Ch. 17 Measuring vital signs Flashcards Preview

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______ _______ are a means of assessing vital or critical physiological functions. one of the most frequent assessments and variations reflect a person's state of health and/or functional ability of the body systems

vital signs

Includes temp, pulse, respirations, BP, SA02, Pain


Even though vital signs are performed on a regular basis what is the frequency determined by?

physician order and/or nursing judgment

facility standards (hospital is typically every 4-8 hours)

How often also depends on the pt’s condition and the events taking place (Common occasions include: admission, beginning of shift, visit to clinic/office, before-during-after surgery or procedures, after administration of drugs, when conditions change.)


A patient is relying on carbon dioxide instead of oxygen. This is known as?

chronic obstructive pulmonary disease (COPD)

if you give the pt. O2 leave it at 2-4 liters or they will have respiratory problems/wont be able to breathe


what is the only exception for not having a prescribed order?

Oxygen because you do not want the pt. to die while trying to find a doctor. BUT get a doctor order asap!


If a pt. needs more than 8 liters of oxygen what do you do?

change the mask or consult with a doctor


what are facility standards for monitoring?

Hospital: every 4-8 hours

Home health: each visit

Clinic: each visit

Skilled nursing facility: weekly to monthly


Your pt. just came from the OR, how often should you monitor them?

every 15 min for the 1st hour then if the pt. is stable you can monitor less frequently


______ is the degree of heat maintained by the body. Heat produced minus heat lost.


Can be affected by
environment - hot shower = hot skin
sex-women temp changes due to hormones
exercise - you exercise to increase temp to burn calories
emotions and stress - triggers sympathetic, releases epi and norepi
circadian rhythm - temp fluctuates 1-2 degrees F over 24 hours.


What are the symptoms of fever?

Body/muscle aches


The doctor orders a _________ __________ that states "if this happens, do this!" Example: "if pain is more than 5, give more norco"

Standing order

There can be multiple standing orders if the first standing order does not work


What is the core temperature?

97-100.8 degrees Fahrenheit/ 36.1-38.2 degrees Celsius.

Typically 1-2/0.6-1.2 degrees higher than skin temperature


___________ temperature is lower than core temperature and uses the oral and axillary method.

Surface (review table 17.3)


Changes in temperature can occur in four ways:
List them



____________ is transfer of heat from a warm to a cool surface by direct contact. Example: If a patient lies on a cold examination table, the heat from the skin will leave the patient and go onto the cold table.



__________ is transfer of heat through currents of air or water.

Example: . Putting a febrile pt into a cool tub or using a fan to reduce fever.



________ is the loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air.

Example: The reason a room gets warm once it is crowded; our body heat leaves us to go to the cool air.



During _________ water is converted to vapor and lost from the skin (perspiration) or the mucous membranes (through the breath)

Note: “insensible loss” – water loss by evaporation



Also known as fever, ________ results in abnormally high temp in response to pyrogens (bacteria). More than 100 degrees Fahrenheit or 37.8 degrees Celsius.


Antigen enters-->Phagocytes attack antigen-->pyrogens are stimulated-->induce prostaglandins-->reset hypothalamic thermostat to change temperature of body.

Some fevers are good – killing invaders!


_______ induces secretion of substances (prostaglandins) that reset the hypothalamic thermostat at a higher temp



What is the difference between intermittent and remittent fever? Both are within a 24-hour period, but....

If the temperature returns to normal at any point in a 24-hour period, it is considered intermittent. Remittent also endure fluctuations, but ALL fluctuations remain above normal temperature.

Remittent - Ebola
Intermittent - Flu


Remittent fever and constant fever both fluctuate. What is the difference?

Constant has a lower degree of fluctuation, less than one degree.

Remittent tends to be greater than three degrees in fluctuation.

Constant - infection/immunocompromised


Why should we avoid treating a fever below 102?

THe body uses the heat to kill or inhibit the growth of microbes; enhances phagocytosis; causes breakdown of lysosomes (self destruction of infected cells); releases interferons (which interfere with viral infection).


What is the term for meds that reduce fevers?



IN hospitals tympanic is used most of the time to check temp. What are the benefits and the downside?

super fast, can be used on anyone. Downside, ear wax can affect reading, needs careful positioning to be accurate.


