Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Nursing Care 1 > Vitals > Flashcards

Vitals Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards NCLEX-RN® flashcards Nursing Fundamentals flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards Nursing Pharmacology flashcards Nursing Maternity flashcards Family Nurse Practitioner (FNP) flashcards
1
Q

Definition of Vital Signs?

A
  • core nursing function
  • key to recognising patient deterioration
  • helps provide information about the r’ship between body systems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the 5 vital signs?

A

1) Temperature (°C)
2) Oxygen Saturation (SaO2)
3) Respiratory Rate (bpm - breaths)
4) Blood Pressure (Bp)
5) Pulse (bpm - beats)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

When do you assess vital signs?

A
  • on admission (a base for improvement/ deteriration)
  • change in health status
  • B/D/A surgery or invasive procedure
  • B/ A surgery or invasive procedure
  • B/ A administration of medication ( that could affect respiratory or circulatory systems)
  • B/ A any nursing intervention (blood infusion/ moving around)
  • after an accident/ injury
  • timeliness (when allocated)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Define temperature?

A

reflects the balance between heat produced & heat lost

measured in degrees Celsius ( °C )

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

2 types of body temperature?

A

Core
- remains @ a constant temp to ensure organs are alive

Shell (surface)
- temp increases & decreases with the environment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Types of ways you can assess temperature

A

you want your temp to be F.E.A.R.O normal

F - forehead 
E - ear 
A - axilla / armpit 
R - rectum 
O - orally
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How does the body regulate temperature?

A 
sensors in the shell & core 
                 \+
integrators in the hypothalamus 
                 =
act as receptors to determine body temp
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the normal temperature range?

A

36-37 °C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

T vocab - pyrexia

A
  • when a person has a fever

- body temp. above normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

T vocab - hyperpyrexia

A
  • very high temperature

- e.g. 41°C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

T vocab - Febrile

A
  • a person who has pyrexia/ fever
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

T vocab - Afebrile

A
  • a person who has a normal temperature
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

T vocab - hyperthermia

A
  • core temperature above 40.6°C
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

T vocab - hypothermia

A
  • core temperature below normal (36°C)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are some nursing interventions for adults with a fever?

A
  • monitor vital signs
  • assess skin colour & temp
  • monitor lab reports (signs for dehydration & infection)
  • feel warm = remove layers
  • feel cold = add layers
  • measure fluid intake & output
  • rest = reduce physical activity
  • give antipyrectic medication
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Define oxygen saturation?

A

Is the measure of how much oxygen your red blood cells are carrying

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

How to assess oxygen saturation?

A

Using a pulse oximeter
- non-invasive device
- that estimates a client’s arterial blood oxygen
saturation (SaO2)
- by a sensor attached to the client’s
- finger,
- toe,
- nose,
- earlobe
- or forehead
- (or around the hand and foot of a newborn)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How does a pulse oximeter work?

A

1) Two, light-emitting diodes (LED’S) – red & infrared –
transmit light

2) A photodetector placed directly opposite the LED.
This measures the amount of red & infrared light
absorbed by oxygenated & deoxygenated
haemoglobin.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What are the different types of Oxygen saturation levels and what to do?

A
  • Normal SaO2 is 95% - 100% room air (RA)
  • If less than 95% = observe & give supplement oxygen
  • If less than 90% = seek assistance/ medical emergency
    if no underlying lung disease
    - (such as Emphysema/ chronic obstructive lung
    disease)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What are potential errors with a pulse oximeter?

A
  • Circulation
  • Activity – if they keep moving around
  • Nail polish/ false nails
  • Minimise motion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Define respiratory rate?

A

Respiration is the act of breathing, so therefore the respiratory rate is amount of breaths per minute

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

RR vocab - inhalation (inspiration)

A

Breathing in or intake of air into the lungs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

RR vocab - exhalation (expiration)

A

Breathing out or the movement of gases from the lungs to the atmosphere

24
Q

RR vocab - ventilation

A

Movement of air in and out of the lungs

25
Q

What sections of the brain control respiration?

A

1) Pons respiratory system
2) Medullary respiratory system

these are in the brain stem

26
Q

How can we assess respIrAtory rate?

A

INSPECTION

  • Rate
    • How many times are they breathing
  • Depth
    • Shallow or deep breaths
  • Rhythm
    • Regular or irregular
  • Quality
    • Measured using a pulse oximetry
  • Effectiveness of respirations

AUSCULTATION
- Listening with a stethoscope

27
Q

What is classified as normal respiration?

A
  • Usually 10-16 breaths per minute
  • Adult normal range = 10-19bpm
  • Respiration should be
  • Regular
  • Quiet (no wheezing)
  • All same size
28
Q

RR vocab - Eupnoea

A

Breathing that is normal in rate and depth

29
Q

RR vocab - Bradypnea

A

Abnormally slow respirations

30
Q

RR vocab - Tachypnoea

A

Abnormally fast respirations, quick, shallow breaths

- E.g. anxiety attack

31
Q

RR vocab - Apnoea

A

The absence of breath

- E.g. sleep apnoea

32
Q

RR vocab - Dyspnoea

A

Difficult or laboured breathing

- noisy/ wheezing a lot

33
Q

What happens to your body when you breathe?

