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CSON IM1 > vital signs > Flashcards

vital signs Flashcards

1
Q

what are your 5 measurements when taking vital signs

A

temp, pulse, BP, resp. rate, O2 saturation

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2
Q

when do you measure vital signs?

A

Admission, per physician order, any changes in patients condition, before major procedures, during blood transfusion, after meds that affect vital signs

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3
Q

normal oral/tympanic/temporal temp range

A

97.6-99.6

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4
Q

normal rectal temp range

A

98.6-100.4

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5
Q

normal axilla temp range

A

96.6-98.6

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6
Q

normal pulse range

A

60-100 BPM

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7
Q

normal respiration range

A

12-20 BPM

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8
Q

normal BP

A

less than 120/80 mmHg

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9
Q

pre-hypertensive BP range

A

sys.: 120-139 dia.:80-89

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10
Q

hypertensive BP range

A

Sys. greater than 140 dia. greater than 9-

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11
Q

hypotensive BP range

A

sys. less than 90 and symptomatic

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12
Q

what are the 2 things body temp. shows

A

heat produced and heat lost

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13
Q

acceptable temp. range

A

96.8-100.4

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14
Q

radiation

A

transfer of heat from surface of one object to another without direct contact

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15
Q

conduction

A

transfer of heat from one object to another with direct contact

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16
Q

convection

A

transfer of hat away by air movement

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17
Q

evaporation

A

transfer of heat energy when a liquid is changed to a gas

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18
Q

diaphoresis

A

visible perspiration

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19
Q

6 factors affecting body temp

A

age, hormonal level, environment, exercise, circadian rhythm, temperature alterations

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20
Q

pyrexia

A

fever

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21
Q

when is pyrexia harmful

A

above 102.2

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22
Q

what increases when someone has a fever ( 4 things )

A

metabolism, oxygen consumption, heart rate, respiratory rate

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23
Q

hyperthermia

A

inability to promote heat loss or reduce production

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24
Q

heatstroke

A

body temp 104 or more

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25
Q

heatstroke signs and symptoms

A

DRY, HOT SKIN, confusion, excess thirst, muscle cramps, increased HR, decreased BP, no sweating

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26
Q

heat exhaustion

A

diaphoresis resulting is excess water and electrolyte loss, body needs to replace

27
Q

hypothermia

A

prolonged exposure to cold which decreases body’s ability to produce heat, temps less than 86 ranging to 96.8

28
Q

fahrenheit to celsius conversion

A

C= (F-32) x 5/9

29
Q

celsius to fahrenheit conversion

A

F= (9/5 x C) +32

30
Q

oral temperature is approx. ___ degree lower than core temp

A

1

31
Q

adult rectal temp. placement

A

1.5 in

32
Q

child rectal temp. placement

A

1 in

33
Q

infant rectal temp. placement

A

.5 in

34
Q

You have delegated vital signs to the nursing assistant. She tells you that the patient has just finished a cup of hot coffee. The nurse’s most appropriate advice would be to

A. take the oral temperature as planned
B. take a rectal temperature.
C. wait 30 minutes and take an oral temperature.
D. advise the patient to drink a glass of cold water.

A

C

35
Q

what do you do for a fever?

A

Obtain blood cultures if ordered, Monitor VS, assess skin color, temperature, turgor and lab work, Reduce frequency of activities to ↓ 02 demand, Maximize heat loss , Extra fluids, Tepid water bath, Oral hygiene, Dry bed linens, Antipyretic meds as ordered

36
Q

pulse

A

palpable bounding of blood flow noted at various points of the body

37
Q

what is the pulse showing

A

an indirect measure of circulatory status

38
Q

what do you do if you get a abnormal radial pulse?

A

obtain an apical pulse

39
Q

why do you check pulse on both wrists at the same time

A

to assess for abnormal rhythm or strength on one or both sides

40
Q

what is considered a normal pulse rhythm

A

2+

41
Q

what is gas exchange

A

the process of transporting oxygen into cells and carbon dioxide out of cells

42
Q

what are the 3 catagories of oxygenation?

A

ventilation, transport, perfusion

43
Q

impaired gas exchange

A

diffusion of gases becomes impaired

44
Q

ventilation

A

movement of gases into and out of the lung

45
Q

diffusion

A

movement of oxygen and carbon dioxide between alveoli and red blood cells

46
Q

perfusion

A

distribution of red blood cells to and from the pulmonary capillaries

47
Q

rate of respirations

A

haw many breaths per min.

48
Q

rhythm of respirations

A

regular or irregular

49
Q

depth of respirations

A

deep, normal, or shallow

50
Q

eupnea

A

ventilation of normal rate and depth

51
Q

bradypnea

A

slow breaths with normal depth <10 BPM

52
Q

tachypnea

A

rapid, shallow breathing >24 BPM

53
Q

apnea

A

pauses in breathing

54
Q

cheyne-stokes

A

rate and depth of breathing increase until apnea

55
Q

biots respiration

A

normal breathing followed by a period of apnea

56
Q

acceptable SpO2 range

A

95%-100%

57
Q

what is BP

A

force exerted against the blood vessels by the blood

58
Q

what do you measure BP in

A

millimeters of mercury

59
Q

Hypotension symptoms

A

skin mottling, clamminess, confusion, high HR, low urine output

60
Q

P in PQRST

A

provokes/palliates

61
Q

R in PQRST

A

quality

62
Q

R in PQRST

A

region/radiation

63
Q

S in PQRST

A

Severity and setting

64
Q

T in PQRST

A

timing

CSON IM1 (28 decks)

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