Week 3: Vital Signs Flashcards
Definition: Afebrile
Lacking a fever
Definition: Apnea
A temporary or prolonged cessation (stopping) of breathing
Definition: Auscultation
Listening to the sounds produced by the body/patient, often with a stethoscope however sometimes can be heard with the naked ear
Definition: Bradycardia
When the heart is beating too slowly (less than 60 BPM)
Definition: Bradypnea
When the patient is breathing abnormally/too slowly
Definition: Core Temperature
Internal body temperature deep in the tissues
Definition: Diastolic
The blood pressure in the arteries when the heart rests between beats (lower number, resting HR, always LOWER than systolic value)
Definition: Hypertension
When blood pressure is TOO HIGH
Definition: Hyperthermia
Core body temperature rises above the normal range of 36-38oC in adults
Definition: Hyperventilation
When breathing is too rapid or deep (caused by anxiety/panic) and can lead to too much oxygen in the body
Definition: Hypotension
When blood pressure is TOO LOW
Definition: Hypothermia
Core body temperature falls below normal range of 36-38oC in adults
Definition: Hypoventilation
When breathing is too slow or shallow and can lead to not enough oxygen, too much CO2
Definition: Hypoxemia
When oxygen levels in the blood are abnormally low; oxygen deficiency
Definition: Korotkoff Sounds
Sounds that occur when blood flows through an artery during a blood pressure measurement (5 phases)
Definition: Pulse
The rhythm throbbing of the arteries as blood is propelled through them, typically felt in the wrists or neck
Definition: Pulse Pressure
The difference between the systolic BP and diastolic BP (120-80=40mmHg)
Definition: Pyrexia
Fever; abnormal elevation of body temperature
Definition: Systolic
The blood pressure when the heart is contracting/beating (top number, always higher than diastolic value)
Definition: Tachycardia
Heart is beating too fast (more than 100 BPM)
Definition: Tachypnea
When the patient is breathing abnormally/too quickly
Definition: TPR
Temperature, pulse, respiration
What are the 5 vital signs?
Heart Rate/Apical Pulse (HR)
Respirations (RR)
Temperature (T)
Oxygen Saturation (SpO2)
Blood Pressure (BP)
Are Vital Signs Subjective or Objective information?
Objective
What is Inspection?
- Careful watching and noticing.
- Compare left to right.
- Requires good lighting and adequate exposure.
- Equipment occasionally needed.
What is Palpation?
Using sense of touch to feel for temperature, moisture, organ size, swelling, pulsation, lumps/masses, presence of tenderness/pain
What is Percussion?
Tapping a patient’s skin with quick movements for assessment to elicit a sound
What is Auscultation?
Listening to sounds produced such as wheezing or congested breathing using ears or stethoscope
What are Fingertips used to feel for during Palpation?
Texture, swelling, pulsation, and determining presence of lumps
What are Fingers and Thumbs used to feel for during Palpation?
Identify the position, shape, and consistency of an organ or mass (grasping action)
What is the Dorsa (back of hands) used to feel for during Palpation?
Temperature
What are Base of Fingers used to feel for during Palpation?
Best for vibration
What is LIGHT palpitation?
Superficial, light, one handed, less than 1 cm deep
What is DEEP palpitation?
Deeper than 1 cm, 1 or two hands, use intermittent pressure, locate organs or abdominal contents
What is Direct Percussion?
Hitting the body directly
What is Indirect Percussion?
Using one middle finger to strike a stationary hyperextended middle finger resting on the body to get a vibrating sound (rest of the hand lifted)
What are some rules to follow regarding Auscultation?
- Don’t listen through a gown/clothes
- Keep the room as quiet as possible
- Keep the patient warm
- Clean the stethoscopes to remove any dirt that can act as artifact
- Ensure you aren’t an artifact (ex. bumping on the tubing)
What is a normal Temperature?
36-38oC (P&P)
What is a normal Pulse/HR?
60-100 (P&P)
What is a normal Respiratory Rate (RR)?
12-20 (P&P)
What is a normal Blood Pressure (BP)?
Systolic: >95, <140
Diastolic: 60-90
(Jarvis)
What is a normal Oxygen Saturation level?
95-100%
Which nursing action best evaluates the effectiveness of the antipyretic medication Acetaminophen (Tylenol) in a patient with an oral temperature of 39.3C?
a) Assess for physical aches.
b) Assess skin temperature by touching the forehead.
c) Assess oral temperature 30 minutes after the agent is administered.
d) Assess skin colour for signs of fever-related flushing.
c) Assess oral temperature 30 minutes after the agent is administered.
What is another word for fever?
Hyperthermia
FUO
Pyrexia
Hypothermia
Pyrexia
What type of control is Temperature under?
Neural and Vascular
What is the body’s thermostat?
Hypothalamus
What is Diaphoresis?
- Sweating & heat loss through evaporation.
- Vasodilation of blood vessels
- Inhibition of heat production
What is shivering an example of?
