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NURS 175 - Nursing Practice Foundations > Lesson 2 - Vital Signs > Flashcards

Lesson 2 - Vital Signs Flashcards

1
Q

Importance of Measuring Vital Signs

A

-measurement of health status
-component of patient assessment
-reflects functioning of “vital” body systems
-base for clinical decision-making
-reflects changes in physiological status

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2
Q

The 5 Vital Signs

A

-temperature
-pulse
-respiratory rate
-blood pressure
-oxygen saturation

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3
Q

The 6th vital sign

A

Pain-considered another vital sign

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4
Q

When to assess Vitals

A

-during home care visit
-upon admission
-according to order or facility practice standards
-before, during, after surgery, invasive diagnostic procedure, administration of some meds/blood products

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5
Q

Vital Order Shortcuts

A

ie q8h means every (q) eight hours (h)

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6
Q

How often to check vitals

A

-depends on: provider orders, situation, or your own judgement

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7
Q

Someone who has had surgery

A

hourly

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8
Q

Older adult in extended care facility

A

monthly

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9
Q

Very ill patient in ICU

A

constantly

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10
Q

stable patient waiting for long term care

A

weekly

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11
Q

patient who says she is feeling faint

A

every 15 mins

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12
Q

patient in hospital with pneumonia

A

once per shift

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13
Q

Thermoregulation

A

-controlled by the hypothalamus
-the balance between heat protection and heat loss

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14
Q

Core temperature

A

-temp of structures deep within the body
-relatively constant
-taken rectally (red thermometer), tympanic (ear)

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15
Q

Surface temperature

A

-temperature on the surface of the body
-fluctuates
-normal is 36-38 degrees celsius
-taken orally (blue thermometer), axillary (armpit), temporal (forehead)

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16
Q

Core Mean Temp

A

36.5-37.5

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17
Q

Oral Mean Temp

A

37.0 (35.5-37.5)

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18
Q

Tympanic Mean Temp

A

36.5 (35.5-38.0)

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19
Q

Rectal Mean Temp

A

37.5 (36.6-38.0)

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20
Q

Axillary Mean Temp

A

36.0 (34.7-37.3)

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21
Q

Temporal Mean Temp

A

35.0

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22
Q

Mean Temp

A

-expected findings/average

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23
Q

Temperature Feedback Mechanism

A

-warm and cold temp sensors in the body send message to hypothalamus and hypothalamus responds

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24
Q

When the body is too hot…

A

-vasodilation
-brings blood closer to the skin to expel heat
-sweating

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25
Q

When the body is too cold…

A

-vasoconstriction
-brings blood away from skin to retain heat
-shivering

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26
Q

What to do when patient is feeling cold

A

-warm blankets
-warm drinks

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27
Q

Heat production

A

-by product of body metabolism
-food is the fuel for metabolism

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28
Q

Basal Metabolic Rate (BMR)

A

-number of calories you burn as your body performs life sustaining functions
-based on surface area and thyroid function
-higher in men
-increases with exercise

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29
Q

Why don’t newborns shiver?

A

-chubby so they stay warmer
-underdeveloped temp regulation system

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30
Q

Relationship between temp and demographic

A

-reasons behind alterations and temp
-older adults have lower average temp
-babies and young kids are sensitive to change
-exercise increases temp temporarily
-women: temp falls before ovulation and increases before menopause

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31
Q

Circadian Rhythm and Temp

A

-body is cooler in the morning and warmer in the evening

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32
Q

Convection

A

body heat lost to surrounding air which is cycled and cooled off

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33
Q

Radiation

A

body heat lost to near objects without touching them

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34
Q

Evaporation

A

perspiration

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35
Q

Conduction

A

body heat lost to near objects through physical touch

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36
Q

Clinical Temp Alterations

A

-infection
-inflammatory response
-deteriorating status
-thermoregulatory disorders (spinal cord injuries)

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37
Q

Hyperpyrexia

A

-extremely high temps associated with severe infection
-41-44 degrees celsius

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38
Q

Pyrexia

A

-raised body temp, fever
-38-40 degrees celsius

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39
Q

Normal temp

A

36-37 degrees celsius

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40
Q

Hypothermia

A

-extremely cold temp
-34-35 degrees celsius
-blankets, warm fluids, remove wet clothing, check room temp

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41
Q

Heat Stroke

A

-prolonged exposure to high temp
-delirium, confusion, muscle cramps, hot dry skin

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42
Q

Heat Exhaustion

A

-body can’t cool off
-excessive sweating, high heart rate

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43
Q

Objective data (temp)

A

-temp reading
-skin colour
-goose bumps
-sweating
-rubbing arms
-panting

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44
Q

Subjective data (temp)

A

-patient says they feel hot/cold

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45
Q

Considerations when assessing temp

A

-choose appropriate equipment
-consider temp influencing factors
-assess in relation to schedule, symptoms

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46
Q

Purpose of breathing

A

-bring oxygen to blood and remove carbon dioxide

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47
Q

Ventilation

A

movement of gas in/out of lungs

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48
Q

Diffusion

A

movement of gas from high to low concentration in alveoli

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49
Q

Perfusion

A

distribution of RBCs to organs/tissues

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50
Q

Inhalation/inspiration

A

-breathe in
-active process

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51
Q

Exhalation/expiration

A

-breathe out
-passive process

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52
Q

Respiration Regulation

A

-voluntary and involuntary control

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53
Q

Medulla Oblongata

A

regulates breathing rate

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54
Q

What drives respirations?

A

-carbon dioxide levels in the blood drive the increase/decrease in respirations

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55
Q

Which nerve controls respirations?

A

-phrenic nerve
-sends signals from brain to diaphragm

56
Q

Tidal volume

A

-inhalation volume is usually 500mL of air

57
Q

How are respirations measured

A

in breaths per minute

58
Q

Newborn (expected findings)

A

30-60 breaths/min

59
Q

Infant (expected findings)

A

30-50 breaths/min

60
Q

Toddler (expected findings)

A

25-32 breaths/min

61
Q

Child (expected findings)

A

15-25 breaths/min

62
Q

Teens (expected findings)

A

16-19 breaths/min

63
Q

Adults (expected findings)

A

12-20 breaths/min

64
Q

Patterns in respirations?

A

expected respiration rates decrease with age

65
Q

Bradypnea

A

-abnormally slow breathing
-less than 10 breaths/min
-breath sounds are regular

66
Q

Tachypnea

A

-abnormally rapid breathing
-more than 24 breaths/min
-breath sounds are shallow

67
Q

Hyperpnea

A

-laboured breathing
-increased in depth and rate
-more than 20 breaths/min
-occurs normally during exercise

68
Q

Apnea

A

-breathing temporally stops and then starts up again

69
Q

Hypoventilation

A

slow and shallow breathing

70
Q

Hyperventilation/kussmaul

A

fast and deep breathing

71
Q

Cheyne-Stokes Respiration

A

alternating periods of apnea and increasingly deep, rapid breathing

72
Q

Dyspnea

A

difficulty breathing

73
Q

Orthopnea

A

requiring a certain body position for comfortable breathing

74
Q

Sleep Apnea

A

breathing stops several times during sleep

75
Q

Nursing Considerations for assessing respirations

A

-patient status (active vs rest)
-underlying conditions
-rate, rhythm, depth, pattern
-breathing effort, flared nares, accessory muscles
-patient stance

76
Q

Counting Respirations

A

-count for 30 seconds
-be discrete so voluntary control doesn’t take over

77
Q

Oxygen Status

A

-evaluates gas exchange and perfusions
-measured as a percentage
-aka Pulse oximetry, pulse ox, oxygen saturation, O2 saturation, O2 sat, sats, SpO2

78
Q

Expected O2 Sat findings

A

-92-100% depending on patient condition and regardless of age

79
Q

COPD

A

-chronic obstructive pulmonary disease
-88-92%

80
Q

ABG

A

-arterial blood gas test
-more accurate
-more painful
-more costly

81
Q

Hypoxia

A

not enough oxygen in the blood

82
Q

Cyanosis

A

-objective evidence of decreased oxygen in the blood
-below 85%

83
Q

Central Cyanosis

A

-blue around lips and tongue

84
Q

Peripheral Cyanosis

A

-blue on extremities
-legs, eyes, fingers

85
Q

Abnormal pulse ox reading

A

-if low result found but patient seems ok… consider positioning, positioning of probe, encourage deep breathing, medical history, assess the trend, consider supplementary o2, report to buddy nurse

86
Q

Low pulse ox results (get help when…)

A

-if also symptomatic with difficulty breathing, uncontrolled coughing, wheezing, cyanosis, losing consciousness

87
Q

Pulse

A

-the effect of the beating of the heart on the bodies arteries
-forcing blood into vessels stretches them
-muscular & elastic arteries stretch and contract

