Assessing Vital Signs Flashcards
(84 cards)
1
Q
These are physical signs that indicate an individual is alive, such as heartbeat, breathing rate, temperature, blood pressures and recently oxygen saturation.
A
Vital sign
2
Q
VITAL SIGN
- These signs may be observed, measured, and ___________ to assess an individual’s level of physical functioning.
A
monitored
3
Q
Normal vital signs _______ with age, sex, weight, exercise tolerance, and condition.
A
change
4
Q
Vital signs include the following. What are these?
A
- Temperature (T/Temp)
- Pulse Rate (BPM)
- Respiratory rate (BPM/CPM)
- Blood pressure (mmHg)
- Pain (Pain scale)
ADD: Oxygen Saturation (%)
5
Q
FAMILIARIZE ONLY!
Guidelines for Obtaining Vital Signs
The nurse must be able to do all of the ff:
- Measure vital signs correctly.
- Understand and interpret the values.
- Communicate findings appropriately.
- Begin interventions as needed.
A
NOTE:
- Activity (talking, gum-chewing, and anxiety) affect the VS. Allow 5 minutes of rest before beginning to take the VS.
6
Q
What is the normal range of temperature for old people?
A
95 F to 97.5 F (35-36.38C)
7
Q
Old people, people with disabilities, babies, and young children typically feel more comfortable at __________.
A
higher temperatures
8
Q
This is measured in either Celsius or Fahrenheit, with a fever defined as greater than 38-38.5 C or 101-101.5 F.
A
Temperature
9
Q
What are the 5 Routes in getting temperature?
A
- Oral
- Rectal
- Axillary
- Tympanic
- Temporal
REMEMBER THE ACRONYM ORATT
10
Q
What is the Normal Range Temp in Oral Route?
A
35.9 - 37.5 C
11
Q
What is the Normal Range Temp in Rectal Route?
A
36.3 - 37.9 C
Note:
- This is 0.4 - 0.5 higher than Oral temp
12
Q
What is the Normal Range Temp in Axillary Route?
A
35.4 - 37.0 C
This is 0.5 C (1F) lower than oral.
13
Q
What is the Normal Range Temp in Tympanic Route?
A
36.7 - 38.3 C
14
Q
What is the Normal Range Temp in Temporal Route?
A
36.3 - 37.9 C
15
Q
Advantages of this Route in getting Temperature
- Convenient, accessible
What route is this?
A
Oral
16
Q
Advantages of this Route in getting Temperature
- This is considered most accurate.
What route is this?
A
Rectal
17
Q
Advantages of this Route in getting Temperature
- Safe; noninvasive accuracy.
What route is this?
A
Axillary
18
Q
Advantages of this Route in getting Temperature
- Convenient, fast, safe, noninvasive does not require contact with any mucus membrane.
What route is this?
A
Tympanic
19
Q
Advantages of this Route in getting Temperature
- Noninvasive device.
What route is this?
A
Temporal
20
Q
In Tympanic temperature, below 36.7 C indicates what?
A
Hypothermia
21
Q
In Tympanic temperature, above 38.3 C indicates what?
A
Hyperthermia
22
Q
Older adult = their temperature is consistently _________ in ALL ROUTES.
A
lower
23
Q
CELSIUS TO FAHRENHEIT Formula
A
°F = (9/5 x °C) + 32
Note:
- 9/5 = 1.8
24
Q
FAHRENHEIT TO CELSIUS Formula
A
°C = 5/9 (°F - 32)
Note:
- Solve for the value inside the Parenthesis first.
25
What are the **2 Types of Body Temperature**?
* Core Temperature
* Surface Temperature
26
What type of temperature is this?
* Temperature of the deep tissues of the body.
* Remains relatively constant unless exposed to severe extremes in environmental temperature
* Assessed by using a thermometer
Core temperature
27
What type of temperature is this?
* Temperature of the skin
* May vary a great deal in response to the environment
* Assessed by touching the skin.
Surface Temperature
28
Temperature measurements are obtained by several methods. What are these?