Signs of fever?

– sweating, shivering, elevated BP/Pulse


True or False: Pregnant women have higher baseline body temp



What is the common range for core temp?

CORE: 97-100.8


T or F: Typically core temperature is 1°F to 2°F (0.6°C to 1.2°C) higher than skin temperature.



The route of ________ temperature taking is most accurate for core; least preferred by pt.; contraindicated for cardiac conditions and newborns who can be injured due to fragile rectal mucosa.



Upside and downside to using Oral and Axillary to check temp:

Oral- upside:Safe, convenient, comfortable; downside: eating/drinking can throw off reading

Axillary- upside: safe, easy to use, good for children and unconscious adult; recommended over rectal. Downside-not good for heavy perspirer, least accurate, not reflective of core.


What part of the body controls thermoregulation?


Hypothalamus controls thermoregulation!

HOT? Then, Vasodilationblood to surface, skin sweats=cooler body temp.

COLD? Then, vasoconstrictionshunts blood away from surface and into core of body. Shivering+Epinephrine=increased metabolism (p.319)
Metabolism-uses energy&generates heat


________ is a fever >105.8°F (41.0°C) and it can cause seizures; very dangerous and requires intervention.


105.8 temperaure and above damages cells, esp brain and can cause confusion stupor or coma. At 109 a person dies.


________ is when the Core temperature below normal (


Monitor for dysrhythmias

Sometimes dr deliberately puts body into hypothermic state to decrease the need for oxygen in body tissues (during cardiac and neurological surgery)


As a fever runs its course, it has three different phases:
1. Initial phase - febrile episode/onset
2. Second phase - course
3. Third phase - defervescence or crisis

Describe each phase

Initial - Febrile episode
Onset of the fever…
Body temp is rising (sudden or gradual)
Pt feels chilly, uncomfortable & may shiver

Second – Course
Reaches maxixum temperature aka “set point”
Remains constant
Feels warm & dry, flushed; may last a few days-few weeks

Third - Defervescence or crisis

Definition of defervescence - the abatement of a fever as indicated by a decrease in bodily temperature.

Feels warm & flushed DUE to vasodilation
Diaphoresis (sweating to an unusual degree as a symptom of a disease) assists with heat loss by evaporation
“fever is breaking” & temp returns to normal


When a person gets a fever, the hypothalamus regulates the temperature. HOwever, when ________ occurs, the body cannot promote heat loss fast enough to balance and heat exhaustion or heat stroke can occur.


heat exhaustion is up to 103, after 103 its heat stroke


________ fever comes in short periods of fever alternating with periods of normal temp; lasting 1-2 days


TB pt would have this


The nurse would monitor the body temperature most closely/frequently in the care of

a. The client with an infection
b. The client who is an infant
c. The client who has experienced heat stroke
d. The client with a head injury

All of the clients depicted would need to have their temperatures monitored closely. However, a client with a head injury may have damage to the hypothalamus and therefore loss of global thermoregulation. The temperature of this client would need to be monitored more frequently.


To convert from fahrenheit to celsius...

(Temperature in F) - 32 X (5/9)=

102 f - 32 x (5/9) = 39


What sites are used to take temp in clinic setting:

From temperature lowest to highest reading: axillae, oral, tympanic, rectal, temportal artery.


The _____ is the rhythmic expansion of an artery produced when a bolus of blood is forced into it by contraction of the heart. The “wave” that begins when the left ventricle contracts and ends when the ventricle relaxes.


Each contraction forces blood into the already-filled aorta, causing increased pressure within the arterial system. The pulse that we feel is the peak of the wave when the artery expands. You cannot feel the pulse during a trough (low point).


What can you use if you cannot feel a pulse to find the pulse?

A doppler


Normal pulses are higher in newborns and decrease over the lifespan. A newborn's pulse is on average 130. A toddler's pulse is around 110. From 6-10, it is in the 90's.

What is the rate for teens - adults over 70?

Pulse rate - Measured in beats per minute (bpm)

Normal range for healthy adults = 60–100 bpm
Average = 70–80 bpm


VIDEO BP explained (shows how pressure is created in arteries)


VIDEO Cardiac Cycle explained

Think in terms of ventricles.
Relaxed = diastole (dilated ventricle - wide open for filling)


Video: CO/Stroke Volume/Preload/Afterload (part 1)

Watch part 2 after 1.


