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NURS 402: Lecture > Vital Signs ppt > Flashcards

Vital Signs ppt Flashcards

1
Q

What is included in vital signs?

A

Temperature

Pulse

Respiration

Blood Pressure

Pain

Pulse oximetry

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2
Q

When do you assess vital signs?

A
  1. On admission to any health care facility or institution
  2. Based on facility or institutional policy and procedures
  3. Any time there is a change in patient’s condition
  4. Any time there is a loss of consciousness
  5. Before and after any surgical or invasive procedure
  6. Before or after activity that may increase risk, like ambulation after surgery
  7. Before administering meds that affect cardiovascular and respiratory function
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3
Q

Normal Oral Temp Range for Health Adults (Celsius and Farenheit)

A

35.8-37.5 C

96.4-99.5 F

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4
Q

Normal Pulse Rate Range for Healthy Adult

A

60-100

Average is 80

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5
Q

Normal Respiration Rate Range for Healthy Adult

A

12 to 20 breaths per minute

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6
Q

Normal Blood Pressure Range for Healthy Adult

A

Less than 120/80

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7
Q

What is the primary source of heat production

A

metabolism

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8
Q

What increases metabolism

A

Hormones, muscle movements, and exercise increase metabolism

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9
Q

What occurs to increase heat production

A

Epinephrine and norepinephrine are released when additional heat is required and alter metabolism

Thyroid hormone and shivering also increase heat production

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10
Q

What happens to energy production when heat production increases?

A

Energy production decreases

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11
Q

Sources of Heat Loss

A
  1. Skin (primary source)
  2. Evaporation of sweat
  3. Warming and humidifying inspired air
  4. Eliminating urine and feces
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12
Q

Transfer of Body Heat to External Environment occurs by:

A
  1. Radiation
  2. Convection
  3. Evaporation
  4. Conduction
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13
Q

Factors affecting temperature

A
  1. Circadian rhythms
  2. Age and gender
  3. Physical activity
  4. State of health
  5. Environmental temperature
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14
Q

Afebrile

A

without fever

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15
Q

Pyrexia

A

with fever (febrile)

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16
Q

Intermittent fever

A

temperature returns to normal at least once every 24 hours

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17
Q

Remittent fever:

A

temperature does not return to normal and fluctuates a few degrees up and down

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18
Q

Sustained or continuous fever:

A

Temperature remains above normal with minimal variations

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19
Q

Relapsing or recurrent fever:

A

Temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days

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20
Q

Equipment for Assessing Temperature

A
  1. Electronic and digital thermometers
  2. Tympanic membrane
    thermometers
  3. Disposable single-use
    thermometers
  4. Temporal artery
    thermometers
  5. Automated monitoring
    devices
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21
Q

Normal oral temp adult

A

35.9–37.5°C;
96.6–99.5°F

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22
Q

Normal Rectal Temp adult

A

36.3–38.1°C;
97.4–100.5°F

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23
Q

Normal Axillary Temp Adult

A

35.4–36.9°C;
95.6–98.5°F

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24
Q

Normal Tympanic Temp Adult

A

36.8–38.3ºC;
98.2–100.9°F

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25
Q

Normal Forehead Temp (Temporal artery) for Adults

A

36.3–38.1°C;
98.7–100.5°F

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26
Q

What is pulse regulated by

A

Regulated by the autonomic nervous system through cardiac sinoatrial node

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27
Q

What does sympathetic stimulation do to heart rate?

A

Increases heart rate

28
Q

What does parasympathetic stimulation do to heart rate?

A

decreases heart rate

29
Q

What is pulse rate?

A

The number of contractions over a peripheral artery over 1 minute

30
Q

What are characteristics of Peripheral Pulse?

A

Rate

Amplitude and quality (strong or weak)

Volume of Blood ejected with each heart beat

Rhythm

31
Q

Sites for detecting pulse by light palpations

A
  1. Temporal
  2. Carotid
  3. Brachial
  4. Radial
  5. Femoral
  6. Popliteal
  7. Doralis pedis
  8. Posterior tibial
32
Q

How to grade pulse strength (Amplitude)

A

Grade 0

Grade +1

Grade +2

Grade +3

33
Q

What is Grade 0 pulse strength

A

absent, unable to palpate

34
Q

What is Grade +1 pulse strength

A

diminished, weaker than expected

35
Q

What is Grade +2 pulse strength

A

normal; brisk, expected

36
Q

What is Grade +3 pulse strength

A

bounding

37
Q

How to find Apical pulse

A

fifth intercostal midclavicular line

38
Q

Ventilation

A

movement of air in and out of lungs

39
Q

What makes up ventilation?

A

Inhalation

Exhalation

40
Q

Inhalation

A

breathing in

41
Q

Exhalation

A

breathing out

42
Q

Diffusion

A

Exchange of oxygen and CO2 between the aveoli of lungs and circulating blood

43
Q

Perfusion

A

Exchange of oxygen and CO2 between circulating blood and tissue cells

43
Q

Rate and depth change in response to what?

A

Changes in response to tissue demands

44
Q

Rate and depth are controlled by what?

A

Controlled by respiratory centers in the medulla and pons

44
Q

Rate and Depth are activated by what

A

Activated by impulses from chemoreceptors

44
Q

What is the most powerful respiratory stimulant?

A

Increase in carbon dioxide is the most powerful respiratory stimulant

45
Q

Eupnea

A

normal, unlabored respiration

one respiration to every four heartbeats

45
Q

Bradypnea

A

Decreased respiratory rate; occurs in some pathologic conditions

45
Q

Tachypnea

A

Increased respiratory rate; may occur in response to an increased metabolic rate

46
Q

Apnea

A

Periods when no breathing occurs

47
Q

Dyspnea

A

Difficult or labored breathing

48
Q

Dyspnea

A

Difficult or labored breathing

49
Q

Orthopnea

A

Changes in breathing when sitting or standing

50
Q

Blood pressure

A

Force of the moving blood against arterial walls

51
Q

Systole/Systolic Pressure

A

Maximum pressure when left ventricle contracts and pushes blood through aortic valve into the aorta

52
Q

Diastole/Diastolic pressure

A

Lowest pressure when the heart rests between beats

53
Q

Pulse Pressure

A

Difference between systolic and diastolic pressure

54
Q

Factors affecting Blood Pressure

A

Age, Race

Exercise

Weight

Circadian Rhythm

Emotional state

Food intake

Body position

Drugs/Meds

Biologic sex

55
Q

Two forms of Decreased Hypotension

A

Hypotension

Orthostatic Hypotension

56
Q

Hypotension

A

less than 90/60mmHg

result of disease processes

side effect of medications

inability of the body to maintain or return back to normal

57
Q

Orthostatic hypotension (postural hypotension)

A

Results from an inadequate physiologic response to position changes

Occurs when rising to an erect position

58
Q

What is orthostatic hypotension caused by?

A

Caused by dehydration, blood loss, or problems of the neurologic, cardiovascular or endocrine systems

59
Q

Equipment for Assessing BP

A

Stethoscope and sphygmomanometer

Doppler ultrasound

Electronic or automated devices

60
Q

Assessing BP what are you listening for

A

Listening for Korotkoff sounds with stethoscope

First sound- systolic

Change or cessation of sounds occurs- diastolic pressure

61
Q

What arteries are commonly used for bp?

A

Brachial

Popliteal

62
Q
A

NURS 402: Lecture (17 decks)

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