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Unit 2 > ATI/PPT vital signs CH 27 > Flashcards

ATI/PPT vital signs CH 27 Flashcards

1
Q

What constitutes vital signs?

A
  • temp
  • pulse
  • respirations
  • BP
  • pain O2 sat is supposed to be 95 or above
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2
Q

Why is it important to monitor vital signs?

A
  • direct reflection of health status

- important to detect variations from normal/baseline to determine disease exacerbation

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3
Q

Evidence Based Finding

A

1-early recognition/timely tx
2-iD pts at risk for adverse events
3-use pre-planned/structural assessment of physiological parameters {protocol}
4-eliminate barriers to emergency assistance when pt’s status is deteriorating

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4
Q

Temperature

A

1-heat produced vs. heat lost
2-surface body temps are lower than core(axillary v. Rectal)
3-thermoregulation=hypothalamus

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5
Q

How is heat produced?

A

1-metabolism,2-hormones,3-exercise,4-shivering

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6
Q

How is heat lost?

A

1-skin,2-sweat evaporation,3-breathing,4-urine/feces

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7
Q

Heat Production

A

Results from increases in basal metabolic rate,muscle activity,thyroxine output,testosterone & sympathetic stimulation

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8
Q

Heat loss

A

1-radiation=transfer of heat from one object to another without contact between them;2-convection=dispersion of heat by air currents/movement;3-evaporation=dispersion of heat through water vapor;4-conduction=transfer from body directly to another surface

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9
Q

Visible perspiration on skin

A

Diaphoresis

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10
Q

Factors affecting temp

A

1-circadian rhythm,2-age,3-gender,4-stress,5-environmental temps

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11
Q

Core temp measurement sites

A

1-rectum,2-tympanic membrane,3-temporal artery,4-pulmonary artery,5-esophagus & 6-urinary bladder

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12
Q

Surface temp measurement sites

A

1-skin,2-mouth,3-axillae

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13
Q

Expected temp ranges

A

1-oral=(96.8-100.4) avg is 98.6
2-rectal=(.9 degrees higher than oral/tympanic)
3-axillary=(.9 degrees lower)
4-temporal=close to rectal,but (1 degree higher than oral,2 degree higher than axillary)

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14
Q

Increased body temp causes/what to look for

A

1-tissue injury like MI,PE,cancer,trauma or surgery/infections/inflammatory processes
2-know if its gradual or sudden onset
3-hyperthermia vs. Neurogenic fever vs. fever of unknown origin
4-ovulation/menses
5-exercise,dehydration,activity

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15
Q

Pt presentation with w/ increased temp(assessment)

A

1-decreased appetite,2-headache,3-dry skin,4-thirst,5-achy muscles,6-increased pulse/respirations

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16
Q

Considerations to temp-newborns & elderly

A

Newborns=lose heat rapidly;(97.7-99.5)

Elderly=loss of subcu fat;harder to get a reading since body struggles trying to regulate

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17
Q

How to reduce fever

A

1-provide antibiotics/Tylenol or Motrin(antipyretics)*don’t give to children/adolescents w/ fever or chicken pox because of Reyes
2-sponge baths,3-cooling blankets,4-cool packs

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18
Q

Assessing temp

A

1-thermometers,2-sites,3-age group,4-contraindicated

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19
Q

Nursing interventions for temp variations

A 
1-frequent monitoring
2-monitoring I/O
3-monitor for seizures
4-med administration
5-IV fluid administration
6-use cooling/warming devices
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20
Q

Nursing dx

A

1-hypothermia as evidenced by…
2-hyperthermia related to..
3-risk for unbalanced body temp(elderly/newborn)
4-ineffective thermoregulation(elderly/preemies)

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21
Q

Oral temp

A

4 years of age & older

**Do NOT use for pts who are mouth breathers or have experienced trauma to face/mouth

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22
Q

Rectal temp

A
  • *DO NOT use on pts with diarrhea,bleeding precautions such as those with low platelets, or have rectal disorders
  • *3 months old and younger should NOT use this site due to rectal perforation
  • more accurate than axillary
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23
Q

Tympanic temp

A
  • ear up & back for adults,down & back for child under 3
  • readings can be inaccurate for children under 3 mo
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24
Q

Pulse

A 
1-autonomicNS=controls HR
2-parasympatheticNS=lowers HR
3-sympatheticNS=raises HR
-can be palpated or auscultated
-result of ventricular contraction
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25
Q

What is the pulse made of?