Note: *There are 3*
* Heat-sensitive patches
* Electronic thermometers
* Tympanic thermometer
29
TYPE OF TEMPERATURE METHOD
* **Patch placed on the skin; color changes on the patch indicate temperature readings.**
Heat-sensitive patches
30
TYPE OF TEMPERATURE METHOD
* **Consist of a rechargeable battery-powered display unit, a thin wire cord, and a temperature processing probe.**
Electronic thermometers
31
TYPE OF TEMPERATURE METHOD
* **A special form of the electronic thermometer; is inserted into the auditory canal.**
Tympanic thermometer
32
WHAT IS THIS?
* When the temperature is above normal (38.3 C or 100.9 F)
Pyrexia, Febrile, or Hyperthermia
33
Fever is a ________, it will destroy invading bacteria.
body defense
34
What are the **3 Classification of Fevers**?
* Constant
* Intermittent
* Remittent
35
CLASSIFICATION OF FEVERS
* **Remains elevated consistently**
Constant
36
CLASSIFICATION OF FEVERS
* **Rises and falls**
Intermittent
37
CLASSIFICATION OF FEVERS
* **Temperature never returns to normal until the patient becomes well**
Remittent
38
This is an **abnormally low** body temperature.
**Hypothermia** (below 36.7 C or 98.0F) drop to 35 C (95F)
39
LOCATION OF PULSES
* Temporal artery
* Carotid
* Apical pulse
* Brachial
* Radial
* Femoral
* Popliteal
* Posterior tibial artery
* Pedal
40
The normal pulse for healthy adult's ranges from ___________ beats per minute (bpm)
60-100
41
Normal pulse rate
* Birth to 3 months
100-150 bpm
42
Normal pulse rate
* 1-3 years old
70-110 bpm
43
What are the **5 Characteristics of the radial pulse**?
* **R**ate
* **R**hythm
* **A**mplitude
* **C**ontour
* **E**lasticity
REMEMBER THE ACRONYM ***R-RACE***
44
In AMPLITUDE OF RADIAL PULSE, the number given means what?
* **0**
Absent
45
In AMPLITUDE OF RADIAL PULSE, the number given means what?
* **1+**
Weak, diminished
46
In AMPLITUDE OF RADIAL PULSE, the number given means what?
* **2+**
Normal
47
In AMPLITUDE OF RADIAL PULSE, the number given means what?
* **3+**
Bounding (requires firm pressure)
48
The pulse rate may _____________ with exercise, illness, injury, and emotions.
flunctuate and increase
49
Girls ages 12 and older and women, in general, tend to have _______ heart rates than do boys and men.
**faster**
Note: This is because of the production of **Estrogen**
50
In ________ Rhythm:
* Count in 15 seconds x 4
* Count in 30 seconds x 2
Regular
51
In ________ Rhythm:
* Count in full minute
* FF up with the Apical pulse
Irregular
52
Under what CHARACTERISTICS OF PULSE RATE is this?
* **With the two fingers feeling for each beat for regularity (equal length of time between each beat) or irregularity (unequal length of time between beats)**
Rhythm
53
Under what CHARACTERISTICS OF PULSE RATE is this?
* Does the pulse volume feel normal? This reflects changes in stroke Volume.
Volume (Amplitude and Contour)
54
In __________, the pulse volume is relatively low.
Hypovolemia
55
Palpate for the ___________, this is the best assessment for amplitude.
What artery is this?
Carotid artery
56
Under what CHARACTERISTICS OF PULSE RATE is this?
* Artery feels straight, resilient, and springy.
* The artery feels rigid.
Elasticity
57
WHAT IS THIS?
* The pulse is **faster than 100** beats per minute.
* It may result from shock, hemorrhage, exercise, fever, acute pain, and drugs.
Tachycardia
58
WHAT IS THIS?
* The pulse is **slower than 60** beats per minute.
* It may result from unrelieved severe pain, drugs, resting, and heart block.
Bradycardia
59
The **Point of Maximum Impulse** is at the ___________.
Assessing apical pulse
Fifth intercostal space
60
This represents the **actual beating of the heart**.