Cardiac output is the TOTAL VOLUME of blood ejected from the _____ ______ in one minute.

Stroke Volume X Pulse

Left ventricle

Total ouput


______ ______ is the amount of blood in ONE good clean PUMP (one contraction) out of the left ventricle.
Avg is 70mL.

Stroke Volume

output of one stroke


T or F: autonomic nervous system regulates the heart rate.. Sympathetic increases HR, Parasympathetic decreases HR.



Factors that influence pulse rate include:

Developmental level - newborns more rapid

Sex - females beats faster typically

Exercise - duh

Food- spicy food will elevate temp and HR releases endorphins and seratonin

Stress – work related.

Fever - raises 10 beats per degree fahrenheit increased (remember metabolism speeds to increase temp);
1)metabolic rate increaes and 2)body attempts to compensate for decrease in BP produced by vasodilation that occurs

Disease-asthma/copd/Ca K prob/ can lower HR

Blood loss-

Position changes - higher when standing sitting compared to lying


Review page 331


Best place to check pulse?

(5 ics midclavicular, lateral to nipple/diagonal) apical, listen for one full minute, should not be lower than 60

Apical is most accurate
Use a stethoscope to auscultate the number of heartbeats at the apex of the heart
A heartbeat is one series of the LUB and DUB sounds


Peripheral pulses and apical pulses are typically the same. So when would you be required to check the apical?

If radial pulse is weak; if the rate is less than 60 or greater than 100; patient is taking cardiac meds (has cardio disease).


Name the pulses!

1. apical
2. carotid
3. brachial
4. radial
5. femoral
6. popliteal
7. dorsal pedalis


A person with a pulse below 60bpm is considered to be ____cardia.

A person with a pulse above 100bpm is considered to be ____cardia.




When documenting a pulse what info should you include?

Which pulse was used, the bpm, description of strength, normal or irregular,and whether or not it was bilaterally equal.


Radial pulse 80 beats/min, strong, regular, equal bilaterally.


Intervals between heart beast es a pulse pattern we refer to as the rhythm. Normally, the heart beats at regular intervals, much like a metronome. When the beats vary enough to be noticed the rhythm is called ______



Pulse volume is the amount of force produced by the blood pulsing through the arteries. There are numbers assigned on a scale of 0 to 3. What do those numbers represent?

0- no pulse felt
1 - weak/thready
2 - normal; not weak or bounding
3 - Bounding or full; little o=pressure needed to be felt


Your patient complains of poor circulation in his left hand. What steps do you take in assessing the pulse?

Check both sides to compare the left hand to the right. This will help determine if the circulation has been compromised in that extremity.


_______ refers to paleness of skin when compared with another part of the body

_______ refers to a bluish or grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood

pallor; (pallor or pale-er...she is pale-er in one area than another)

cyanosis (cyan=blue; cyanara if you don't fix the problem, running out of air!)



– cyanosis around the mouth


The nurse is assessing the dorsalis pedis pulses on an 88-year-old client. She notes the feet to be cool and assesses weak, thready pulses. The nurse’s next action would be to

a. Assess the popliteal and femoral pulses
b. Assess a 1-minute apical pulse
c. Notify the physician STAT
d. Apply a warm pack and reassess in 20 minutes

The question is telling us the pt is cool and has a weak pulse....We are quite distal to the heart, so what should we do?

A - Assess the popliteal and femoral pulses

Completing an assessment of other peripheral pulses will provide further data about the adequacy of circulation to the legs.


Review the following nursing diagnosis that could cause weak/thready pulse

Ineffective tissue perfusion

risk for impaired skin integrity

deficient fluid volume

excess fluid volume

decreased cardiac output


_______ is the exchange of oxygen and carbon dioxide in the body (one inspiration + one expiration = cycle)



Respiration involves two separate processes: Mechanical and Chemical.

The movement of air into and out of the resp sys is _______.

The exchange of oxygen and carbon dioxide is ______.

mechanical (physical)

chemical (CO2 and O2 are chemicals)


What is the common term for pulmonary ventillation?