A

1-rate(BPM),2-quality,(strong vs. weak)3-rhythm,4-volume,5-equality

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26
Q

Rate

A

Number of times per minute you feel/hear the pulse

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27
Q

Rhythm

A

Regularity of impulses

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28
Q

Strength(amplitude) or stroke volume

A
  • Volume of blood ejected against arterial wall w/ each heart contraction & condition of arterial vascular system
  • strength of impulse should stay same from beat to beat
  • strength is 0-4(0=absent,unable to palpate,1=diminished/weaker than expected,2=brisk,expected,3=increased,strong,4=full volume,bounding
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29
Q

Equality

A
  • peripheral pulse impulses should be symmetrical in quality & quantity from right side of body to left
  • assess strength/equality to evaluate adequacy of vascular system
  • inequality or absence of pulse on one side can indicate a disease state such as thrombus or aortic dissection
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30
Q

Cardiac output

A

Amount of blood per minute

CO=SV x HR

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31
Q

Pulse deficit

A

Difference in apical/radial pulse

-must be done by 2 nurses

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32
Q

Dysrhythmia

A

Irregular heart rhythm, generally with an irregular radial pulse

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33
Q

Expected HR range

A

Adults=60-100/minat rest
Infants=120-160/min
Adolescent=80-90/min

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34
Q

Tachycardia

A

Rate greater than expected range, or 100/min

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35
Q

Factors that lead to tachycardia

A

1-exercise,2-fever/heat exposure,3-meds,4-changing position from lying down to sitting/standing,5-acute pain,6-hyperthyroidism,7-anemia,hypoxemia,8-stress/anxiety/fear,9-hypovolemia,shock,heart failure,hemorrhage

36
Q

Meds that cause tachycardia

A
  • epinephrine
  • levothyroxine
  • beta2-adrenergic agonists(albuterol)
37
Q

Bradycardia

A

Rate less than expected range or slower than 60/min

38
Q

Factors leading to bradycardia

A

1-long term physical fitness,2-hypothermia,3-meds,4-changing position from standing/sitting to lying down,5-chronic,severe pain,6-hypothyroidism,7-relaxation

39
Q

Nurse interventions, monitor for…

A

1-pain,2-anxiety,3-fatigue,4-shock,5-insomnia,6-medication side effects(know expected outcomes)

40
Q

Meds that cause bradycardia

A
  • digoxin
  • beta blockers(propranolol)
  • calcium channel blockers(verapamil)
41
Q

Peripheral pulse points

A 
1-carotid
2-brachial
3-femoral
4-radial
5-dorsalis pedis
6-posterior tibial
42
Q

Two types of pulses

A

Peripheral(felt or palpated) and apical(auscultated)

43
Q

Apical pulse

A

Auscultated(listened to) over the apex of the heart;lub-dub

44
Q

Nursing dx

A
  • decreased cardiac output due to blood loss
  • ineffective peripheral tissue perfusion(disease)
  • deficient fluid volume
  • acute pain
45
Q

Respiration definition

A
  • Chemoreceptors in carotid arteries & aorta primarily monitor carbon dioxide levels of the blood.
  • rising CO2 triggers respiratory center of brain to increase RR
  • increased RR rids body of CO2
46
Q

Process of Respiration

A

1-ventilation,2-diffusion,3-perfusion

47
Q

Ventilation

A
  • Exchange of oxygen&carbon dioxide in the lungs

- measure w/ the RR,rhythm,&depth

48
Q

Diffusion

A
  • exchange of oxygen&carbon dioxide between alveoli & red blood cells
  • Measure w/ pulse oximetry
49
Q

Perfusion

A
  • flow of red blood cells to and from the pulmonary capillaries
  • measure w/ pulse oximetry
50
Q

Rate

A
  • number of full inspirations/expirations in 1 min
  • determined by observing number of times pts chest rises/falls
  • expected reference range is 12 to 20/min
51
Q

Depth

A
  • amount of chest wall expansion that occurs w/ each breath

- altered depths are deep or shallow

52
Q

Rhythm

A
  • observation of breathing intervals

- expect a regular rhythm(eupnea) w/ an occasional sigh

53
Q

Pulse Oximetry

A
  • noninvasive, indirect measurement of oxygen saturation of the blood
  • percent of hemoglobin that is bound w/ oxygen in arteries is the percent of saturation of hemoglobin
  • reference range is 95% to 100%
  • acceptable levels for some is 91% to 100%
54
Q

Factors affecting respirations

A

1-Age=rate decreases w/ age(newborns=35-40/min;school aged=20-30/min)
2-Sex=men/children=diaphragmatic breathers/abdominal movements more noticeable;women=thoracic muscles,chest more pronounced
3-Pain=can decrease respirations;increases at first then stabilizes
4-Anxiety=increases rate&depth
5-Acid base balance=illnesses, COPD,emphysema
6-meds
7-Neurological injury=brain stem decreases rate&rhythm
8-Anemia=low oxygen;increases in RR & alterations in rhythm to compensate