Vasoconstriction
Is an Oral Temperature typically warmer or cooler than a Rectal Temperature?
It is commonly 0.5 degrees cooler than a Rectal Temperature
What is a Fever (pyrexia)?
Pyrogens such as bacteria and viruses cause a rise in body temperature
What is Hyperthermia?
Elevations in core body temperature due to thermoregulation failure
What is Hypothermia?
Low temperature usually due to exposure to the cold; therapeutic hypothermia may be used to lower body’s oxygen requirements
What does Afebrile mean?
No fever
What are the common Temperature sites on the body?
Temporal artery (forehead)
Tympanic (ear)
Oral (mouth)
Axilla (armpit)
Skin
Rectum
What is Core Temperature?
Deep tissues of the body where temperature remains relatively constant, making it more accurate.
EX. Rectal, tympanic, temporal artery
What is Surface Temperature?
Temperature of the skin/subcutaneous tissue that is a rough estimate of the core temperature.
EX. Skin, mouth, axilla
What are factors affecting Temperature?
Age
Exercise
Hormones
Circadian cycle
Stress
Environment
Temperature changes
Ingestion of food
What happens with Older Adults and Temperature?
- They become more sensitive to temperature extremes.
- Average body temp in older adults is ~36oC, reading of 35oC may be expected.
What happens with Infants and Temperature?
- Infants are sensitive to heat loss, with 30% of body heat lost through the head.
- Exposure to temperature extremes must be avoided.
What would be the most appropriate site to assess temperature in an infant? (Choose 2)
Axillary
Oral
Rectal
Skin
Tympanic
Axillary and Tympanic
When should an Oral Temperature be delayed 20 minutes?
When the patient has eaten/drank something hot or cold
When should an Oral Temperature be delayed 2 minutes?
After the patient has smoked
When should an Oral Temperature be delayed 5 minutes?
When the patient has been chewing gum
When should you NOT use an Oral Temperature?
- On infants or small children
- When patient has oral trauma from surgery.
- History of epilepsy, shaking, chills, confusion, unconsciousness, uncooperativeness
True or False: Tympanic (ear) Temperatures may not accurately reflect a change in body temperature during or after exercise.
True
True or False: Tympanic (ear) Temperatures may be affected by devices that warm or cool the ambient environment, such as incubators, radiant warmers, facial fans.
True
True or False: Tympanic (ear) Temperatures can be affected by otitis media, impacted cerumen, hearing aids, and ear surgery.
True
True or False: Axillary Temperatures are safe and accurate for infants and young children.
True
True or False: Axillary Temperatures can be impacted by the external environment such as additional blankets, cold rooms, exposure of the thorax.
True
When should Rectal Temperature be used?
When other routes are not practical or possible, such as in comatose patients, critically ill patients, or patients with breathing tubes.
Why are Rectal Temperature not commonly used?
They are discomfortable and time-consuming, and they require the patient to be side-lying.
Which of the following is contraindicated with taking a rectal temperature measurement?
a) Patient requires assistance to move to a side-lying position.
b) Patient has painful and swollen hemorrhoids.
c) Patient is incontinent of urine.
d) The last temperature recorded was 0.2° F above baseline.
b) Patient has painful and swollen hemorrhoids.
What should the nurse do when measuring an adult patient’s radial pulse?
Palpate the patient’s inner wrist on the thumb side with the fingertips of your three middle fingers.
Why do we use our fingers and not our thumb when taking a radial pulse?
Our thumb has a pulsation that will interfere with accuracy; the fingertips are the most sensitive parts of the hand for palpation of the artery
What is a Pulse (anatomically)?
When blood is pushed out of the heart, the walls of the aorta distend creating a pulse that travels distally towards the periphery
What does Pulse measure?
Measures blood flow palpable at various points in the body
What is the equation for Cardiac Output?
Cardiac output (CO)= stroke volume X heart rate
What do you assess/report when taking a pulse?
- Rate
- Rhythm
- Strength/Force
How do you count a Pulse?
Count 30 seconds and multiply by 2 if regular. If irregular pulse count for a full minute.
What are the most common Pulse sites?
Carotid
Apical
Branchial
Radial
Femoral
Popliteal
Dorsalis Pedis
What is Dysrhythmia?
An interruption in normal rhythm with early, late, or missed beats
What does a Pulse strength/force of 3+ mean?
Full, bounding pulse
What does a Pulse strength/force of 2+ mean?
Normal pulse
What does a Pulse strength/force of 1+ mean?
Weak, thready pulse
What does a Pulse strength/force of 0 mean?
Absent pulse
What does strength/force of Pulse mean?
Determines volume of blood on arterial walls and condition of vascular system
What is equality of Pulse?
The pulse rate, rhythm, and force are equal on both sides.
- Clot formation could alter equality
What are some factors that could affect heart rate (HR)?
Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural
Pulmonary condition
What is Ventilation?
Respirations; assessed by rate, rhythm, and depth of respirations
What is Diffusion and Perfusion?
