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CSON IM1 > EXAM 2- Vital Signs > Flashcards

EXAM 2- Vital Signs Flashcards

1
Q

6 vital signs

A
  • temperature
  • pulse
  • blood pressure
  • respiratory rate
  • oxygen saturation
  • pain
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2
Q

when would you measure vital signs?

A
  • on admission
  • per physician order (routine, Q4)
  • any change in pt condition
  • before/after any procedure
  • during blood transfusion
  • after medications/interventions that affect vitals
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3
Q

normal temperature range for adults

A

96.8 - 100.4

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4
Q

normal oral/ tympanic/ temporal temperature

A

97.6 - 99.6

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5
Q

normal rectal temperature

A

98.6 - 100.4

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6
Q

normal axilla temperature

A

96.8 - 98.6

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7
Q

normal pulse bpm range

A

60-100 bpm

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8
Q

normal respiration rate range

A

12-20 breaths per minute

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9
Q

normal blood pressure range for adults

A

< 120/80 mmHg

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10
Q

pre-hypertensive bp range

A

stysolic 120-139
diastolic 80-89

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11
Q

hypertensive bp range

A

systolic > 140
diastolic > 90

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12
Q

hypotensive bp range

A

systolic < 90 and asymptomatic

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13
Q

what does body temp measure?

A

tha constant balance between heat produced & heat lost

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14
Q

temperature sites

A
  • oral
  • rectal
  • axillary
  • tympanic membrane (ear)
  • temporal artery (forehead>side of face)
  • esophageal (endoscopy procedures)
  • pulmonary artery
  • urinary bladder (special catheters)
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15
Q

how does the neural and vascular system control/regulate temp?

A
  • anterior hypothalamus - controls heat loss (sweat)
  • posterior hypothalamus - controls heat production (shivering when cold creates energy> heat via vasoconstriction)
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16
Q

what is the thermostat of the body?

A

anterior/posterior hypothalamus

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17
Q

methods of heat loss

A
  • radiation
  • conduction
  • convection
  • evaporation
  • diaphoreses (pale, sweaty)
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18
Q

examples of heat production

A
  • BMR (basal metabolic rate)
  • shivering
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19
Q

how does the skin help regulate temp?

A
  • insulation
  • vasoconstriction
  • sensation
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20
Q

radiation

A

transfer of heat from surface of one object to surface of another without direct contact

ex: sun radiation

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21
Q

radiation

A

transfer of heat from surface of one object to surfae of another without direct contact

ex: sun radiation

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22
Q

conduction

A

transfer of heat from one object to another with direct contact

ex: heating pad on skin

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23
Q

convection

A

transfer of heat away by air movement

ex: when your temp is high, the room air will transfer your heat out

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24
Q

evaporation

A

transfer of heat energy when a liquid is changed to gas

sweating

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25
Q

evaporation

A

transfer of heat energy when a liquid is changed to gas

sweating

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26
Q

diaphoresis

A

visible perspiration

sweat

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27
Q

how does age affect body temp?

A

infants & elderly have poor core temp control

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28
Q

how do hormone levels afect body temp?

A

temp fluctuates with cycle stage

ex: menopause causes hot flashes

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29
Q

how does the environment affect body temp?

A

prolonged exposure exausts the hypothalamus eventually

heat stroke, frostbite, hyper/hypothermia

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30
Q

how does exercise affect body temp?

A

increased metabolism creates heat

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31
Q

how does circadian rhythm affect body temp?

A

temp is lowered in sleep

?

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32
Q

pyrexia

A

fever

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33
Q

for adults, fevers are usually not harmful if under what temp?

A

102.2 ºF

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34
Q

true or false:

fever is an important defense mechanism

A

true

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35
Q

true or false:

temp should be taken once for a pt with a fever

A

false

temp should be taken several times throughout the day

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36
Q

what does fever cause?

A
  • increase in metabolism & oxygen demand
  • increased HR & RR
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37
Q

febrile

A

fever

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38
Q

afebril

A

no fever/ without fever

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39
Q

FUO

A

fever of unknown origin

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40
Q

hyperthermia

A

inability to promote heat loss or reduce production

leads to heat stroke

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41
Q

heat stroke

A

dangerous heat emergency/ high mortality rate
* body temp >104 ºF

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42
Q

signs/ symptoms of heat stroke

A
  • body temp > 104 ºF
  • MOST IMPORTANT: hot/dry skin
  • confusion, excess thirst, muscle cramps
  • increased HR, decreased BP
  • no sweating (body has exhausted all excess fluids = dehydration)
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43
Q

heat exhaustion

A

diaphoresis results in excess water & electrolyte loss

the body needs to replace them

44
Q

heat exhaustion

A

diaphoresis results in excess water & electrolyte loss

the body needs to replace them

45
Q

hypothermia

A

prolonged exposure to cold decreases the body’s ability to produce heat
* temp < 86-96.8 ºF

can be accidental or intentional (slows body to allow time to heal)

