Module 4: Vitals Flashcards
1
Q
Vital Signs
A
Temperature Pulse Respiration Blood Pressure O2 Saturation (Pain is often included but not necessarily)
2
Q
Vital Signs reflect…
A
the health of a person
3
Q
When should vitals be taken?
A
- to get a baseline with pre/post medications or pre/post vitals
- upon admission
- based on institutional policy/procedure
- before and after activity that increases risk, surgery, or medication administration affecting cardio/resp.
- when physician orders it
- WHENEVER YOU FEEL YOU NEED TO DO THEM
4
Q
Can you take just one vital sign?
A
Absolutely Not
5
Q
Who can take vitals?
A
People who are delegated healthcare personnel, but it is the nurses responsibility to assure its correct
6
Q
We need to have a what for vital comparison?
A
Baseline vitals
7
Q
“Close the Loop”
A
Responsibility of the nurse to follow up on delegation of vitals - the nurse has the responsibility if someone else is told to do it
8
Q
Thermoregulatory center is in …
A
the hypothalamus
9
Q
Primary source of body heat production?
A
metabolism
10
Q
What things increase metabolism and heat production?
A
- hormones (EP and NEP), muscle movements, and exercise
- NEP and EP are released and alter metabolism which leads to energy production decreases and heat production increases
11
Q
Sources of Heat Loss
A
- Skin (primary source)
- evaporation of sweat
- warming and humidifying inspired air
- eliminating urine and feces
12
Q
Physical Processes Transferring Body Heart to External Environment?
A
- Radiation
- Convection
- Evaporation
- Conduction
13
Q
Radiation
A
the diffusion or dissemination of heat by electromagnetic waves (ex: not having a hat)
14
Q
Convection
A
transference of heat by motion between areas of unequal density
15
Q
Evaporation
A
conversion of a liquid to a vapor (lose heat)
16
Q
Conduction
A
transference of heat to another object during direct contact (ex: ice pack)
17
Q
Factors Affecting Body Temperature
A
- Circadian Rhythm
- Age and Gender
- Environmental Temperatures
18
Q
How does core temperature fluctuate during the day?
A
- core temperature is lowest in the morning
2. body temperature highest in the alte afternoon (4-8 pm)
19
Q
How does Age and Gender influence core body temperature?
A
- Older and Younger people have less adaptable ability (from things like less sweat glands or less muscle mass)
- Men and Woman have hormone changes differing body temperature (Female Progesterone leads to more fluctuation)
20
Q
Types of Fever
A
- Intermittent - Temp returns to normal once every 24 hours
- Remittent - fluctuating a few degrees
- Sustained/Continuous - stays stable at the same temperature
- Relapsing - returning to normal for 1+ days with fever for several days reoccurring
21
Q
FUO
A
Fever of unknown origin - a fever greater than 38 Celsius lasting more than 3 weeks with no identifiable cause
22
Q
Methods of Taking Temperature
A
Blue Oral Blue Axillary Red Rectal Tympanic Membrane Temporal Arterial Temperature Sensitive (invasive) Single Use Thermometer Mercury Glass Thermometer Infrared Thermometer
23
Q
Sites for Temperature Assessment
A
Forehead Orallly Axillary Rectal Temporal Artery
24
Q
Contraindications for Oral Temperature
A
Vomiting Cognition issues Eating or Drinking Oxygen Use Smoking Age Seizure Status Open Sores Age (<4 is too young to cooperatre) Recent Oral Surgery
25
Contraindications for Rectal Temperature
```
Cardiac Issues (Vagus nerve stimulation lowers HR)
Rectal Surgery
Thrombocytopenia
Neutropenia
Age
Cognitive Issues
```
26
Contraindications of Tympanic Temperature
```
Pain
Infection
Scar Tissue
Cerumen Excess
Age (Under 3 can perforate the E tubes)
```
27
What might alter Temporal Artery Temperature?
Hair, Scarring, Cranial Surgery
28
Oral Normal Temperature
37 C / 98.6 F
29
Rectal Normal Temperature
37.5 C / 99.5 F
30
Axillary Normal Tempearture
36.5 C / 97.7 F
31
Tympanic Normal Temperature
37 C / 98.6 F
32
Forehead Normal Temperature
34.4 C / 94 F
33
Temporal Arterial Normal Temperature
37.5 C / 99.5 F
34
What temperatures are about a degree above and below Oral?
