Vitals Flashcards
6 Vital Signs
Temperature Pulse Respiratory rate Blood pressure Pain Oxygen saturation
Average oral temp? Range?
- 6
96. 4 - 100
Advantages to oral temp? Disadvantages?
Convenient, accessible
Safety, physical abilities, accuracy
Average axillary temp? Range?
.9-1 degree lower than oral
- 6
- 8-99
Takes 5-10 min manual
Rect temperature average? Range?
1 degree higher than oral
.7 - .9
97.3 - 101
Tympanic temperature average? Range?
Set to either oral or rectal
How to do a tympanic temperature? Child? Adult?
Point towards tympanic membrane
Child: pull down and back
Adult: pull up and back
Variables affecting temperature
Circadian rhythms - lowest 1st thing in the morning
Hormones
Age
Exercise
Stress
Afebrile vas. Febrile
No fever
Fever
Hyperthermia
Above normal temperature reading
Hypothermia
below normal temperature reading
What does pulse measure?
Speed and strength of heart contractions, peripheral artery pressures, rhythm
Normal pulse range
60 -100 bpm
Pulse rating scale (volume)
4 point scale for measuring
0 for pulse means
weak or absent
+1
weak
+2
normal
+3
strong/increased
+4
bounding
6 places to check pulse
carotid, brachial, radial, femoral, popliteal, pedal
8 factors affecting heart rate
age gender activity emotional status pain environmental factors stimulants medications
how to check the apical pulse
most direct 5th intercostal space midclavicular line (mid clavicle) regular: 30sec x2 irregular: 60 seconds
Tachycardia
greater than 100 bpm
Bradycardia
less than 60 bpm
asystole
without heart beat
What would you do first if your patient has a radial pulse of 120 bpm
take an apical pulse
Normal respiration range
12-20 per minute
Eupnea
normal
tachypnea
fast over 20
bradypnea
less than 12
apnea
not breathing
dyspnea
difficulty/irregular breathing
orthopnea
upright have easier time breathing
what is blood presure
force exerted by the flow of blood pumped into the large arteries
factors that determine blood pressure (5)
cardiac output
peripheral vascular resistance
volume of circulating blood
elasticity of blood vessel walls (increase)
Measuring BP - sytole
contraction
Measuring BP - diastole
relaxation
pulse pressure
difference between systole and diastole
BP sites
brachial
thigh
avoid what for bp
av shunts or fistulas
affected arm of post-mastectomy patient
BP at Brachial Site
palpate brachial pulse
auscultation of BP
Normal BP - systolic/diastolic
systolic < 120
diastolic < 80
hypotension (orthostatic)
drop in systolic bp of at least 20 or at least 10 for diastolic BP within three minutes of standing
drop in bp from sitting to standing
Hypertension
high blood pressure
Elevated BP (pre-hypertension)
120 - 129/<80
Hypertension Stage 1
130-139 or 80-89
Hypertension stage 2
greater than or equal to 140
greater than or equal to 90
Common errors in BP measurements
incorrect cuff size unrecognized ausculatory gap incorrect cuff placement above the heart legs dangling
Factors influencing BP
age, sex, race diurnal rhythm weight exercise emotion/stress/pain white coat syndrome medications hypervolemia, hypovolemia
5th vital sigh
pain
asses treat evaluate pain (0-10)
pulse oximetry
measurement of the oxygen saturation of the hemoglobin molecule
normal is greater than 95%
you measure pulse ox on your patient having a routine physical exam, and it is 90%. What do you do first
recheck the reading at another site
have them take a deep breath
thready pulse
feeble, weak
difficult to feel or once felt is obliterated easily with slight pressure
When assessing a clients pulse the nurse is able to palpate for some time before losing it when exerting more pressure. The pulse is beating at 80 bpm, Which of these should the nurse document as the character of the clients pulse?
thready pulse
an athlete wants to increase her intake of complex carbs and asks the nurse about potential sources. Which food is considered a complex carb?
bread
polypharmacy
use of many medications at the same time, can pose many hazards for older adults.
a nurse in a clinic is caring for a female client who is of chidlbearing age. Which vitamins or minerals should the nurse recommend to prevent neural tube defects during pregnancy?
folic acid