A normal respiratory rate for a newborn is 40-90bpm.
Toddlers range from 20-40. Children from 20-25. What is the range from teens until adulthood?



CEntral chemorreceptors are sensitive to changes in CO2 and pH. A minor increases in either of these results in:

stimulation of respirations

(Body needs to expel when the level is too high... must breath it out!)


Partial pressure of oxygen in arterial blood (PaO2) is usually between 80-100. When this number falls below normal, peripheral chemoreceptors in the carotid and aortic bodies....

stimulate respirations.

Need to breath in more O2!


_______ is caused by negative pressure that occurs when the thorax expands; _____ is the exact opposite


expiration (muscles relax, decreasing size of chest)

inspiration takes longer than expiration


What factors affect respiration?

developmental level - faster as newborn
exercise - duh
pain - increase in resp rate but decrease in depth. Think of stubbing your toe and how you breathe.
stress - anxiety or fear , think panic breathing
fever - for every 1 degree fahrenheit the temp rises, rep ate increase 4 breaths
hemoglobin - increases in an effort to maintain adequate oxygen due to decreased amt of hemoglobin
blood loss - same as BP, starts off normal but increases as more blood is lost
position - standing maximizes resp depth, lying flat reduces depth.


What observations do we make when assessing respiration?

Respiratory rate (# of times a person breathe in a full minute; count for full minute is new pt and to ensure accuracy vs for 15-30)

depth (tidal volume is the amt of air taken in on inspiration) - can be deep, shallow, or normal

rhythm-regular or irregular (cheyne stokes in the dying, Biot's, kussmauls)

effort-effortless, dyspnea (labored breathing), orthopnea (inability to breath lying down), bradypnea, tachypnea


What should we do if the respiratory rate varies from normal?

count for a full minute by auscultation instead of watching the chest/abdomen rise and fall.


If you adminstered a narcotic and the patient's breathing is bradypnea, what can you give them to fix this?

NARCAN aka NALOXONE 0.5mg every 5 min, three times


The nurse will expect to find a slower respiratory rate in the client who has smoked for many years.

a. True
b. False


Clients who have smoked over many years will have an increased respiratory rate to compensate for loss of elasticity of the airway.


How do you know if a person has ronchi vs rales?

After coughing Ronchi clears


Breath sound video


Why is the tongue and oral mucosa the best indicators for hypoxia? WHy not the nails, lips, skin?

Because areas aside from tongue and oral mucose may be related to cold or reduced circulation. Hypoxia could cause these signs but they are not as reliable as the internal WARM area of the mouth that is usually unaffected by cold.


What is a sign of chronic hypoxia?

clubbing of the fingers (looks like drumsticks)


There are two methods for measuring O2 and CO2 levels in the body. What are they? Which is most reliable?

ABG (Most reliable) - measure PAO2/PC02/Bicarbonate
Pulse ox - measures O2 saturation with a light beam

PA02 (pp of O2 in blood),
PC02 (pp of CO2),
Bicarbonate - blood pH


_________ is rapid and deep breathing resulting in excess loss of CO2 (hypocapnea). Too much carbon monoxide can cause this. Pt may complain of feeling light-headed and tingly



________ is when the rate and depth of respirations are decreased and CO2 is retained. Can happen in high altitude.



____ _____ is the pressure of the blood as it is forced against arterial walls during cardiac contraction.

Blood Pressure

Normal is 120/80; above this is pre hypertensive


__________ is peak pressure exerted against arterial walls asthe ventricles contract and eject blood.

_______ is the minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest




______ _______ is the difference between the systolic and diastolic pressures. This is what is felt when palpating the pulse.

pulse pressure

Systolic # - diastolic # = PP


The body constantly regulates and adjusts arterial pressure in order to supply blood to body tissues via perfusion of the capillary beds.

BP is regulated by what three factors?

Cardiac function
Peripheral vascular resistance
Blood volume (5-6 L in body)


Blood viscosity influences the ease of blood flow through t the vessels and is determined by the _____ (percentage of red blood cells in plasma).



