Vital Signs/Random info Flashcards
What is the normal temperature range ?
96.8 F to 100.4 F (36 C to 38 C)
What is the normal pulse rate ?
60-100 bpm
What are normal respiration rates ?
12 to 20 breaths/minute
What is the normal BP range ?
Systolic <120 mm Hg
Diastolic <80 mm Hg
What is normal pulse pressure ?
30 - 50 mm Hg
What is the normal pulse oximetry ?
greater than or the same as 95%
What is the normal capnography ?
35-45 mm Hg
What do you do if vitals are in the lowest parameters ?
Let the provider know immediately
What is the range for Stage 1 hypertension ?
Systolic 130-139 mm Hg
Diasolic 80-89 mm Hg
What is the range for Stage 2 hypertension ?
Systolic: greater than or same as 140 mm Hg
Diastolic: Greater than or same as 90 mm Hg
What can lower Bp ?
-Dehydration (less salt in the boyd or diuretics )
-Opiod analgesics (pain meds)
What can increase BP ?
-Sodium
-Smoking
-Alcohol
-Caffeine
-Vasoconstrictors
-Excessive volume of IV fluids
Lower extermity sites for auscultation ?
-Behind the knee in the popliteal space mid thigh
-Prone prone position
-Systolic pressure is usually 10 to 40 mm Hg giher than the brachial artery
Apical pulse site
4th ot 5th intercoastal space at left midclavicualr line
*Site used to auscultate for apical pulse
Brachial pulse site
Groove between biceps and triceps muscles at antecubital fossa
*Site used to assess status of circulation to lower arm and to auscultate blood pressure
Radial pulse site
Radial or thumb side of forearm at wrist
*Common site used to assess character of pulse peripherally and status of circulation to hand
If radial pulse seem irregualr what should you do ?
Perform apical reading to ger a legit count
Temporal pulse site
Ove temporal bond of head, above and lateral to eye
* Easily accessible site used to assess pulse in childre
Cartoid pulse site
Along medial edge of sternoclediomastoid muscle in neck
* Easily accessible site used during physioloical shock, cardiac arrest, or when other sites are not palpable
Ulnar pulse site
Ulnar or little finger side of forearm at wrist
* Site used to assess status of circulation to hand; also used to perfon an Allen’s test
Femoral pulse site
Below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine
* Site used to assess character of pulse during physiological shock or cardia arrest when other pulses are not palpable; used to assess status of circulation to leg
Posterior tibial pulse site
Inner side of ankle, below medial mallelus
* Site used to assess status of circulation to foot
Dorsalis pedis pulse site
Along top of foot, between extension tendons of great and first toe
*Site used to assess status of circulation to foot
Factors affecting pulse oximeter readings: Erroneous readings causes
-Cold room
-Too bright
-Peripheral vascular disease
*Hot room and dark room won’t effect reading
Factors influencing temperature: Oral
-Pt ingested cold/hot fluids or food
-Smoking
-Receiving O2 by mask/cannula
-Wait 20-30 mins before taking temp
What are the sites to obtain temp reading ?
-Oral
-Skin
-Axillary
Rectal (most accurate for core temp)
-Tympanic
-Esophageal
-Pulmonary
-Bladder
Fomula to convert Fahrenheit to Celsius
C= (F - 32) x 5/9
Example: 40 C = (104 F - 32) x 5/9
Formula to convert Celsius to Fahrenheit
((C x 9) /5) + 32 = F
What are factors increasing respiratory rate ?
-Fever
-Anxiety
-Exercise
-Smoking
-Amphetamines + cocaine
-Anemia
-Increased altitudes
-Abnormal blood cell function
What are factors decreasing respiratory rate ?
-Pain
-Opioid analgesics, anesthetics + sedative-hypnotics
-Bronchodilators
-Injury to brainstem
Describe Heatstroke
-Body temp is 104 F or greater
-Increasing HR (tachycardia)
-Lowering BP (hypotension
Heatstroke symptoms
-Hot, dry skin
-Delirium, convulsions, or coma (CNS abnormalities)
-Giddiness
-Excessive thirst
-Nausea
-Cramps
-Incontinence
-No sweat due to severe electrolyte loss + hypothalamic malfunction
Exertional heatstroke
occurs in athletes, soliders, or laborers performing physcial activities
Nonexertional heatstroke
occurs during low level physcially activities in the elderly with comorbidities (DM or cardiovascular disease)
Describe heat exhaustion
-Treatment : fluids and electrolytes
-Caused by environmental heat exposure and excess sweating
-Results in excess water + electrolyte loss
Distinguish a professional nurse role/care in comparison to an ancillary/unlicensed staff
What the nurse would be able to delegate (critical thinking, assessment, evaluation would be the nursing role. Bed, bath, etc would be delegated to ancillary staff
Medical orders
Are part of the plan, but if the pt changes, the assessment changes, so the plan has to change
When gathering data
-Make tentative dx in the planning phase
-Don’t forget to find out what pain relief methods working in the pst as part of the planning
Pain
If you don’t have the option of adminstering med yet, nonpharm Interventions( repositioning,etc) explore those options first before doing anything else
Would you ever be making assumtpions ?
No
-Relating to delegation to an unlicensed person
-Don’t assume any delegated task was performed. Always follow up
Cultural differences and interpersonal interactions
-try to avoid
-when in doubt clarify
Options before therapy
-Know when to administer analgesics
-If analgesics is available before the perocedure, do it
If pt has met outcomes for a problem
-GET A # to go with that intuition
-# per minute
If you have pain meds ordered and the pt’s vital signs are the only parameter and the vitals are elevated
-Give the medication
-Potentially indicators or pain
In general, for an older adult pt if give a list of vital signs to choose
-their bp would be lower
If a pt says they feel dizzy, if they’re standing
-Make them sit ot lay down
-safety first
If someone says thier pain is very high but they’re chatting
Chronic pain doesn’t show the same as acute pain, they still have pain
If the pt has a wound dressing and it becomes saturated (blood, fluid) and drippping
You would change the dressing and replace with a new one
What is physiologically happening during the diastole ?
-Heart is relaxed (resting phase of the heart )
-Ventricles relax and the atria contrct to mvoe blood into the ventricles and fill their coronary arteries
What is physiologically happening during the systole ?
-Ventricles contract and eject blood from the left ventricles into the aorta and from the right ventricle into the pulmonary artery
Most important thing to do to prevent infection
Wash your hands
Restless
means issues with oxygentation in test questions
Diaphorectic means
sweating