A

Inhalation = Chest expands & diaphragm contracts

Exhalation = Chest contracts & diaphragm relaxes

34
Q

Define Blood Pressure?

A

is a measure of the pressure exerted by the blood as it flows through the arteries

35
Q

What are the 2 types of blood pressure readings?

A

SYSTOLIC

  • measures the pressure in your arteries when your heart beats
  • measures the force of blood being pushed around your body when the heart contracts

DIASTOLIC

  • measures the pressure in your arteries when your heart rests between beats.
  • Is the pressure of the blood when the ventricles are at rest, lower pressure, present at all times within the arteries
36
Q

How is blood pressure measured?

A
  • Millimetres (mm) of mercury (Hg) = (mmHg) and
    recorded as a fraction
  • E.g. (systolic pressure )/(diastolic pressure ) = 120/80
    mmHg
37
Q

What are the 2 ways we can assess BP and the equipment needed for it?

A

INVASIVE

  • Canular needle into the radial artery
  • hooked up to a monitor

NON-INVASIVE

  • Auscultation (audio) - stethoscope
  • Palpation - sphygnomanometer
38
Q

What are the names of abnormal blood pressure?

A

Hypertension & hypotension

39
Q

What is hypertension?

A

Hyper = high

Is generally classified as a blood pressure of greater than 140/90 mmHg

40
Q

What is hypotension?

A

Hypo = low

Is generally classified as a blood pressure of less than 90/60 mmHg

41
Q

When shouldn’t you take a person’s BP?

A
  • when the arm/ shoulder has been injured
  • arm/ shoulder has a disease
  • there’s a cast or bandage on any part of the limb
  • person has surgical removal of lymph nodes on that
    side
  • Person has an intravenous infusion in that limb
  • The person has an arteriovenous fistula
    > E.g. renal dialysis
42
Q

What is the correct procedure when taking BP manually or automatically?

A
  • consent
  • gather equipment
  • prepare environment
  • perform hand hygiene
  • position & prepare patient – rested
    > arm supported
    > elbow extended
    > palm upwards
  • apply the cuff (correct width) over the brachial artery 2.5cms above the bend
43
Q

What is the process for manual BP?

A
  • consent
  • gather equipment
  • prepare environment
  • perform hand hygiene
  • position & prepare patient – rested
    > arm supported
    > elbow extended
    > palm upwards
  • apply the cuff (correct width) over the brachial artery 2.5cms above the bend
  • First, perform a preliminary palpatory systolic estimation,
  • position the stethoscope over the brachial pulse
  • pump up the cuff
  • auscultate (listen to) the patient’s blood pressure
  • remove the cuff
  • ensure the patient is comfortable
  • clean & replace the equipment appropriately
  • perform hand hygiene
  • document & report relevant information
44
Q

Describe each phase of the korotkoff sounds

A

Phase 1 - sharp tapping = systolic BP
Phase 2 - swishing or swooshing sound
Phase 3 - a light tapping compared to phase 1
Phase 4 - soft blowing sound that fades
Phase 5 - the last sound is heard followed by silence this
is the diastolic BP

45
Q

Define what a pulse is?

A
  • a wave of blood created by the contraction of the left ventricle of the heart
  • Pulse waves represents the amount of blood that enters the arteries with each ventricular contraction
  • The pulse reflects the heartbeat
  • Heart rate control
46
Q

How do you express the pulse measurement unit?

A

expressed as beats per minute (bpm)

47
Q

What are the two types of pulse sites?

A

> Peripheral pulse

   - Located away from the heart 
   - E.g. wrist/ foot

> Apical pulse
- Is a central pulse, located at the apex of the heart

48
Q

How do you assess the pulse?

A

PALPITATION (FEELING)
- Think you can feel “palp”

  • Middle two/ three fingertips used for palpitating all pulses except the apex of the heart
  • Apply moderate pressure

AUSCULTATION (AUDIO)
- Auscultation = audio

  • The apex of the heart, auscultate with stethoscope
  • Doppler ultrasound
49
Q

What are normal pulse values?

A
  • 60-80 beats per minute (bpm) at rest

- Adult normal pulse/ heart-rate range 60-100 bpm

50
Q

What should the nurse be aware of before assessing the patient?

A
  • Any medication that could affect the heart rate
  • Whether the person has been physically active
  • Any baseline data about the norm heart rate for the person
    > Could be an athlete with a heart rate of 30 normally
  • If they should assume a particular position
    > E.g. sitting/ lying down
51
Q

Pulse vocab - Tachycardia

A

greater than 100bpm

52
Q

Pulse vocab - Bradycardia

A

Less than 60bpm

53
Q

Pulse vocab - Arrhythmia

A

An irregular pulse

54
Q

What is peripheral vascular resistance?

A

> is the internal diameter/ capacity of the arterioles & capillaries this determines the peripheral resistance
can increase BP (especially diastolic BP)

Increased vasconstriction = raises BP
decreased vasconstriction = lowers BP

55
Q

What is blood volume?

A

Blood volume decrease - BP decreases
> this is due to the decrease fluid in the arteries
> e.g. hemorrhage/ dehydration

Blood volume increases – BP increases
> because the greater fluid volume within the circulatory system
> e.g. rapid intravenous infusion

Nursing Care 1 (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions