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Nursing Semester 1 > Chapter 30: Vital Signs > Flashcards

Chapter 30: Vital Signs Flashcards

(71 cards)

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1
Q

List times when a patients vital signs are normally assessed:

A

A) On admission to a healthcare agency, to establish baselines

B) Part of a physical assessment

C) During an inpatient stay, as routine monitoring

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2
Q

Most frequent and routine measurements obtained by health care providers:

A

Temperature

Pulse

Blood pressure

Respiratory rate

Oxygen saturation

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3
Q

Average temperature range:

A

96.8-100.4 degrees F

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4
Q

Average oral/tympanic temperature

A

98.6 F

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5
Q

Average rectal temperature:

A

99.5 F

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6
Q

Average axillary temperature

A

97.7 F

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7
Q

Average pulse:

A

60 to 100 beats/min, deep and regular

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8
Q

Average adult respiration

A

12 to 20 breaths/min, deep and regular

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9
Q

Average blood pressure

A

Systolic <120

Diastolic <80

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10
Q

Average pulse pressure:

A

30-50 mm HG

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11
Q

Average core temperature for elderly

A

95-97 F as a result of decreased immunity

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12
Q

Lowest temperature is at ____ while highest temperature is at ____

A

Lowest: 6 am

Highest: 4 pm

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13
Q

Which part of brain controls body temperature?

A

Hypothalamus

Senses minor changes in body temperature

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14
Q

Anterior hypothalamus controls

A

heat loss

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15
Q

Posterior hypothalamus controls

A

heat production

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16
Q

When metabolism decreases,

A

less heat is produced.

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17
Q

Heat production occurs during

A

rest, voluntary movements, involuntary shivering and non shivering thermogenesis

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18
Q

7 factors that can cause an individual’s body temperature to change:

A

Age
- Newborn’s temp unstable baseline temp drops with age, infants and elderly more susceptible to environmental temp extremes

Exercise
-Increases body temperature

Hormonal fluctuations
-Women’s temp higher at ovulation

Circadian rhythms
- lowest temp: 6 am, highest 4pm

Stress
- levels of extreme temps affect core body temp

Environment

Smoking
-causes vasoconstriction that can decrease temp of skin

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19
Q

Factors influencing vital signs (9)

A

Infection

renal disease

Respiratory disease

Cardiovascular disease

Physical Environment

Emotional state of patient

Medications

Food and fluid intake

Activity level and tolerance

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20
Q

Pain SOCRATES meaning:

A

Site
Where is pain located?

Onset
When did pain start? gradual or sudden?

Character
Quality of pain? Stabbing, burning, aching in nature?

Radiation
Does pain radiate anywhere?

Associations
signs and symptoms associated with pain

Time Course
Any pattern to pain?

Exacerbating/relieving factors
What makes it worse or help it?

Severity
0-10 scale

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21
Q

Patterns of fever (SIRR)

A

Sustained: constant body temp that has little fluctuation

Intermittent: Fever spikes interspersed with usual temp levels. (Temp returns to acceptable value at least once in 24 hours)

Remittent: fever spikes and falls without a return to acceptable temperature levels

Relapsing: periods of febrile episodes and periods with acceptable temperature values (febrile episodes often longer than 24 hours)

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22
Q

Hyperthermia:

A

elevated body temperature related to the inability of the body to promote heat loss or reduce heat production

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23
Q

Malignant hyperthermia

A

hereditary condition of uncontrolled heat production that occurs when susceptible people receive certain anesthetic drugs

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24
Q

5 types of thermometers

A

Electric thermometer (oral/anus/axillary)

temporal artery thermometer (forehead of child typically)

tympanic thermometer (Ear)