Factors tht influence BP?

developmental stage - newborn is low, gradually increases through childhood.
family history - genetics?
lifestyle - heavy drinker (3 or more)/smoker/poor diet/caffeine
exercise - more O2 needed when moving
body position - higher when standing than sitting or lying down.
stress - picture road rage and how it makes you feel
pain (increase initially, decrease due to chronic)
obesity - heart has to work harder
diurnal variations - daily schedule can cause fluctuations
medications - a given
diseases - MI, COPD, etc


Blood pressure can be measured ____ or ______.

First method is done only in in-client setting, where a catheter is threaded into an artery under sterile conditions (SWANZGANZ CATHETER). It is attached to tubing that is connected to an electronic monitoring system. Pressure is constantly displayed as a waveform on the monitor screen electronic.

The second method uses a Sphygmomanometer and Stethoscope, which is used to auscultate the systolic and diastolic pressure.

Direct (first method) or indirect (second method)


T or F: a proper fitting cuff covers 40% of width and 80% of arm length.



If the cuff is too narrow or tight, your reading will be a false _____. If your cuff is too wide, the reading will be too _____.

high; low


You cannot take blood pressure on an the arm if there is an IV device, on the side that had breast cancer/shoulder surgery, presence of renal fistula dialysis, skin graft, paralyzed/diseased or extensive trauma to arm. In these instances, use ______, _____ or _____

forearm thigh or calf

note diastolic will be similar but systolic will be higher


The sounds you are listening for when assessing BP are called ________ ounds

korotkoff sounds (KO ROW COUGH)

1st sound
As you deflate the BP cuff, a sound that occurs during systole (systolic BP)

2nd sound
As you further deflate the cuff, a soft swishing sound caused by blood turbulence

3rd sound
Begins midway through the BP and is a sharp, rhythmic tapping sound

4th sound
Similar to the third sound, but softer and fading

5th sound
Silence, corresponding with diastole (diastolic BP)



Sometimes there is a gap in systolic pressure while taking BP. What is this gap called?

auscultatory gap

document this!


_________ or postural hypotension is a sudden drop in BP when moving from a lying to a sitting or standing position. Decrease of 10mmHg in BP associated with dizziness and fainting.



Prehypertension is diagnosed after two readings are taken ___ _____ apart, with pt sitting and the reading is 120-130 over 80-89.

Book says 139 but slides say 130

6 minutes

Prehypertension means 50% chance of developing HTN in 10+ years, but can be prevented if you exercise and eat right


Hypertension is diagnosed after readings above 140/90 on ____ separate occassions.

Hypertension is referred to as the silent killer because the symptoms are usually mild or absent. Those who do experience symptoms may complain of early morning subocciptial headaches, fatigue and visual changes.


HTN is a major cause of illness and death in the U.S. Increases the stress on the heart and blood vessels; left untreated it may lead to heart attack, heart failure, peripheral vascular disease, kidney damage, or stroke.

Severity is directly related to the degree of elevation
DIET /Exericse – low fat low sodium low carb high protein, wlking 3 x a day for 15 minutes


What is the difference between primary (or essential) hypertension versus secondary hypertension?

Primary is diagnosed when there i no known cause for the bp elevation. Accounts for at least 90% of all cases of hypertension

secondary occurs when there is clearly identified cause for the persistent rise in BP.


The clinic nurse is reviewing the blood pressure readings from the client’s home self-monitoring device. The client states “Look, yesterday my blood pressure jumped up to 150/90. I should be taking more medicine.” The nurse’s best response is

a. “Yes, that is dangerously high. What were you doing?”
b. “Yes, I’m sure your physician will want to increase the dose.”
c. “The doctor will first look at the pattern of your results.”
d. “Don’t worry, I’m sure it’s just because you were stressed.”

Correct answer: C

It is important for the nurse to complete client teaching about the necessity to look at trends/patterns of the readings, rather than a one-time elevation.


Vital signs include what?

2. Pulse
3. Respirations and SP02
4. BP
5.Pain assessment

Provide an indication of a person’s state of health and functioning of the body systems


What do you do if you detect orthostatic hypotension?

1. help client lie down, notify dr in charge
2. obtain orthostatic vital signs: take pulse and BP with pt supine, sitting and standing. Take pressure 1-3 minutes after position change
3. Document: position + pulse + BP for each position


T or F: Nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of vital signs, vital sign trends, and decisions based on abnormal vital sign findings.