55
Q

Tachypnea

A

Increased respirations

56
Q

Bradypnea

A

Decreased respirations

57
Q

Apnea

A

Absence of respirations

58
Q

Dyspnea

A

Difficulty w/ respirations

59
Q

Orthopnea

A

Difficulty w/ respirations while lying flat

60
Q

Respiratory patterns

A

1-Cheyne-stokes=near death breathing pattern;stop-go
2-tachypnea=fast
3-bradypnea=slow
4-biots=irregular

61
Q

Nursing dx

A
  • ineffective breathing pattern
  • impaired gas exchange
  • risk for activity intolerance
62
Q

Blood Pressure-definition and formula

A

-How stretchy your arteries are
-Cardiac output & Systemic (peripheral) vascular resistance
BP=CO x SVR

63
Q

Systole

A

Top reading of BP, highest amount of pressure on artery

64
Q

Diastole

A

Bottom reading of BP; lowest amount of pressure on artery

67
Q

Cardiac output is determined by

A

1-HR
2-Contractility
3-Blood volume
4-Venous return
-increases in any of these increase CO and BP
-decreases in any of these decrease CO and BP

68
Q

Systemic Vascular Resistance(SVR) reflects

A

The amount of constriction or dilation of the arteries, & diameter of blood vessels

  • increases in SVR increase BP
  • decreases in SVR decrease BP
69
Q

Classifications of BP: normal

A

Systolic=less than 120 AND

Diastolic=less than 80

70
Q

Classifications of BP: prehypertension

A

Systolic=120-139 OR

Diastolic=80-89

71
Q

Classifications of BP: stage 1 hypertension

A

Systolic=140-159 OR

Diastolic=90-99

72
Q

Classifications of BP: stage 2 hypertension

A

Systolic=greater than 160 OR

Diastolic=greater than 100

73
Q

Classification: How to classify

A
  • base classification on highest reading
  • pt who has 124/92 has stage 1 instead of prehypertension because DBP places pt in that category
  • If pt has SBP over 140 and DBP over 90 that are avgs of 2 or more readings, pt must come back for 2 or more visits for additional readings
  • if readings are elevated on 3 separate occasions over several weeks,pt has hypertension
74
Q

Orthostatic(postural) Hypotension definition

A
  • BP that decreases when pt changes position from lying to sitting or standing
  • it can result from various causes(peripheral vasodilation,med adverse effects,fluid depletion,anemia,prolonged bed rest)
  • **see chart on p. 598
75
Q

Orthostatic Hypotension: how to assess

A

1-take pts BP and HR in supine position
2-have pt change to sitting or standing, wait 1-3 min and reassess BP and HR
3-pt has OH if the SBP decreases more than 20 and/or DBP decreases more than 10 w/ a 10-20% increase in HR
**Do NOT delegate this procedure to an assistive personnel

76
Q

Factors affecting BP

A 
1-age
2-circadian rhythms 
3-stress
4-ethnicity
5-sex
6-meds
7-exercise
8-obesity
9-family hx
77
Q

Factors affecting BP: Age

A
  • infants=have lower BP that increases w/ age
  • older children/adolescents=varying BP based on body size;larger kids have higher BP
  • adults=can increase w/ age
  • older adults=can have a slightly elevated systolic pressure due to decreased elasticity of blood vessels
78
Q

Factors affecting BP: Circadian rhythm

A
  • BP lowest in early morning

- peaks during later part of afternoon/evening

79
Q

Factors affecting BP: Stress

A

Associated w/ fear,emotional strain, and acute pain; increases BP

80
Q

Factors affecting BP: ethnicity

A

AA have a higher incidence of hypertension in general and at earlier ages

81
Q

Factors affecting BP: Sex

A
  • Adolescent to middle-aged men have higher BP than female counterparts
  • Postmenopausal women have higher BP then their male counterparts
82
Q

Factors affecting BP: Meds

A
  • lower BP=opiates,antihypertensives,cardiac meds

- raise BP=cocaine,nicotine,cold medications,oral contraceptives,alcohol and antidepressants

83
Q

Factors affecting BP: exercise

A
  • During=increases SBP

- After=Can cause a decrease in BP for several hrs after

84
Q

Factors affecting BP: obesity

A

Contributes to hypertension

85
Q

Factors affecting BP: Diet

A
  • Diets high in sodium increase risk of hypertension

- BP increases after eating food

86
Q

Factors affecting BP: family hx

A

Family hx of hypertension can increase the risk, this is an example of a nonmodifiable factor

87
Q

Hypotension definition

A
  • BP below the expected reference range(SBP less than 100/DBP below 60) & can be a result of fluid depletion,heart failure,or vasodilation
  • seen in athletes,blood loss or ineffective pump
88
Q

Pulse pressure definition

A

Difference between the SBP and DBP readings

Unit 2 (12 decks)

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