disposable paper thermometers

temperature sensitive strips

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25
5 sites commonly used to measure body temperature
Oral (most common) -under tongue Axillary -frequently used for healthy newborns Tympanic Temporal Rectal
26
Examples of nursing diagnoses for patients with body temperature alterations include (5)
Risk for imbalanced body temperature hyperthermia hypothermia ineffective thermoregulation risk for hypothermia
27
Pulse is the
palpable bounding of blood flow in a peripheral artery
28
Infant heart rate
120-160 beats/min
29
Toddler heart rate
90-140 beats/min
30
Preschooler heart rate
80-110 beats/min
31
School-age child heart rate
75-100 beats/min
32
Adolescent heart rate
60-90 beats/min
33
Adult heart rate
60-100 beats/min
34
Factors that influence pulse rate (7)
Exercise Temperature Emotions Medications Hemorrhage Postural changes Pulmonary conditions
35
Tachycardia:
an abnormally elected HR ABOVE 100 beats/min in adults
36
Bradycardia:
Slow HR Below 60 beats/min in adults
37
Document pulse strength as:
Bounding (4) Full or strong (3) Normal and expected (2) Diminished or barely palpable (1) Absent (0)
38
Respiration is the mechanism the body uses to:
exchange gases between the atmosphere and the blood and the blood and the cells
39
Respiration involves (3)
Ventilation (movement of gases in and out of the lungs) Diffusion (movement of oxygen and carbon dioxide between the alveoli and the red blood cells) Perfusion (distribution of red blood cells to and from the pulmonary capillaries)
40
Assess ventilation by determining...
respiratory rate, depth, rhythm and end-tidal carbon dioxide value
41
Assess diffusion and perfusion by
determining oxygen saturation
42
Hypoxemia:
low levels of arterial O2
43
A respiratory rate above ____ is an important risk factor for
27 breaths/min cardiac arrest
44
Hypothermia:
low body temperature -Frostbite results from exposure to subnormal temperatures Hypotension- decreased blood pressure
45
Febrile
person with fever
46
Heat stroke
when prolonged exposure to high environmental temps overwhelms the body's heat loss mechanisms
47
Heat exhaustion
when extreme or prolonged exposure to high environmental heat leads to profuse sweating and consequent water and electrolyte loss
48
Factors that cause pulse rate to vary:
Age Gender Fever Stress Medications Hypovolemia Pathology Electrolyte balance Hypoxia/hypoxemia
49
Dysrhythmia:
interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or DYSRHYTHMIA
50
Factors influencing character of respirations (8)
Exercise Acute pain Anxiety Smoking Body position Medications Neurological injury Hemoglobin function
51
Bradypnea:
rate of breathing is regular but abnormal slow (less than 12 breaths/min)
52
Tachypnea:
rate of breathing is regular but abnormally rapid (above 20 breaths/min)
53
Hyperpnea:
respirations are labored increased in depth increased in rate (greater than 20 breaths/min) (occurs normally during exercise)
54
Apnea:
respirations cease for several seconds. Persistent cessation results in respiratory arrest
55
Hyperventilation
rate and depth of respirations increase. Hypocarbia sometimes occurs
56
Hypoventilation
respiratory rate is abnormally low, and depth of ventilation is depressed Hypercarbia sometimes occurs
57
Cheyne-Stokes respiration
respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. Respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth pattern reverses...breathing slows and becomes shallow concluding as apnea before respiration resumes
58
Kussmaul's respiration:
respirations are abnormally deep, regular and increased in rate
59
Biot's respiration
respirations are abnormally shallow for 2-3 breaths, followed by irregular period of apnea
60
Factors affecting determination of pulse oxygen saturation (2)
Interference with light transmission Interference with arterial pulsations
61
SaO2 normal range:
95% and 100%
62
Systolic pressure:
Contraction of the heart forces the blood under high pressure in the aorta Peak of maximum pressure when ejection occurs
63
Diastolic pressure:
when the ventricles relax, the blood remaining in the arteries exerts a minimum or DIASTOLIC pressure minimal pressure exerted against the arterial walls at all times
64
Pulse pressure:
difference between systolic and diastolic
65
Hypotension:
occurs when the systolic BP falls to 90 mm HG or below
66
Hematocrit:
% of red blood cells in blood, determines blood viscosity When the hematocrit rises and blood flow slows, arterial BP increases The heart contracts more forcefully to move the viscous blood through the circulatory system
67
Hypertension:
Asymptomatic Diastolic readings greater than 90 mm Hg and systolic greater than 140 mm Hg
68
Orthostatic hypotension
Postural hypotension occurs when a normotensive person develops symptoms and a drop in systolic pressure by at least 20 mm Hg or a drop in diastolic pressure by at least 20 mm Hg within 3 MINUTES of rising to an UPRIGHT POSITION
69
Factors influencing Blood pressure:
Age Stress Ethnicity Gender Daily Variation Medications Activity and Weight Smoking
70
Prehypertension:
Systolic 120-139 | Diastolic 80-89
71
Stage 2 hypertension
Systolic >160 | Diastolic >90

Nursing Semester 1 (24 decks)

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