1: Vital signs Flashcards
(126 cards)
1
Q
What is the first step of the nursing process?
A
Assessment!
2
Q
most common objective assessment done by nurses
A
Vital signs
3
Q
objective assessment
A
When nurses asses an individual
4
Q
Subjective assessment
A
When a patient tells us the problem
5
Q
Range for temperature
A
98.6-100.4 F
6
Q
Range for pulse
A
60-100 bpms
7
Q
range for respirations
A
12-20
8
Q
range for blood pressure
A
<120/<80
9
Q
Pulse/heart rate reflects
A
Heart contraction. beats/min
10
Q
Cardiac output
A
blood flow per minute
11
Q
Radial
A
wrist
12
Q
Apical
A
apex of the heart, 4th-5th ICS
13
Q
carotid
A
along sternocleidomastoid muscle
14
Q
Places for circulation assessment rather than vitals
A
- brachial
- femoral
- popliteal
- posterior
- doralis pedis
15
Q
Assess all four for pulse
A
Rate
Rhythm
Strength
Symmetry
16
Q
what do you do if you palpate an irregular pulse
A
Listen to apical pulse for a full minute
17
Q
Stroke volume
A
amount of blood the LV pumps out with each contraction
18
Q
Cardiac output=
A
(Heart rate)(stroke volume)
19
Q
what will happen to the Cardiac output when someone is dehydrated
A
heart rate increases, therefore CO increases
20
Q
what will happen to the CO if a med decreases the HR?
A
Decrease in CO
21
Q
Bradycardia
A
slow, less than 60bpm
22
Q
Tachycardia
A
fast, more than 100 bpm
23
Q
how to assess rhythm
A
regular or irregular?
- regularly irregular (predictable)
- irregularly irregular (unpredictable)
24
Q
how to assess quality of pulse
A
Bounding (4+) Strong (3+) Normal (2+) Diminished (1+) Absent (0)
25
actors influencing pulse rate
- exercise
- temperature
- emotions
- medications
- hemorrhage/fluid loss
- postural changes
- pulmonary conditions
26
improved physical condition =
Decrease heart rate
27
fever affects on HR
Fever= Increase in HR
28
Hypothermia affects on hr
Hypothermia decreases HR
29
Emotions affect of HR
pain/anxiety = increases HR
30
Hemorrhage/fluid loss affects on HR
Increases Heart rate
31
change from standing to sitting affects on HR
Sit to stand increases HR
32
impaired O2 could lead to
increased HR
33
if circulation is compromised, what may be present
pallor or cyanosis
34
pallor
paleness of skin
35
cyanosis
bluish or grayish discoloration due to excessive CO2 and deficient O2
36
systolic pressure
peak pressure exerted against arterial walls as ventricles contract & eject blood
37
Diastolic pressure
Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest
38
Pulse pressure
difference between the systolic and diastolic pressures
39
Blood pressure is the result of interaction of
- Cardiac output
- peripheral vascular resistance
- blood volume
- blood viscosity
40
Decrease in radius =
increase in resistance, increase blood pressure
41
increase in radius =
decrease in resistance = decreased pressure
42
increase in blood volume=
increase in blood pressure
43
Decrease in blood volume =
Decrease in Blood pressure
44
physiological factors that influence BP
```
age
stress
ethnicity
gender
medications
activity
weight
smoking
```
45
2 ways of measuring BP
1. indirect or noninvasive
| 2. direct method
46
Indirect method or noninvasive
external devices like a BP cuff
47
direct method
- done in critical care setting
- catheter threaded into an artery
- connected to electric monitoring system
48
1st korotkoff sound
systolic BP
49
5th korotkoff sound
silence, corresponding with diastole
50
which do you use to assess BP?
Systolic number
51
What is more common, hypertension or hypotension?
