Vitals 2 Flashcards
When is a good time to take vital signs
on admission When clients health status changes Before and after surgery Before and after administration of medications Before and after nursing interventions
What are some things that can interfere with oral temperature readings
just eating hot/cold foods/drinks
just smoked
What are considerations with tympanic membrane readings
Excess cerumen can interfere
Must contact with all sides of ear canal
What are considerations with axillary measurements
Less accurate, infants and children only
One degree below normal oral temp
What are considerations with rectal measurements
Accurate
Adult and Child Positioning
Lubricant, insert in rectum 1-1.5 inches
One degree higher then oral
What are the average pulse rates
adults and elderly-- 60-100 newborns-- 80-180 1 year-- 80-140 5-8-- 75-120 10-- 50-90 teens-- 50-90
What are the 9 sites to measure pulse
temporal carotid radial brachial femoral apical popliteal psterior tibial dorsalis pedis
Whatshould the nurse be aware of while assessing the RR
normal breathing patterns
health probs that could influence it
meds that could influence it
the relationship of the clients respirations to the cardiovascular system
What are the factors that increase RR
exercise
stress
increased environmental temp
lower oxygen concentration
What are the factors that decrease RR
decreased environmental temp
meds like narcotics
increased ICP
Normal tidal volume is
500 ml
the depth of respirations are usually described with what words
normal
deep
shallow
What is assessed for respiration assessment
rate depth rhythm quality effectiveness
What are the altered breathing patterns for rate
tachypnea
bradypnea
Apnea
What are the altered breathing patterns for volume and what are their defs
Hyperventilation- rapid deep breaths
Hypoventilation- shallow respirations
What are the altered breathing patterns for rythm and what are their defs
cheyne-stokes breathing- random breathing between very deep to very shallow to periods of apnea
What are the altered breathing patterns for effort and what are thire defs
dyspnea- labored and difficult with an unsatisfied need for air
Orthopnea- ability to breathe only in an upwright position
What are the altered breathing patterns for sounds and what are their defs
stridor- shrill, harsh sounds heard during inspiration with a laryngeal obst
Wheeze- high pitched sounds coming from the lobes during expiration or inspiration
Crackles- can be fine or course, fine sounds like sticky surfaces pulling apart, course sounds like low rumbling
What are the altered breathing patterns for chest movements
Use of excessory muscles like the external intercostals and neck muscles
What are the altered breathing patterns for secretions and coughing and what are their deffs
Hemoptysis- presence of blood in the sputum
Productive cough-
Non-productive cough
What are the average changes in RR over the lifespan
15-25 for ages 5-10
15-20 for teens and older adults
How to assess for orthostatic hypotension
place client in supine for 10mins
record BP
slowly have the client sit up or stand and immediately record BP
repeat in 3 minutes
What is indicative of ortho htypo
20 mmhg drop in systolic
10mmHg drop in diastolic
What are the sites to take the BP
upper arm and thigh
