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

ATI/PPT vital signs CH 27 Flashcards

(86 cards)

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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
What is the pulse made of?
1-rate(BPM),2-quality,(strong vs. weak)3-rhythm,4-volume,5-equality
26
Rate
Number of times per minute you feel/hear the pulse
27
Rhythm
Regularity of impulses
28
Strength(amplitude) or stroke volume
- 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
29
Equality
- 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
30
Cardiac output
Amount of blood per minute CO=SV x HR
31
Pulse deficit
Difference in apical/radial pulse | -must be done by 2 nurses
32
Dysrhythmia
Irregular heart rhythm, generally with an irregular radial pulse
33
Expected HR range
Adults=60-100/minat rest Infants=120-160/min Adolescent=80-90/min
34
Tachycardia
Rate greater than expected range, or 100/min
35
Factors that lead to tachycardia
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
Meds that cause tachycardia
- epinephrine - levothyroxine - beta2-adrenergic agonists(albuterol)
37
Bradycardia
Rate less than expected range or slower than 60/min
38
Factors leading to bradycardia
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
Nurse interventions, monitor for...
1-pain,2-anxiety,3-fatigue,4-shock,5-insomnia,6-medication side effects(know expected outcomes)
40
Meds that cause bradycardia
- digoxin - beta blockers(propranolol) - calcium channel blockers(verapamil)
41
Peripheral pulse points
``` 1-carotid 2-brachial 3-femoral 4-radial 5-dorsalis pedis 6-posterior tibial ```
42
Two types of pulses
Peripheral(felt or palpated) and apical(auscultated)
43
Apical pulse
Auscultated(listened to) over the apex of the heart;lub-dub
44
Nursing dx
- decreased cardiac output due to blood loss - ineffective peripheral tissue perfusion(disease) - deficient fluid volume - acute pain
45
Respiration definition
- 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
Process of Respiration
1-ventilation,2-diffusion,3-perfusion
47
Ventilation
- Exchange of oxygen&carbon dioxide in the lungs | - measure w/ the RR,rhythm,&depth
48
Diffusion
- exchange of oxygen&carbon dioxide between alveoli & red blood cells - Measure w/ pulse oximetry
49
Perfusion
- flow of red blood cells to and from the pulmonary capillaries - measure w/ pulse oximetry
50
Rate
- 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
Depth
- amount of chest wall expansion that occurs w/ each breath | - altered depths are deep or shallow
52
Rhythm
- observation of breathing intervals | - expect a regular rhythm(eupnea) w/ an occasional sigh
53
Pulse Oximetry
- 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
Factors affecting respirations
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
Tachypnea
Increased respirations
56
Bradypnea
Decreased respirations
57
Apnea
Absence of respirations
58
Dyspnea
Difficulty w/ respirations
59
Orthopnea
Difficulty w/ respirations while lying flat
60
Respiratory patterns
1-Cheyne-stokes=near death breathing pattern;stop-go 2-tachypnea=fast 3-bradypnea=slow 4-biots=irregular
61
Nursing dx
- ineffective breathing pattern - impaired gas exchange - risk for activity intolerance
62
Blood Pressure-definition and formula
-How stretchy your arteries are -Cardiac output & Systemic (peripheral) vascular resistance BP=CO x SVR
63
Systole
Top reading of BP, highest amount of pressure on artery
64
Diastole
Bottom reading of BP; lowest amount of pressure on artery
67
Cardiac output is determined by
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
Systemic Vascular Resistance(SVR) reflects
The amount of constriction or dilation of the arteries, & diameter of blood vessels - increases in SVR increase BP - decreases in SVR decrease BP
69
Classifications of BP: normal
Systolic=less than 120 AND | Diastolic=less than 80
70
Classifications of BP: prehypertension
Systolic=120-139 OR | Diastolic=80-89
71
Classifications of BP: stage 1 hypertension
Systolic=140-159 OR | Diastolic=90-99
72
Classifications of BP: stage 2 hypertension
Systolic=greater than 160 OR | Diastolic=greater than 100
73
Classification: How to classify
- 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
Orthostatic(postural) Hypotension definition
- 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
Orthostatic Hypotension: how to assess
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
Factors affecting BP
``` 1-age 2-circadian rhythms 3-stress 4-ethnicity 5-sex 6-meds 7-exercise 8-obesity 9-family hx ```
77
Factors affecting BP: Age
- 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
Factors affecting BP: Circadian rhythm
- BP lowest in early morning | - peaks during later part of afternoon/evening
79
Factors affecting BP: Stress
Associated w/ fear,emotional strain, and acute pain; increases BP
80
Factors affecting BP: ethnicity
AA have a higher incidence of hypertension in general and at earlier ages
81
Factors affecting BP: Sex
- Adolescent to middle-aged men have higher BP than female counterparts - Postmenopausal women have higher BP then their male counterparts
82
Factors affecting BP: Meds
- lower BP=opiates,antihypertensives,cardiac meds | - raise BP=cocaine,nicotine,cold medications,oral contraceptives,alcohol and antidepressants
83
Factors affecting BP: exercise
- During=increases SBP | - After=Can cause a decrease in BP for several hrs after
84
Factors affecting BP: obesity
Contributes to hypertension
85
Factors affecting BP: Diet
- Diets high in sodium increase risk of hypertension | - BP increases after eating food
86
Factors affecting BP: family hx
Family hx of hypertension can increase the risk, this is an example of a nonmodifiable factor
87
Hypotension definition
- 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
Pulse pressure definition
Difference between the SBP and DBP readings

Unit 2 (12 decks)

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