46
Q

ºF to ºC formula

A

C = (F - 32) x (5/9)

round to one decimal

47
Q

ºC to ºF formula

A

F = (9/5 x C) + 32

round to one decimal

48
Q

assessing oral temp

A
  • most common
  • appx. one degree lower than core temp
  • may be glass or electronic
49
Q

true or false:

oral temp is easily influenced by hot/cold foods & drinks

A

true

50
Q

assessing rectal temp

A
  • adult: insert 1.5”
  • child: insert 1”
  • infant: insert 0.5”

feces may give inaccurate readings

51
Q

which assessment of temp is the most accurate?

A

rectal

52
Q

assessing axillary temp

A
  • safest method
  • must be left in place for 5-10 minutes
  • moisture in axillary area may reduce temp
53
Q

assessing tympanic temp

A
  • rapid
  • unaffected by PO intake
54
Q

assessing temporal temp

A
  • most accurate compared to core/ rectal
  • rapid (2-3 sec)
  • fewer errors than tympanic

follows temporal artery (mid forehead> temple> side of face> underear)

55
Q

how long should you wait to take an oral temp if a pt has drank hot coffee?

A

30 minutes

56
Q

what do you do for a fever?

nursing interventions

A
  • obtain blood cultures if ordered
  • monitor VS, skin color, turgor, labs
  • reduce O2 demand
  • maximize heat loss (no excess clothes, linens)
  • extra fluids
  • tepid bath (room temp, DONT shock temp)
  • oral hygiene (rapid bacteria growth, especially for intubated pts)
  • dry bed linens
  • antipyretic meds as ordered
57
Q

pulse

A

palpable/ audible bounding of blood flow noted at various points on the body

indirect measure of circulatory status

58
Q

which part of the stethoscope are for low pitch? high pitch?

A
  • bell - low pitch
  • diaphragm - high pitch (most common)
59
Q

radial pulse

A
  • most common for routine vitals
  • used for pt teaching
  • assesses circulaiton status to the hand
60
Q

apical pulse

(with stethoscope)

A
  • if pulse is abnormal
  • if taking meds that affect HR
  • if radial is unaccessible
  • located in 5th ICS, mid-clavicular
61
Q

carotid pulse

A
  • used if pt condition suddenly worsens
  • need pulse quickly
  • DON’T measure bilateral at the same time
62
Q

dorsalis pedis pulse

A
  • top of foot
  • assesses circulation to foot
  • via doppler if unable to palpate
  • access bilaterally at the same time
63
Q

pulse strength

A

4+, 3+, 2+ (normal), 1+ 0

4+ is bounding, 1+ is weak/thready, 0 is unable to palpate

63
Q

gas exchange

A
  • process of transporting oxygen into cells
  • transporting carbon dioxide out of cells
64
Q

ventilation

A

moving air in/out of lungs (inspiration in/ expiration out)

65
Q

respirations

A

CO2 and O2 exchange occurs across alveoli in lungs

66
Q

ischemia

A

insufficient oxygen to tissues

leads to cell injury/death, or hypoxia

67
Q

ischemia

A

insufficient oxygen to tissues

leads to cell injury/death, or hypoxia

68
Q

hypoxia

A

insufficient cell O2

69
Q

hypoxemia

A

insufficient oxygen in blood (specifically in arteries)

70
Q

respiratory acidosis

A

not moving CO2 out of cells, excess CO2 in cells

71
Q

process/problems of ventilation

A
  • oxygen: in, carbon dioxide: out
  • issue - lack of surfactant (surfactant allows lungs to expand, not present in newborns)
  • issue - meds can open airways for asthmatic pts
72
Q

process/ problems of transport in respirations

A
  • transfer of hemoglobin (transfers O2 and CO2 to/from cells)
  • issues - low RBC (anemia), blood loss (trauma/ surgery)
73
Q

process/ problems of perfusion

A
  • allows O2 and CO2 to exchange
  • heart controls perfusion
  • issue - lack of perfusion/ lack of pumping blood
74
Q

issues in ventilation, transport, or perfusion can lead to what?

A
  • ischemia (insufficient oxygen in blood)
  • hypoxia (insufficient oxygen in tissues)
  • hypoxemia (insufficient O2 in blood/ arteries)
75
Q

impairment of gas exchange

A

occurs when the diffusion of gases (O2 and CO2) becomes impaired

76
Q

what causes impaired gas exchange?

