37
Q

Breathing is a _____ process. The brain stem regulates involuntary control. The body regulates ventilation through CO2 and O2 and hydrogen ion concentrations in arterial blood. If oxygen falls below acceptable parameters, respiratory rate and depth of ventilation will increase.

A

passive

38
Q

____ is a low blood level of oxygen. _____ helps to control ventilation in patients with chronic lung disease. Because low levels of arterial O2 provide the stimulus that allows a patient to breathe, administration of high oxygen levels is fatal for patients with chronic lung disease

A

Hypoxemia

Hypoxemia

39
Q

Although breathing is normally passive, muscular work is involved in moving the lungs and chest wall. Normally, 500 mL of air is inhaled in a breath (this is referred to as tidal volume). Inspiration is an active process. Expiration is ____.

A

passive

40
Q

Assessment of Ventilation includes?

A

rate, depth, rhythm

41
Q

Review rhythm ventilation slide

A

?

42
Q

______ is the rate and depth of respirations increase. Hypocarbia sometimes occurs.

A

hyperventillation

43
Q

_______is the respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs.

A

hypoventilation

44
Q

________ is the respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. The pattern reverses; breathing slows and becomes shallow, climaxing in apnea before respiration resumes.

A

Cheyne-Stokes respiration

45
Q

______ are the respirations are abnormally deep, regular, and increased in rate.

A

Kussmaul’s respiration

46
Q

______ are respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea.

A

Biot’s respiration

47
Q

Exercise increases rate and _____ to meet the body’s need for additional oxygen and to rid the body of CO2.

A

depth

48
Q

______ alters the rate and rhythm of respirations; breathing becomes shallow. Patient inhibits or splints chest wall movement when pain is in area of chest or abdomen.

A

Pain

49
Q

_____ increases respiration rate and depth as a result of sympathetic stimulation.

A

Anxiety

50
Q

______ changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking.
A straight, erect posture promotes full chest expansion.

A

Chronic smoking

51
Q

A stooped or _____ position impairs ventilatory movement.

A

slumped

52
Q

•Lying flat prevents ____ chest expansion.

A

full

53
Q

•Opioid analgesics, general anesthetics, and sedative-hypnotics _____ rate and depth.

A

depress

54
Q

•Amphetamines and cocaine sometimes ____ rate and depth.

A

increase

55
Q

•_______ slow rate by causing airway dilation.

A

Bronchodilators

56
Q

•Injury to brainstem impairs respiratory center and _____ respiratory rate and rhythm.

A

inhibits

57
Q

•Decreased ______ levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate.

A

hemoglobin

58
Q

•Increased _____ lowers amount of saturated hemoglobin, which increases respiratory rate and depth.

A

altitude

59
Q

Abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemoglobin to carry oxygen, which _____ respiratory rate and depth.

A

increases

60
Q

Evaluate the respiratory processes of diffusion and perfusion by measuring the _____ of the blood.

A

oxygen saturation

61
Q

Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. After oxygen diffuses from the alveoli into the pulmonary blood, most of the oxygen attaches to hemoglobin molecules in red blood cells. ______carry the oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues.

A

Red blood cells

62
Q

Factors that interfere with or increase tissue oxygen demand affect the usual value for SvO2, which is ____

A

70%.

63
Q

_____ probes have greater accuracy at lower saturations and are least affected by peripheral vasoconstriction. You can apply disposable sensor pads to a variety of sites, even the bridge of an adult’s nose or the sole of an infant’s foot. Awareness of these factors allows accurate interpretation of abnormal SpO2 measurements.

A

Earlobe

64
Q

Factors affecting oxygenation

*Physiological

A 
Physiological
Anemia
Hypovolemia
Increased BMR
Chest wall conditions
65
Q

Factors affecting oxygenation

*Developmental

A

Infants, toddlers, older adults

66
Q

Factors affecting oxygenation

*Lifestyle

A

Smoking

Exercise

67
Q

Factors affecting oxygenation

*Environmental

A

pollutants

dust

68
Q

This is typically on the finger, but can be attached to any peripheral site. The ear lobe, finger tip, toes etc. Keep in mind what you are monitoring—if someone just had surgery on their lower leg, you are most concerned about blood flow to that leg!! So put the pulse ox on a ____ of that leg!

A

toe

69
Q

What are you going to do for the hypoxic patient??

A

Maintain their airway!
Use your resources—RT–!!!
Oxygenate them (MD order)!
Position them!

70
Q

Normal circulating volume is _____ mL. Rapid infusion of volume elevates blood pressure. Decreased volume, which can be caused by hemorrhage or dehydration, causes blood pressure to fall.

A

5000 mL

71
Q

The thickness or viscosity of blood affects the ease of blood flow through small vessels. _______, or percentage of red blood cells, determines viscosity.

A

hematocrit

72
Q

Factors affecting BP

A 
Age
Race
Gender
Stress/Pain
Medication
Pregnancy
Exercise
73
Q

Potential Errors in BP Assessment

A 
See Table 29-11 on p 462
Improper cuff size
Improper application of cuff
Deflating too quickly
Hearing difficulty
Repeating reading too quickly
74
Q

Patient Measurement of BP

A

Benefits
Detection of new problems (prehypertension)
Patients with hypertension can provide to their health care provider info about patterns of BP.
Self-monitoring helps adherence to therapy.

Disadvantages
Improper use risks inaccurate readings.
Unnecessary alarming of patient
Patients may inappropriately adjust medications.

75
Q

Safety GUidelines for Skills

A

Cleaning devices between patients decreases the risk for infection.
Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown.
Analyze trends for vital signs, and report abnormal findings.
Determine the appropriate frequency of measuring vital signs based on the patient’s condition.

461-Foundations (45 decks)

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