Above: Rectal, Temporal Arterial
Below: Axillary
35
Core Temperatures
Rectal, (possibly tympanic)
36
Routine newborn temperature is taken...
Axillary
37
Important thing to do when taking Tympanic Temperature?
in an adult, pull back on the ear
In a child above age 3/4 y/o you pull down and back
38
When taking a rectal temperature you must use what 2 things?
Gloves and Water Soluble Lubricants
39
Pulse is regulated by the ____ through _____
ANS through pacemaker (cardiac sinoatrial node)
40
What is the heart's pacemaker?
Cardiac Sinoatrial Node
41
Parasympathetic stimulation does what to heart rate
decreases it (Sympathetic increases it)
42
What is Pulse Rate?
number of contractions over a peripheral artery for one minute
43
Physical Effects of Fever?
```
Anorexia
Headache
Diaphoresis
Thirst
Dehydration
Muscle Aches
Elevated Respiration
Elevated pulse Rate Due to Fluid Deficiency
Possibly Seizures
```
44
Hypothermia
Temperatures below 95/93.2 F or 34C
45
Febrile
100.4 F or 38.3 C
46
Peripheral Pulse
throbbing sensation that can be palpated over peripheral arteries (due to a pump of blood being put into circulation by the contraction of the left ventricle)
47
When taking pulse you are on the look out for what 3 things?
Rate, Amplitude/Quality, Rhythm
48
Tachycardia
Increased heart rate 100-180 bpm in adults
49
Bradycardia
Decreased heart rate (below 60 bpm) in adults
50
How to record pulse amplitude/quality?
0,+1,+2,+3 scale with 0 being absent, 1 being weak, 2 being normal, and 3 being bounding
51
Normal Adult Heart Rate?
60 to 100 bpm
52
Ways to Measure Pulse?
1. Palpate peripheral arteries
2. Auscultate apical pulse with stethoscope
3. Assessing apical-radial pulse
53
Methods of Assessing Pulse?
1. Inspection
2. Palpation (2-3 middle fingers lightly over the pulse)
3. Doppler Ultrasound
4. Stethoscope and Apical Pulse
54
When palpating pulse, never use your...
thumb
55
The apical pulse is located...
on the left side, mid-clavicular, 5th intercostal space
56
Areas of Peripheral Pulses
```
Temporal
Carotid
Brachial
Radial
Ulnar
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibial
```
57
Which peripheral pulse is checked only during an emergency for RATE?
Carotid
58
Never do what with carotid pulse?
take both sides at the same time
59
Pulse/Apical Deficit
Difference between the apical and radial pulses
Do not want this to occur, and the radial pulse will never be higher than the apical
Requires two people to learn
60
Stroke Volume
the volume of blood ejected from the left ventricle with each heartbeat(contraction)
61
Cardiac Output
the amount of blood ejected per minute
62
Cardiac Output Equation
Stroke Volume * Heart Rate
63
Dysrhythmia
irregular heart rate
64
Decent Cardiac Output Range?
3.5 to 8 Liters of blood per minute
65
Typical Child Pulse Rate
80-100 bpm
66
Typical Infant Pulse Rate
100-160 bpm
67
Typical Older Adult Pulse Rate
low 70s - 60 bpm
68
Pulmonary Ventilation
movement of air in (inhalation) and out (exhalation) of the lungs
69
Respiration involves what three things?
Ventilation, Diffusion, and Perfusion
70
While heart rate is controlled by ANS, what controls respiration?
ANS and External Control
71
External Respiration (Diffusion)
the exchange of oxygen and carbon dioxide between the alveoli and circulating blood
72
Internal Respiration (Perfusion)
the exchange of oxygen and carbon dioxide between the circulating blood and tissue cells
73
Respiratory Centers controlling Rate and Depth of Breathing are located in..
the Medulla and Pons
74
What stimulation causes activation of breathing?
stimulation of peripheral chemo receptors detecting oxygen OR pH
75
The most powerful respiratory stimulant is...
an increase in CO2
76
Factors Affecting Respiration
```
Exercise
Respiratory and Cardiovascular Disease
Alterations in Fluid, Electrolyte, and Acid Balances
Medications
Trauma
Infection
Pain
Anxiety
```
Diabetic Ketoacidosis increasing resp to get rid of ketones (and cause a sweet smell)
Low Carb/High protein diet increasing resp to get rid of ketones (and cause a sweet smell)
Medications like opioids suspend/decrease drive for respiration
Medications like EP and Caffeine increase drive for respiration
77
Ways to Assess Respiration?
Pulse Oximeter
Auscultate with Stethoscope
Inspection
Monitoring Arterial Blood Gas Results
78
Things to look for when Inspecting Respirations?
Rate
Depth
Rhythm
Ease of Breathing
Use of accessory muscles of the neck
color of skin
blanching of nail bed within 3 seconds is good circulation, longer is concerning
79
Tachypnea
increased respirations
80
Bradypnea
decreased respirations
81
Minimal time to count respiration/pulse is...
30 seconds (multiply by 2) (sometimes can do 15 seconds for pulse and multiply by 4)
But, first time should always be done for 60 seconds
82
Apnea
periods with no breathing (greater than 4-6 minutes leads to brain death)
83
Dyspnea
means rapid breathing or shallow breathing
84
Blood Pressure
the force of blood against the arterial walls
85
Blood pressure rises when and falls when?
Rises when the ventricle contracts (Systolic) and falls when the heart relaxes (Diastolic)
86
Pulse Pressure
Differences between systolic and diastolic pressure (S-D = PP)
87
Equipment for BP
Stethoscope
Sphygmomanometer (with right cuff size)
Doppler Ultrasound
Electronic or automated devices
88
Too small a BP cuff can lead to...
false high reading
89
Too small a BP cuff can lead to...
false low reading
90
Average adult breathing rate?
12-20 BPM
91
Contraindications for Blood Pressure
IV placement on arm
AV Fistula
Birth control implant in arm
Any healthcare device in arm indicates to use the other
Mastectomy leading to lymphoedema potential
BP cuff being made of latex could cause allergies
hypo/hypervolemia
wounds in upper extremities
92
Korotkoff sounds?
First noise is the systolic pressure, fifth/final is diastolic
Aucultatory gap between the first and second sounds
93
Basic BP Pressure Reading Procedure
1. pick correct cuff and wash hands
2. Assume sitting position with arm horizontal to heart and find brachial artery pulse
3. Expose arm and place cuff
4. palpate radial pulse and inflate until extinction, note number and add 30 mmHg
5. pump to that number after putting stethoscope diaphragm over brachial pulse a minute later
6. allow deflation of 2-3 mmHg per second and note first and final sounds
7. remove, clean equipment and hands, mark recordings
94
Systolic
highest amount of pressure (working phase of heart)
95
Diastolic
lowest amount of pressure (resting phase of heart)
96
How is BP written?
Systolic/Diastolic
97
How is Pulse Pressure written?
Systolic - Diastolic
98
Factors that Influence BP?
```
Age, Gender, Race
Circadian Rhythm
Food Intake
Exercise
Weight
Emotional State
Body Position
Drugs/Medications
Peripheral Resistance
Blood Volume
Viscosity of Blood
```
99
Standard "Normal" BP in Adults
below 120/80
100
Hypertension
- Diagnosis after 3 readings above normal limit (140/90)
| - Prehypertension, stage 1, and stage 2 stages
101
Prehypertension Average
120-139/80-89
102
Stage 1 Average
140-159/90-99
103
Stage 2 Average
Greater or Equal to 160/100
104
Hypotension
below the lower limit of normal for blood pressure
105
Orthostatic Hypotension
temporary fall in BP related to postural changes (standing up) that can lead to falls
106
What can lead to False BP Highs
Uncalibrated Sphygmomanometer
Assessing BP after exercise
A narrow Cuff
Releasing the valve too slowly
Reinflating the bladder during auscultation
107
What can lead to False BP Lows
hearing deficit in nurse
noise in environment
viewing the meniscus from above eye level
applying too wide a cuff
crack stethoscope
misplacing the bell instead of the diaphragm
failing to pump cuff 30 mmHg above the disappearance of the pulse
108
Abnormalities in Vitals as titled by Nursing Diagnosis
Risk for Altered Body Temperature
Hypothermia
Hyperthermia
Ineffective Thermoregulation
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Inability to Sustain Spontaneous Ventilation
109
Rectal thermometers are what color?
Red (and only rectal thermometers ared red, while oral is blue)