3 factors

A
  • ineffective ventilation
  • reduced capacity for gas transportation (reduced hemoglobin and/or RBC)
  • inadequate perfusion
77
Q

eupnea

A

ventilation of normal rate & depth

rate of 12-20 breaths/min

Eu (normal) + pnea (lungs)

78
Q

factors that can influence respirations

A
  • exercise
  • acute pain - shallow breaths
  • anxiety
  • smoking
  • bed position (sitting up opens airway/ allows lungs to expand)
  • medications (albuterol increases breaths/min, opioids decrease breaths/min)
  • neurological injury (spine, vent, trach)
  • hemoglobin function (low hemoglobin = high RPM)
79
Q

dyspnea

A

difficulty breathing

80
Q

orthopnea

A

positional difficulty breathing

pt has a hard time breathing when laying down or in a certain position

81
Q

bradypnea

A
  • slower than normal rate (< 12 RPM)
  • normal depth and rhythm
82
Q

tachypnea

A

rapid, shallow breathing (> 20 RPM)

83
Q

apnea

A

period of cessation of breathing

84
Q

cheyne-stokes

A

rate & depth of breathing increase, tehn decrease until apnea

85
Q

how do we assess diffusion & perfusion?

A
  • indirect measurement of oxygen saturation (with pulse oximetry)
  • measured with light absorption with photo detector
  • pulse saturation (Sp02) estimates arterial saturation (Sa02)
86
Q

acceptable oxygen saturation range

A

95-100%

87
Q

true or false

the more oxygen support needed, the more critical the pt is

A

true

88
Q

factors that can affect pulse ox readings

A
  • nail polish
  • temp of extremity (cold = low/inaccurate readings due to low blood flow)
  • lighting
  • skin pigmentation (darker skin is harder to read)
89
Q

your post op pt is breathing rapidly, what is the FIRST thing you should do?

A

assess the oxygen saturation

90
Q

you measure the O2 saturation at 77%, what is the FIRST thing you should do?

A

check the probe

91
Q

blood pressure

A

the force exerted against the blood vessels by the blood

  • measured in millimeters of mercury (mmHg)
  • systolic - maximum pressure
  • diastolic - minimal exertion
  • pulse pressure - systolic minus diastolic
92
Q

factors that affect bp

5

A
  • cardiac output - volume of blood ejected from the heart (more output = higher bp)
  • peripheral resistance - ex: plaque (higher bp)
  • blood volume - higher bp
  • viscosity - blood thickness (more RBC = higher viscosity)
  • elasticity - expanding/ contracting
93
Q

korototkoff sounds

5

A
  1. systolic
  2. whooshing
  3. crisp
  4. blowing softly
  5. silence diastolic
94
Q

which artery would you palpate to obtain a manual bp?

A

bracial artery

95
Q

upon first assessing a pt, how long should they rest and how many times should you take their bp to obtain a baseline?

A
  • rest at least 5 minutes before assessing
  • record in both arms initially, use same arm routinely after that if possible
96
Q

factors that can influence bp

A
  • age
  • stress
  • ethnicity/ gender
  • daily variation
  • medications
  • activity, weight
  • smoking
97
Q

hypertension quick facts

A
  • more common thatn hypotension
  • thickening of walls
  • loss of elasticity
  • family history + risk factors
  • usually no sympoms
98
Q

which diagnosis is a major factor underlying strokes and heart attacks?

A

hypertension

99
Q

hypotension quick facts

A
  • dilation of arteries
  • loss of blood volume
  • decrease of blood flow to vital organs (kidneys first)
  • can be orthostatic/ postural as well

systolic < 90 mmHg

100
Q

symptoms of hypotension

A
  • skin mottling
  • clamminess
  • confusion
  • increased HR
  • decreased urine output
101
Q

after obtaining an abnormal electric/automatic bp, what is the FIRST thing you should do?

A

recheck with a manual bp

they are more susceptible to error, unable to detect low bp accurately

102
Q

alternate bp sites

A
  • thigh - supine position (not ideal), bent knee, systolic is usually higher than 10-40 mmHg
  • arterial line - catheter inserted in an artery
103
Q

PQRST for pain

A
  • Provokes/palliates - what makes it worse/ better?
  • Quality - can you describe the pain– sharp, dull, aching, etc?
  • Region/radiation - where’s the pain? does it radiate?
  • Severity/setting - how severe is your pain on a scale of 0-10?
  • Timing - is it worse during the morning/evening, etc?
104
Q

when should you assess pain?

A
  • often
  • before procedures, activity, and medicate if available
  • at elast 30min after pain meds
  • do not assume your pt’s pain level (it is subjective)
105
Q

when assessing pain, what would you document?

A
  • pain levels in EMR
  • any accomanying symptoms in notes
  • interventions initiated (medications)
  • f/u assessment

CSON IM1 (15 decks)

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