Vital Signs Power Point Flashcards
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.
effectiveness
Vital Signs
Temperature Pulse Respiration Blood Pressure Pain Assessment Pulse Oximetry
______ reflects the balance between heat the body produces and loses
temperature
_____ is the measurement of heart rate and rhythm. ____ corresponds to the bounding of blood flowing through various points in the circulatory system.
pulse
______ 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.
respiration
_______ reflects the force the blood exerts against the walls of the arteries during contraction (systole) and relaxation (diastole) of the heart.
blood pressure (BP)
______ 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.
Systolic BP (SBP)
_______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.
Diastolic BP (DBP)
Vital Sgns - Key Steps
- Obtaining Vital Signs- accuracy
- Interpretation of data- evaluate results and consider environmental factors
- Recording Data- in chart, documentation (or it did not happen)
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.
provider
more frequently
Despite extremes in environmental conditions and physical activity, temperature control mechanisms of humans keep body core temperature (temperature of the deep tissues) relatively _____
constant
Core temperature
98.6F or 37C
Acceptable Temperature range
98.6 - 100.4 F
36 - 38 C
_____ 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.
Age
30%
______ stimulates muscle activity and requires an increased blood supply and increased carbohydrate and fat breakdown. _____ will increase heat production and body temperature.
Exercise
Exercise
____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.
Women
______ 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.
Circadian rhythm
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.
environment
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.]
excessive heat production
______ occurs with exposure to cold. The core body temperature drops, and the body is unable to compensate.
Hypothermia
_____ hypothermia ranges from 93.2 -96.8.
mild
_____ hypothermia ranges from 86-93.2.
moderate
____ hypothermia ranges less than 86.
severe
Hypothermia causes a decrease in metabolism, mental functioning, pulse, respiration, BP and can cause _____ if untreated.
cardiac arrest
Treatment for hypothermia includes _____.
gradual warming
Hypothermia can be used in a ______ way.
therapeutic
_____ 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).
frostbite
becomes cyanotic
_____ thermometers are—not used in hospitals 2° mercury hazards
glass
____ thermometers are rapid, must have correct technique to be accuracy, not affected by eating/smoking, less sensitive in detecting fevers in small children
tympanic
____ thermometers are safe, non invasive, and offer easy access.
temporal
Quick, accurate assessment for emergencies use _____ because body preserves brain flow, peripheral pulses weaken, hard to find.
carotid
_____ pulse for accuracy-on certain medications like digoxin, use stethoscope
Apical
When auscultating an apical pulse, assess rate and ___ only.
rhythm
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.
factors
_______ 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.
Inefficient contraction
Factors that affect pulse
Exercise Fever or excess temperature Acute pain and anxiety Unrelieved chronic pain Medications Age Metabolism Hemorrhage Postural changes Pregnancy
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.
passive
____ 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
Hypoxemia
Hypoxemia
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 ____.
passive
Assessment of Ventilation includes?
rate, depth, rhythm
Review rhythm ventilation slide
?
______ is the rate and depth of respirations increase. Hypocarbia sometimes occurs.
hyperventillation
_______is the respiratory rate is abnormally low, and depth of ventilation is depressed. Hypercarbia sometimes occurs.
hypoventilation
________ 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.
Cheyne-Stokes respiration
______ are the respirations are abnormally deep, regular, and increased in rate.
Kussmaul’s respiration
______ are respirations are abnormally shallow for two to three breaths followed by an irregular period of apnea.
Biot’s respiration
Exercise increases rate and _____ to meet the body’s need for additional oxygen and to rid the body of CO2.
depth
______ 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.
Pain
_____ increases respiration rate and depth as a result of sympathetic stimulation.
Anxiety
______ changes pulmonary airways, resulting in increased rate of respirations at rest when not smoking.
A straight, erect posture promotes full chest expansion.
Chronic smoking
A stooped or _____ position impairs ventilatory movement.
slumped
•Lying flat prevents ____ chest expansion.
full
•Opioid analgesics, general anesthetics, and sedative-hypnotics _____ rate and depth.
depress
•Amphetamines and cocaine sometimes ____ rate and depth.
increase
•_______ slow rate by causing airway dilation.
Bronchodilators
•Injury to brainstem impairs respiratory center and _____ respiratory rate and rhythm.
inhibits
•Decreased ______ levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate.
hemoglobin
•Increased _____ lowers amount of saturated hemoglobin, which increases respiratory rate and depth.
altitude
Abnormal blood cell function (e.g., sickle cell disease) reduces ability of hemoglobin to carry oxygen, which _____ respiratory rate and depth.
increases
Evaluate the respiratory processes of diffusion and perfusion by measuring the _____ of the blood.
oxygen saturation
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.
Red blood cells
Factors that interfere with or increase tissue oxygen demand affect the usual value for SvO2, which is ____
70%.
_____ 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.
Earlobe
Factors affecting oxygenation
*Physiological
Physiological Anemia Hypovolemia Increased BMR Chest wall conditions
Factors affecting oxygenation
*Developmental
Infants, toddlers, older adults
Factors affecting oxygenation
*Lifestyle
Smoking
Exercise
Factors affecting oxygenation
*Environmental
pollutants
dust
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!
toe
What are you going to do for the hypoxic patient??
Maintain their airway!
Use your resources—RT–!!!
Oxygenate them (MD order)!
Position them!
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.
5000 mL
The thickness or viscosity of blood affects the ease of blood flow through small vessels. _______, or percentage of red blood cells, determines viscosity.
hematocrit
Factors affecting BP
Age Race Gender Stress/Pain Medication Pregnancy Exercise
Potential Errors in BP Assessment
See Table 29-11 on p 462 Improper cuff size Improper application of cuff Deflating too quickly Hearing difficulty Repeating reading too quickly
Patient Measurement of BP
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.
Safety GUidelines for Skills
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.