Hypertension
52
What causes hypertension
- thickening of walls
- loss of elasticity
- family history
- risk factors
53
Normal rang for BP
less than 120/80
54
Elevated BP
120-129 and <80
55
Hypertension stage 1
Systolic:130-139 or Diastolic:80-89
56
Hypertension stage 2
>140 or >90
57
Hypotension
systolic BP <90
58
symptoms of hypotension
- pallor
- clamminess
- confusion
- increased HR
- decreases urine output
59
orthostatic or postural hypotension
sudden drop in BP when going from a lying to sitting/standing
60
Conditions not appropriate for electronic BP measurement
```
irregular heart rate
vascular obstruction
shivering/tremors
seizures
inability to cooperate
blood pressure less than 90 systolic
```
61
Temp range for oral
98.6
62
average rectal temp
99.5
63
axillary temp
97.7
64
Etiology of hypotension
Vascular dilation, inadequate pumping of heart, loss oxblood volume (Hemorrhage/dehydration)
65
Clinical presentation of hypotension
- Pallor
- Clamminess
- Confusion
- Increased HR
- Decreased urine output
- weakened pulse
66
Orthostatic or postural hypotension
sudden drop of BP on moving from a lying to a sitting or standing position
67
Patient conditions not appropriate for ELECTRONIC blood pressure measurement
- irregular heart rate
- peripheral vascular obstruction
- shivering/tremors
- seizures
- inability to cooperate
- blood pressure less than 90 mmHg systolic
68
Benefits of patient measurement of BP
- Detection of new problems (pre-hypertension)
- Patients with hypertension can provide to their health care provider info about patterns of BP
- Self-monitoring helps adherence to therapy
69
Disadvantages of patient measurement of BP
- Improper use risks inaccurate readings
- Unnecessary alarming of patient
- Patients may inappropriately adjust medications
70
Three processes of respiration
- ventilation
- diffusion
- perfusion
71
Ventilation
flow of gasses in and out of lungs; the amount of air in the alveoli
72
Diffusion
Gas exchange between alveoli & pulmonary capillaries
73
Perfusion
Flow of blood in the pulmonary capillaries
74
Hypoxemia
Low O2
75
How is respiration controlled
medulla
76
Respiratory rate:
Breaths/minute
77
Ventilatory depth
Deep/normal/shallow
78
Ventilatory rhythm
regular/irregular
79
Ventilatory assessment with diffusion and perfusion
O2 saturation
80
Apnea
Cessation of breathing --> respiratory arrest
81
Bradypnea
< 12/min
82
Tachypnea
>20/min
83
Hyperventilation
Increase rate and depth
84
Hypoventilation
Decreased rate and depth
85
Effort for dyspnea
Labored breathing
86
Effort for orthopnea
inability to breathe when horizontal. many sleep in recliners rather than laying flat
87
SOB
Shortness of breath
88
Abnormal patterns of breathing q
Cheyne-stokes
Biot
Kussmauls
89
Cheyne-stokes
- Irregular rate/depth
- Apnea/hyperventilation
- slow/shallow increases to abnormally fast/deep and then reverses
- Common among those who are actively dying
90
Biot
Shallow 2-3 breathes... apnea and repeats
91
Kussmauls
Deep, regular, increases rate
- high acidity in blood
- Diabetes with a high blood sugar
92
What does hyperventilation result in?
Excess loss of CO2 (hypocapnea)
93
What happens to CO2 during hypoventilation
Co2 is retained (Hypercapnea)
94
Normal measurement of oxygen saturation
95-100%
95
How are Arterial blood gases (ABGs) measured?
Directly measures the partial pressure of O2, CO2 and blood PH
96
What does oxygen saturation assess
diffusion and perfusion of oxygen
97
How does light influence oximetry accuracy
bright light directly on the probe can throw off oximetry
98
How does shivering/tremors influence oximetry accuracy
Movement makes it difficult to pick up signal
99
How does pulse volume influence oximetry accuracy
sensor detects pulsatile flow, when BP is low the pulse may be too weak
100
how does vasoconstriction influence oximetry accuracy
reduces blood flow and the sensor may not detect signal
101
How does carbon monoxide poisoning influence oximetry accuracy
may give a falsely high saturation reading since CO binds very well to hemoglobin and displaces oxygen
102
What happens to the pulse when O2 levels are low
Increases
103
Factors that influence respirations
```
exercise
acute pain
anxiety
smoking
medications
```
104
What causes low BP?
shock, dehydration, hemmorhage
105
How to measure temperature
Heat produced-minus-heat lost
106
Temperature is influenced by
physiological cycles
age, activity, environment, basal metabolic rate
site of measurement
107
Afebrile
Person with a normal temperature
108
Conduction
transfer with direct contact
109
Example of conduction
Ice packs/cool cloths
110
radiation
transfer from one surface to another without direct contact
111
Example of radiation
heater/fireplace
112
Convention
transfer away through air movement: fan to cool
113
Evaporation
transfer when liquid id converted to gas
114
How does heat move through the concentration gradient
MOVES DOWN!!! from warmer to cooler
115
which endocrine gland controls/influences temperature
Pituitary Gland
116
Pyrexia
Fever
117
Abnormal temperature
100.4 due to alteration in hypothalamic set point
118
What kind of reaction is a fever
A functional reaction, which can sometimes me good
119
How can a fever be good?
often in response to pyrogens (fever producing cytokines)
120
Pyrogens induce _____
Secretion of chemical mediators
121
How is hyperthermia different from fever
Hyperthermia is caused due to dysfunctional thermoregulation. NOT INTENDED AND NOT EVER GOOD
122
Hypothermia
Core temperature below normal
123
Can you exceed 100% for SpO2?
No!
124
Malignant Hyperthermia is
Genetically predisposed
125
Heat exhaustion _____ heat stroke?
Precedes heat stroke
126
vital signs delegation
nurses can delegate activity of vital signs but it is their responsibility to interpret