Which of the following clients is experiencing an abnormal change in vital signs? A client whose (select all that apply):

1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
2) Rectal temperature is 97.9°F in the morning and 99.2°F in the evening
3) Heart rate was 76 before eating and is 60 after eating
4) Respiratory rate was 14 when standing and is 22 after walking

1) Blood pressure (BP) was 132/80 mm Hg sitting and is 120/60 mm Hg upon standing
3) Heart rate was 76 before eating and is 60 after eating

The BP change is abnormal; a BP change greater than 10 mm Hg may indicate postural hypotension. The change in heart rate is abnormal; heart rate usually increases slightly after eating rather than decreasing. The temperatures are within normal range for the rectal route, and temperature increases throughout the day. It is normal to have an increased respiratory rate after exercise.


The nurse assesses clients' breath sounds. Which one requires immediate medical attention? A client who has:

1) Crackles
2) Rhonchi
3) Stridor
4) Wheezes

3) Stridor

Stridor is a sign of respiratory distress, possibly airway obstruction. Crackles and rhonchi indicate fluid in the lung; wheezes are caused by narrowing of the airway. Crackles, rhonchi, and wheezes indicate respiratory illness and are potentially serious but do not necessarily indicate respiratory distress that requires immediate medical attention.


The nurse assesses the client's pedal pulses as having a pulse volume of 1 on a scale of 0 to 3. Based on this assessment finding, it would be important for the nurse to also assess the:

1) Pulse deficit
2) Blood pressure
3) Apical pulse
4) Pulse pressure

2) Blood pressure

If the leg pulses are weak, the nurse should assess the blood pressure in order to further explore the reason for the low pulse volume. If the blood pressure is low, then a low pulse volume would be expected. The pulse deficit is the difference between the apical and radial pulse. The apical pulse would not be helpful to assess peripheral circulation. The pulse pressure is the difference between the systolic and diastolic pressures.


Which of the following clients has indications of orthostatic hypotension? A client whose blood pressure is:

1) 118/68 when standing and 110/72 when lying down
2) 140/80, HR 82 bpm when sitting and 136/76, HR 98 bpm when standing
3) 126/72 lying down and 133/80 when sitting, and reports shortness of breath
4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy

4) 146/88 when lying down and 130/78 when standing, and reports feeling dizzy

Orthostatic hypotension is a drop of 10 mm Hg or more in blood pressure upon moving to a standing position, with complaints of feeling dizzy and/or faint.


A client who has experienced prolonged exposure to the cold is admitted to the hospital. Which method of taking a temperature would be most appropriate for this client?

1) Axillary with an electronic thermometer
2) Oral with a glass thermometer
3) Rectal with an electronic thermometer
4) Tympanic with an infrared thermometer

3) Rectal with an electronic thermometer

The rectal route is the most accurate for assessing core temperature, especially when it is critical to get an accurate temperature. Therefore, in this situation it is preferred. Temperature is a particularly relevant data point for this client with hypothermia as it indicates the patient's baseline status and response to treatment. The electronic thermometer is safer than glass and is relatively accurate. Mercury thermometers are no longer used in the hospital setting. The accuracy of tympanic thermometers is debatable.


Which of the following clients would have the most difficulty maintaining thermoregulation?

1) Young child playing soccer during the summer
2) Middle-aged adult snow skiing
3) Young adult playing golf on a hot day
4) Older adult raking leaves on a cold day

4) Older adult raking leaves on a cold day

Older adults have more difficulty maintaining body heat because of their slower metabolism, loss of subcutaneous fat, and decreased vasomotor control.


Which of the following clients should have an apical pulse taken? A client who is:

1) Febrile and has a radial pulse of 100 bpm
2) A runner who has a radial pulse of 62 bpm
3) An infant with no history of cardiac defect
4) An elderly adult who is taking antianxiety medication

3) An infant with no history of cardiac defect

An apical pulse should be taken if the radial pulse is weak and/or irregular, if the rate is 100, if the patient is on cardiac medications, or when assessing children up to 3 years. It is difficult to palpate a peripheral pulse on infants and young children.