Vitals Flashcards
what is the importance (frequency) of checking vitals?
check pt as per provider orders or a sudden change in the patient
what interventions should the RN do or anticipate doing if vital signs are abnormal?
- assess the patient
- assess the device they are using to take patients vitals to make sure the device is working correctly
what are some clinical findings of orthostatic hypotension?
a change in the patients BP due to the laying, sitting and standing position
what vital signs can be delegated to assistive personnel?
temperature, pulse, BP, respirations, oxygen saturation and pain level
hypothermia vs. hyerthermia
hypo: below the average temp (36.0 C or 96.8 F)
hyper: above the temp of 100.4 F
febrile vs afebrile
febrile: having a fever
afebrile: free from fevers
bradycardia vs. tachycardia
brady: pulse below 60 bpm
tachy: pulse above 100 bpm
bradypnea vs tachypnea
brady: respirations lower than 12
tachy: respirations above 20
hypotension vs hypertension
hypo: BP below 120/80
hyper: BP above 120/80
what scale is used for infants pain?
FLACC
when is the Wong Baker Faces Pain Scale used? (for what ages)
3+
Is pain subjective or objective?
subjective because it’s what the patient says
acute vs chronic pain
acute: <6 months
chronic: >6 months
what is the nursing priority to measure and intervene when dealing w/ pain?
measure the pain and do a continuous pain assessment (what makes it worse/better?)
pharmacological vs non-pharmacological pain interventions?
- pharmacological: review provider orders for mild, moderate and severe pain, educate patient on misconceptions about pain meds (medicate patient as per providers order)
- non-pharmacological: position and re-position patient frequently, educate pt on the use of strategies to reduce pain, distraction, cognitive behavior (no medication is necessary)
when is non-opiod medication used?
for mild to moderate pain (monitor for salicylism and gastric upset)
when is opioid medication used?
for moderate to sever pain (monitor for sedation, respiratory depression and constipation)
what objective patient findings may be associated with pain?
facial expressions, moaning, crying, decreased attention span
what is the max L/min you can give to a patient per mask?
- nasal cannula: 1-6 L/min
- simple mask: 6-12 L/min
- partial rebreather: 6-11 L/min
- non rebreather mask: 10-15 L/min
what should you do if a patient is a chronic user of oxygen airway?
humidify patient (anything above 6 will dry a patient out)
what is cardiac output made up of?
HR, contractility, blood volume, venous return
what are the respiration complications?
- bradypnea
-hypoventilation - apnea
- tachypnea
- hyperventilation
- cheyne: stokes respiration
- kussmaul respirations
who is more likely to experience bradycardia, especially during the night?
athletes (no action needs to be taken)
what pulse can a PCA NOT take on a patient?
apical pulse
