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nurs 1200 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are the 5 vital signs

A

Temp
Pulse
Resp
Blood Pressure
Pain

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2
Q

Normal Blood Pressure

A

120/80

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3
Q

Normal Temp Range

A

96.4 - 99.5

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4
Q

Normal Respirations Range

A

12-20 breaths per minute

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5
Q

Normal Pluse Range

A

60-100 beats per minute

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6
Q

LOC

A

Level Of Consiousness

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7
Q

When to asses vitals

A

admission
change in condition
change in LOC
before and after an invasive prodcedure
before and after activites that may cause change
before meds
per facility policy

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8
Q

Factors affecting body temp

A

Age
menopause
pregnancy
time of day
physical activity
overall health

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9
Q

What temp is does a fever start at

A

100.5

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10
Q

What is hyperthermia
causes
benefits

A

increase above normal body temp
causes; illness, cancer, trauma, surgery
benefits; start immune system, inital something is wrong

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11
Q

S & SX (signs and symptoms) of Hyperthermia

A

confusion&delerium (older patient)
fatigue
flushed face
hot, dry skin
increased pulse and resp rate
loss of appetite
muscle aches
shivering
thirst

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12
Q

Hyperthermia treatment
priority
pharmacological
nonpharmacological

A

Priority; treat the cause
pharmacological; antipyretics(NSAIDS/Acetaminophen)
nonpharmacological; cool sponge baths, increase fluid intake

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13
Q

What is hypothermia
-causes

A

decrease in temperature below the lower limit of normal
causes; exposure to cold, chronic conditions, perioperative clients, new born babies

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14
Q

S & SX (signs and symptoms) of hypothermia

A

poor coordination
slurred speech
poor judgement
amnesia
hallucinations
vital sign decrease

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15
Q

Hypothermia treatment

A

rewarming
with a warming blanket, warm fluids, and/or additonal clothing/blankets

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16
Q

Temperature routes

A

sublingual
tympanic
temporal
rectal
axillary

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17
Q

Advantages and contraindications of sublingual temp

A

advantages;
most common
easily acessible
contraindications:
intake of hot/cold fluids or food
smoking
chewing gum

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18
Q

advantages and contraindications of tympanic temp

A

advantages;
easily accessible
contraindications;
drainage in ear
ear pain
ear infection
scars on tympanic membrane

19
Q

advantages and contraindications of temporal temp

A

advantages;
more accurate than axillary
contraindications;
forehead coverings
affected by external temps

20
Q

advantages and contraindications of rectal temp

A

advantages;
most accurate
contraindications;
special thermometer
heart disease or surgery (vagual stim. can cause heart rate to bottom)
neutropenic precautions
low platelet count
spinal cord injuries

21
Q

advantages and contraindications for axillary temp

A

advantages;
use when sublingual and rectal sites are contraindicated or not acessible
contraindications;
least accurate of them all
unable to keep arm down until reading is complete

22
Q

pulse characteristics

A

rate
rhythm (regualr or irregular)
amplitude (strength)
bradycardia (-60)
tachycardia (+100)

23
Q

factors affecting pulse rates

A

age
biological sex
fever
medication use
physical activity
presence of disease
stress

athletes have a lower heart rate, stress/anxiety have higher heart rate

24
Q

pulse location

A

temporal
carotid
apical (PMI pulse, between 4&5 rib)
brachial
radial
femoral
popliteal
post. tibia artery
pedal

25
Q

tachycardia
rate
causes

A

fast heart rate
between 100-180 bpm
causes;
drugs
fever
hypotensive
low oxygen blood
pain
stress

26
Q

bradycardia
rate
causes

A

below 60 bpm
causes;
decreased body temp
deleruim
heart attack
hypothyroidism
intracranial pressure
medications
sleep
sleep apnea
vagal stimulation

27
Q

pulse amplitude
how its measured

A

the quality or fullness of the sound
meausured by grades
0-absent, unable to palpate
+1 - deminished, weaker than expected
+2 - brisk, expected
+3 - bounding

28
Q

respiration characteristics

A

rhythm - reg or irreg
depth- force of inhalation/exhalation

29
Q

factors affecting respiration

A

acid-base balance
acute pain
age
anemia
anxiety
brain lesions
exercise
increased altitude
medications
respiratory disease

30
Q

respiration rhythms

A

apnea - without resporations
tachypnea - rate greater than 24 breaths per min
bradypnea - rates less than 10 breaths per min

31
Q

respiration rates

A

normal - 12-20 breath/min
tachypnea - >24 bpm
bradypnea - <10 bpm
hyperventilation - increased rate and depth
hypoventilation - decreased rate and depth
cheyne-stokes - alternating periods of deep rapid breathing, followed by periods of apnea (regular)
Biots resp - varying depth and rate of breathing followed by periods of apnea (irregualr)

32
Q

pulse oximetry
range
false reading causes

A

measures the % of oxygen saturation in the blood
range; 95% - 100%
false reading causes;
cold hands
wrong location
equipment malfunction
fingernail polish/acrylic

33
Q

Blood pressure top number

name

A

systolic

34
Q

Blood Pressure bottom number

name

A

diastolic

35
Q

blood pressure ranges

A

normal; < 120/80

elevated; 120-129/80

hypotension; below 90/60

hypertensive stage 1; 130-139/80-89

hypertensive stage 2; >140/>90

hypertensive crisis; >180/>120

36
Q

factors affecting blood pressure

A

age
biological sex
body position
circadian rhythm
drugs/medications
emotional state
exercise
food intake
race
weight

37
Q

factors causing false low blood pressure readings

A

hearing deficit
noise in enviornment
applying cuff thats too wide
inserting stethoscope in ears incorrectly
releasing valve too fast

38
Q

factors causing false high blood pressure readings

A

incorrectly calibrated manometer
applying cuff that is too narrow
releasing valve too slow
reinflating bladder during ausculatation

39
Q

hypertension
at risk?

A

over 130/80
at risk?
family hx (history)
race
sleep apnea
diabetes
cholesterol
african american males

40
Q

hypotension

A

less than 90/60

41
Q

orthostatic hypotension

preventions

A

rapid movement of sitting to standing, gets dizzy

let patient dangle and get up slowly

42
Q

oxygentation

A

amount of oxygen in the blood

43
Q

perfusion

A

volume of blood

nurs 1200 (8 decks)

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