Assessed by measuring oxygen saturation
What is Inspiration?
- The respiratory center sends impulses along the phrenic nerve causing the diaphragm to contract.
- Abdominal organs move downward and forward to move air into the lungs, ribs retract upwards from body midline.
What is Expiration?
- Diaphragm relaxes and abdominal organs return to their position
What should you Assess/Inspect for signs or symptoms of Respiratory Alterations?
- Labored breathing (difficulty breathing)
- Cyanosis of lips, nails, skin
- Restlessness
- Irritability
- Confusion
- Reduced level of consciousness
What is Dyspnea?
Laboured or difficulty breathing
What is Orthopnea?
Difficulty breathing when lying flat
On the last assessment of a patient’s respiration, her respiratory rate was 10 breaths per minute.
What should the nurse do when conducting the next assessment of this patient’s respiratory rate?
Count breaths for 60 seconds
The nurse measures a patient’s oxygen saturation level as being 83%. What would the nurse do first?
a) Reassess the oxygen saturation in a different location until the nurse finds a placement where the saturation is 85%.
b) Promptly report the assessment data to the charge nurse.
c) Encourage the patient to rest quietly in bed for 30 minutes.
d) Ask the patient whether he or she is having trouble breathing.
d) Ask the patient whether he or she is having trouble breathing.
What is Oxygen Saturation?
Oxygen saturation (Sp02) measures percentage of red blood cells bound with oxygen in the arteries
What are factors that affect O2 Saturation measurements?
- Outside light
- Client motion
- Nail polish
- Peripheral vascular disease, low blood flow, edema in extremities
What is considered a normal Capillary Refill time?
3 seconds or less
What is the Diaphragm of the stethoscope used for?
High pitched sounds, breaths, normal heart sounds, bowels, BP
What is the Bell of the stethoscope used for?
Low pitched sounds, abnormal heart sounds, heart murmurs, carotid sounds
What is the systolic value measure?
The contraction of the ventricles
What does the diastolic value measure?
Ventricles at rest
What is Pulse Pressure?
The difference between systolic and diastolic pressures.
(120-80=40)
How do you calculate Pulse Pressure?
Systolic - Diastolic = Pulse Pressure
What is the 1st Korotoff Sound mean?
When blood begins to return are a measure of the systolic blood pressure; the force with which the blood is pushing against the artery walls when the ventricles are contracting.
What is the 5th Korotoff Sound mean?
This is the force of the blood when the ventricles are relaxing and is equal to the diastolic blood pressure.
What are the 2 steps of a manual BP?
Step 1: Palpate radial pulse; inflate cuff until pulse disappears.
Continue to inflate 20-30 mmHg more and ensure pulse is still not present.
Release valve and wait 30 sec.
Step 2: Place stethoscope over brachial artery, quickly inflate to 20- 30mmHg above systolic estimate through palpation.
Slowly release valve (2mmHg/sec), note first sound, muffled sound, and silence.
Why do we use manual BP cuffs over automatic BP cuffs?
Electronic devices useful for very frequent measurements, but more sensitive to movement and prone to error
What are some factors that can lead to Falsely HIGH BP readings?
- Anxiety/Anger
- Exercise
- Pain
- Arm above level of the heart
- Patient supports own arm
- Faulty leg position
- Looking up at the meniscus
- Cuff too narrow for the extremity
- Deflating cuff too quickly
- Deflating cuff too slowly
- Halting during descent then re-inflating to check systolic
- Failure to wait 1-2 minutes
What are some factors that can lead to Falsely LOW BP readings?
- Arm below level of the heart
- Cuff wrap too loose or uneven
- Cuff under-inflated
- Failure to palpate radial artery while cuff is inflated
- Stethoscope too hard on brachial artery
- Deflating cuff too quickly
What are other factors that influence BP?
Age
Stress
Ethnicity
Gender
Daily variation
Medications
Activity, weight, smoking
What is Orthostatic (Postural) VS?
- Patient reports dizziness upon standing.
Have the patient rest supine for 2 or 3 minutes, take baseline readings of pulse and BP
Repeat pulse and BP with the patient sitting and then standing (ideally to 2 minutes apart).
Which of the following values for vital signs would the nurse address first?
a) Oxygen saturation by pulse oximetry = 86%.
b) Pulse rate = 72 beats per minute.
c) Temp = 37.2°C, tympanic.
d) BP = 160/86 mm Hg.
e) Respirations = 28 breaths per minute.
a) Oxygen saturation by pulse oximetry = 86%.
An 82-year-old is admitted to the ER with complaints of shortness of breath and malaise (tired, fatigue, feeling blah). He recently visited his GP and was prescribed an antibiotic for pneumonia. The patient indicates that he also takes a medications for his “high blood pressure.” Which vital sign value would take priority in initiating care?
a) O2 sat – 94%
b) BP – 138/84
c) Temp – 39.3 C tympanic
d) Respirations – 24/min
c) Temp – 39.3 C tympanic