88
Q

Stroke Volume

A

amount of blood pumped from the left ventricle per beat

89
Q

Cardiac Output

A

-heart rate x stroke volume

90
Q

Control of the heartbeat

A

electrical impulsed through SA and AV node

91
Q

Role of Sympathetic Nervous System

A

-increases the activity of the SA node
-responds to increased oxygen demands

92
Q

Role of Parasympathetic Nervous System

A

-decreases activity of SA node to maintain homeostasis
-rest mode

93
Q

Strong hearts

A

-fewer bpm needed to circulate blood
-athletes
-lower pulse

94
Q

Weak hearts

A

-more bpm needed to circulate blood
-higher pulse

95
Q

Bradycardia

A

-less than 60 bpm in adults
-too slow

96
Q

Tachycardia

A

-more than 100 bpm in adults
-too fast

97
Q

Disrhythmia

A

abnormal heart/pulse rates

98
Q

Assessing pulse rate

A

-rate, rhythm, strength, equality
-physiological conditions can alter heart

99
Q

Newborn (expected pulse rate)

A

120-160 bpm

100
Q

1-3 years old (expected pulse rate)

A

90-140 bpm

101
Q

6-8 years old (expected pulse rate)

A

75-110 bpm

102
Q

10-12 years old (expected pulse rate)

A

75-110 bpm

103
Q

Teen (expected pulse rate)

A

60-90 bpm

104
Q

Adult (expected pulse rate)

A

60-100 bpm

105
Q

Pulse Amplitude

A

the strength at which the pulse beats are felt

106
Q

0 - non-palpable or absent

A

-cannot feel pulse

107
Q

1+ - diminished, weak, barely palpable

A

easy to lose, not strong

108
Q

2+ - strong

A

lost with slight pressure

109
Q

3+ - full, increased

A

lost with moderate pressure

110
Q

4+ - bounding

A

strong, unable to/significant pressure needed to obliterate

111
Q

Assessing Pulse - Regular Rhythm

A

-assess for at least 30 seconds
-peripheral pulse ie. neck/carotid, wrist/radial, groin/femoral, foot

112
Q

Assessing Pulse - Irregular Rhythm

A

-assess for at lease 60 seconds
-apical pulse; stethoscope placed on heart

113
Q

Which artery is used for measuring BP?

A

brachial

114
Q

Systolic Blood Pressure

A

-arterial pressure during systole/heart contraction
-top number

115
Q

Diastolic Blood Pressure

A

-lowest pressure in arteries during diastole/relaxation
-bottom number

116
Q

Determinants of Blood Pressure

A

-cardiac output
-peripheral resistance
-blood volume
-blood viscosity
-artery wall elasticity

117
Q

Influences on Blood Pressure

A

-age
-medications
-stress
-ethnicity (asian, indigenous, african have higher BP)
-gender (boys after puberty and post menopausal women have higher BP)
-activity, weight, smoking
-daily variations

118
Q

Hypertension

A

-chronically high BP
-“silent killer”
-serious health complications
-mostly related to lifestyle

119
Q

Optimal BP

A

<120/<80

120
Q

Normal BP

A

<130/<85

121
Q

High normal BP

A

130-139/85-89

122
Q

Grade 1 Hypertension (HTN)

A

140-159/90-99

123
Q

Grade 2 HTN

A

160-179/100-109

124
Q

Grade 3 HTN

A

> 179/>109

125
Q

Unit of BP

A

mmHg (millimeters of mercury)

126
Q

Hypotension

A

-chronically low BP
-seriousness depends on cause ie. internal bleeding

127
Q

Orthostatic Hypotension

A

-results from postural change ie. laying down to standing

128
Q

Manual BP Assessment

A

-more difficult to learn
-time consuming
-more reliable if done well

129
Q

Machine BP Assessment

A

-not as reliable
-convenient
-if you get an abnormal reading complete a manual assessment
-avoid over-reliance on technology

130
Q

Cuff placement

A

-upper arm
-lower arm
-thigh

131
Q

Korotkoff Sounds

A

-heard to detect systolic and diastolic BP

132
Q

Abnormal BP Measurement

A

-ask patient how they are feeling
-consider body size, race, recent activity, health status, medications
-report and document

133
Q

If BP is low…

A

be present when patient moves/get up to prevent falls

134
Q

If any vital signs are abnormal…

A

1) check again to be sure
2) assess patient - how are they feeling?
3) look if this abnormality is a trend or new
4) document
5) report
6) reassess in 15 mins

135
Q

Explaining Results

A

-be able to provide the patient with the results of their vitals and inform them if they are normal/abnormal and what this means

NURS 175 - Nursing Practice Foundations (11 decks)

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