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NUR 170 > Vitals expected ranges > Flashcards

Vitals expected ranges Flashcards

1
Q

Adult BP expected reference range

A

Systolic 90 to 119; Diastolic 60 to to 70 mm Hg

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2
Q

Adult pulse expected reference range

A

60 to 100 bpm

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3
Q

Adult body temp expected reference range

A

35.9° to 38° (96.7° to 100.5° F)

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4
Q

Adult respiration expected reference range

A

12 to 20 breaths/minute

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5
Q

Adult oxygen saturation expected reference range

A

95% to 100%

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6
Q

Sites for measuring BP

A

upper arm and thigh

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7
Q

Manifestations of bradypnea

A

dizziness, fatigue, confusion, impaired coordination

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8
Q

Elevated BP

A

Systolic 120 to 129 and Diastolic less than 80

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9
Q

Stage I hypertension

A

Systolic 130 to 139 OR Diastolic 80 to 89

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10
Q

Stage II hypertension

A

Systolic 140 or higher OR Diastolic 90 or higher

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11
Q

Hypertensive crisis

A

Systolic higher than 180 AND/OR Diastolic higher than 120

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12
Q

When is orthostatic hypertension indicated?

A

-decrease in systolic BP of greater than or equal to 20 mm Hg
-increase in diastolic BP of greater than or equal to 10 mm Hg
-within 3 minutes of change of position

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13
Q

What to do to check for orthostatic hypotension?

A

-take BP with pt laying supine
-take BP with pt sitting on side of bed
-take BP with pt standing

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14
Q

When is hypotension indicated?

A

Lower than 90/60 mm Hg

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15
Q

What are symptoms of hypotension?

A

dizziness, tachycardia, pallor, increased sweating, blurred vision, nausea and confusion

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16
Q

When is BP not supposed to be used on a limb?

A

-IV line
-arteriovenous shunt or fistula
-side of mastectomy or axillary lymph node removal

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17
Q

What is eupnea?

A

normal, unlabored respiration; one respiration to four heartbeats

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18
Q

What is tachypnea?

A

increased respiratory rate; may occur in response to an increased metabolic rate
breaths greater than 24 a minute

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19
Q

What is bradypnea?

A

decreased respiratory rate; occurs in some pathologic conditions
breaths less than 10 a minute

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20
Q

What is apnea?

A

periods when no breathing occurs

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21
Q

What is dyspnea?

A

difficult or labored breathing

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22
Q

What is orthopnea?

A

changes in breathing when sitting or standing

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23
Q

What is hyperpyrexia?

A

Fever equal to or greater than 41° C (106)

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24
Q

When should you not use oral temp on a pt?

A

oral cavity disease
nose or mouth surgery
risk of seizures
receiving O2 via mask

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25
Q

When should you not use tympanic temp on a pt?

A

drainage from the ear
ear pain
ear infection
scars on tympanic membrane

26
Q

Where should a temporal temperature not be taken?

A

on side of head that pt has been lying on or over scar tissue, open lesions or abrasions

27
Q

When should rectal temp not be used?

A

on children with diarrhea
pts who have undergone rectal surgery
pts who have diseases of the rectum
cardiac or cardiac surgery pts

28
Q

How do you document temp?

A

record temp in EHR
identify site used if other than oral
report abnormal findings to the primary care provider

29
Q

How do you document pulse?

A

Record pulse rate
Amplitude and quality (bounding, full, expected, diminished, absent)
rhythm (regular or irregular)
Identify site of assessment (apical, radial, femoral, carotid)
Report abnormal findings to primary care provider

30
Q

How do you document respirations?

A

Respiratory rate
depth
rhythm
report any abnormal findings to the primary care provider

31
Q

How do you document BP?

A

record findings on EHR or flow sheet
place readings under time of acquiring BP not time of entering the values
report any abnormal findings to the primary care provider
Identify arm used and site of assessment for BP (if other than brachial used)

32
Q

How do you document pulse ox?

A

Date and time of reading
SPO2 value
amount of oxygen and delivery method (if pt is on O2)
Lung assessment (if relevant)
any relevant interventions required as a result of the reading

33
Q

What does afebrile mean?

A

normal body temperature

34
Q

What chemicals are released in the body when additional heat is required?

A

epinephrine and norepinpehrine

35
Q

What is an example of radiation?

A

The body gives off waves of heat from uncovered surfaces

36
Q

What is an example of convection?

A

An oscillating fan blows currents of cool air across the surface of a warm body

37
Q

What is an example of evaporation?

A

Body fluid in the form of perspiration and insensible loss is vaporized from the skin

38
Q

What is an example of conduction?

A

The body transfers heat to an ice pack, causing the ice to melt

39
Q

What are pyrogens?

A

substances that cause fever

40
Q

What is tachycardia?

A

HR of 100-180 bpm

41
Q

What are some tachycardia causes?

A

elevated temp
condition causing poor oxygenation of the blood
exercise
pain
strong emotions
some medications

42
Q

What is bradycardia?

A

HR below 60 bpm

43
Q

What are some bradycardia causes?

A

sleep
hypothermia
aging
medications
vagal stimulation (body movement)

44
Q

How do you document bradycardia?

A

report any difficulty breathing, changes in LOC, decreased BP, EKG changes, chest pain

45
Q

What parts of the brain control respiratory rate and depth?

A

medulla and pons

46
Q

What activates respiratory rate and depth?

A

impulses from chemoreceptors

47
Q

What is the most powerful respiratory stimulant?

A

CO2

48
Q

What is primary hypertension?

A

characterized by increase above normal in both systolic and diastolic pressures
no known cause

49
Q

What is secondary hypertension?

A

caused by another disease condition
common causes include kidney disease, adrenal cortex disorders, and aorta disorders

50
Q

What is a neurogenic fever?

A

fever of unknown origin (38.9° C or 101° F)
lasting longer than 3 weeks
does not respond to antipyretics
result of damage to hypothalamus
increased intracranial pressure

51
Q

When is an axillary temperature used?

A

when both oral and rectal sites are contraindicated or inaccessible

52
Q

What can cause tachypnea?

A

exercise
age
increased metabolic rate
any condition causing increased CO2 and decrease in O2
increased altitude
anemia
anxiety

53
Q

What can cause bradypnea?

A

increased intracranial pressure
Medications (opioids like morphine and hydromorphone)

54
Q

Expected range for school age BP

A

94 to 106/ 55 to 62 mm Hg

55
Q

Toddler heart rate expected range

A

80 to 130 bpm

56
Q

Expected reference range for toddler respiratory rate

A

25 to 30 breaths/min

57
Q

School age expected reference range for heart rate

A

74 to 110 bpm

58
Q

Adolescent expected reference range for heart rate

A

70 to 100 bpm

59
Q

School age child expected reference range for respiratory rate

A

18 to 30 breaths/min

60
Q

Preschooler respiratory reference range

A

22 to 34 breaths/min

61
Q

Preschooler expected reference range for heart rate

A

75 to 129 bpm

62
Q

Infant expected reference range for heart rate

A

80 to 140 bpm

NUR 170 (6 decks)

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