Apical pulse
61
WHAT IS THIS?
* The difference between **radial** and **apical** rates; signifies that the pumping action of the heart is faulty. (1 min each)
Pulse deficit
62
WHAT IS THIS?
* Observing the rise and fall of the patient's hospital gown while you appear to be taking their pulse.
Respiratory rate
63
Count RR for 30 secs x 2 = _________.
RRcpm
64
Normal RR range?
**12 - 20** breaths/min
65
Normal RR range for old people?
**15 - 22** breaths/min
66
Respiratory rates over 20 or under 12 breaths per minute (when at rest) may be considered ________.
abnormal
67
FAMILIARIZE ONLY!
**"Remember the following for accuracy of your BP readings"**
* Instruct client to avoid Nicotine & caffeine 30 mins prior to measurement
* Empty bladder and avoid talking to client.
68
FAMILIARIZE ONLY!
**"Position of the Patient while getting their BP"**
* Sitting position
* Arm and back are supported
* Feet should be resting firmly on the floor
* Feet not dangling
* Raise patient arm so that the brachial artery is roughly at the same height as the heart. If the arm is held too high, the reading will be artifactually lowered, and vice versa.
69
In BP Readings,
* The **higher number**; represents the ventricles contracting.
**Systolic** ( < 120 mmHg)
70
In BP readings,
* The **second number**; represents the pressure within the artery between beats.
**Diastolic** ( < 80 mmHg)
71
WHAT IS THIS?
* This is the **difference between systolic and diastolic**
**Pulse Pressure** (30-50 mmHg)
72
IN GETTING THE BP
* If the cuff is too small, the readings will be artificially _________.
elevated
73
IN GETTING THE BP
* If the cuff is too large, the readings will be artificially __________.
lowered
74
FAMILIARIZE ONLY!
**"In order to measure the BP"**
* Systolic blood pressure is the pressure at which you can first hear the pulse
* Diastolic blood pressure is the last pressure at which you can still hear the pulse (Phase V)
* Avoid moving your hands or the head of the stethoscope while you are taking readings as this may produce noise that can obscure the Sounds of Korotkoff.
**REMEMBER FOR ACCURACY OF READINGS**
* If the BP is surprisingly high or low, repeat the measurement towards the end of your exam. (Repeated blood pressure measurement can be uncomfortable)
75
What stage of abnormal result is this in BP?
* **Systolic pressure consistently 120 to 139, or diastolic 80 to 89**
Pre-high blood pressure
76
What stage of abnormal result is this in BP?
* **Systolic pressure consistently 140 to 159, or diastolic 90 to 99.**
Stage 1 high blood pressure
77
What stage of abnormal result is this in BP?
* **Systolic pressure consistently 160 or over, or diastolic 100 or over**
Stage 2 high blood pressure
78
What abnormal result is this in BP?
* May be indicated by a **systolic pressure lower than 90**, or a pressure 25 mmHg lower than usual.
Hypotension
79
What abnormal result is this in BP?
* **High blood pressure greater than 139 - 89**
Hypertension
80
FAMILIARIZE ONLY!
**"Blood pressure may be affected by many different conditions"**
* Cardiovascular disorders
* Neurological conditions
* Kidney and urological disorders
* Pre eclampsia in pregnant women
* Psychological factors such as stress, anger, or fear
81
This form of low blood pressure might cause **dizziness, lightheadedness or fainting** when rising from sitting or lying down.
Orthostatic Hypotension
82
FAMILIARIZE ONLY!
**"Remember the following for accuracy of your readings"**
* Orthostatic (postural) measurements of pulse and blood pressure are part of the assessment for hypovolemia
* First measuring BP when the patient I supine and then repeating them after they have stood for 2 minutes, which allows for equilibration.
83
WHAT IS THIS?
* Measurement of gas exchange and red blood cells oxygen carrying capacity has become available in all hospitals and many clinics.
Oxygen Saturation
84
This provide important information about cardio-pulmonary dysfunction and is considered by many to be a **fifth vital sign**. What is this?
Oxygen Saturation
