Vital Signs

Question 1

What are normal vital signs for an adult ?

Answer 1

BP: >90/60 mm hgb - <120/80 mm hgb
Temp 96.8- 100.4
HR: 60-100 beats/min
Respiration’s: 12-20 breathes/min
O2: > or equal to 94

Question 2

Guidelines for measuring VS

Answer 2

Measuring VS is your responsibility 
Assess equipment is working right and appropriate equipment
What’s the usual VS range
Patient health history, therapies, meds
Control environmental factors
Organization
Verify/Commun. Significant finding 
Educate patient on findings

Question 3

What are the 6 VS

Answer 3

Temp
BP
SpO2
Respiration
Heart Rate
Pain

Question 4

Normal Ranges for adults VS

Answer 4

Temp: 96.8- 100.4
BP: >90/60 - <120/80 mm Hg
O2: > or equal to 94
Respiration: 12-20 breaths/min
Heart Rate: 60-100 beats/min

Question 5

Alterations in VS

Answer 5

Age
Exercise
Stress
Trauma
Illness
Infection
Disease
Medications
More

Question 6

Body temp functions

Answer 6

Temp regulated by hypothalamus
Body keeps temp @ cool level
Core temp is temp of deep tissues that’s most constant and true

Question 7

Factors determining temp

Answer 7

Site (oral, rectal, tympanic)
Time ( lowest temp 6:00 highest temp 1600)
Always use same instrument

Question 8

Body temp regulation

Answer 8

Thermoregulation
-balance between heat production and heat loss
- for temp to stay at constant range and acceptable body must constantly produce and get rid of heat
Hypothalamus controls body temp
- like a thermostat

Heat conservation: vasoconstriction (narrowing) of vessels to reduce blood flow to the skin and extremities resulting in reduce heat loss
Heat loss: sweating, stopping heat production, vasodilation (widening) of blood vessels, which send blood to surface vessels to promote heat loss

Skin regulates temp through insulation w/ fat

Question 9

Assessment of temp

1st 3

Answer 9

Site How to measure Pro Con

Oral- probe under tou he back corner, quick easy, comfy, inaccurate w/ foods and o2 cooperation

Temporal- on 4head move or rest on temporal artery, easy, rapid, comfy, sweating & hair

Tympanic- in ear pull ear up out and back, easy, rapid not influenced by food etc, injury

Question 10

Assessment of temp

2nd 3

Answer 10

Rectal- lube probe insert in rectum no force and withdraw if resistance, more reliable if oral temp no good, painful, injury, invasive, cooperation

Axillary- place under arm in center of axilla,inexpensive, lengthy, probe in same position, sweat, not accurate

Infrared- place device few inches away from 4head get result, inexpensive safe noninvasive quick, sweat and environmental temp

Question 11

Elevated and slow HR

Answer 11

Elevated: >100 beats/min tachycardia

Slow: <60 beats/min bradycardia

Irregular HR- dysrhythmia

Question 12

Apical pulse

Answer 12

HR or heart rhythm irregular have to do apical pulse

• can’t be delegated
• also known as maximal impulse (PMI)
• found at apex of heart (bottom)

To find: 
Sit or lay down
Sternal notch move right below 
Move hand to left and count in between ribs space (start at space 2) 
At 5 space move hand to mid clavicle
Stethoscope I’m replace 
Hear each lub dub 1 HR determine new HR

Question 13

Pulse Deficit

Answer 13

Inefficient contraction of heart to send pulse to wrist

Asses apical and radial same time (partner needed)
Difference between 2 is pulse deficit

Often associated with abnormal heart rhythm

Question 14

Respiration

Answer 14

Breathing controlled by medulla oblongata

Respiration involves: ventilation, diffusion, perfusion

Function control: regulated CO2 levels

Mechanics or breathing: inspiration: active process
Expiration: passive process

Question 15

Respiration assessment

Answer 15

Respiratory rate:
Chest rise and fall don’t tell patient

Ventilators depth:
Unflavored or labored (working to breathe or normal)

Ventilatory depth:
Pattern even or uneven

Question 16

SPO2 assessment

Answer 16

Measure arterial o2: measures % of hgb saturated w/ o2
No BP and o2 at same time
Include unit of measure and oxygen source

Question 17

SpO2 readings can be wrong

Answer 17

Tremors
Cold extremities
Dark nail polish

Question 18

Blood Pressure

Answer 18

Force exerted on wall as of artery by pulsing blood under pressure from heart

• needs to remain under pressure to have the power to travel to tissue in body
• less pressure tissues won’t receive blood
• too much pressure small vessels in tissue may rupture

Question 19

BP function, factors and pulse pressure

Answer 19

Function of arterial BP:
Cardiac output
Peripheral resistance 
Blood volume
Viscosity (thick)
Elasticity (recovery back to size)

Factors influencing BP:
Age, stress, ethnicity, genetics, gender, daily variation, medications, activity, weight, smoking

Pulse pressure:
Difference between systolic and diastolic pressure

Question 20

Hypertension VS hypotension

Answer 20

Hyper- BP 130/80 or higher 
Asymptomatic 
Thickening of arterial walls
Loss of elasticity of arterial walls
Heart must exert more force to push blood out into system this increasing pressure 

Hypo- BP < 90/60
Decrease blood flow to vital organs and tissues
Orthostatic/ postural changes ( BP drop when standing up)
Decrease in BP
Increase in HR
body unable to keep up with demands

Question 21

Meds for hypertension

Answer 21

Most likely on meds to control BP

job of meds to keep in normal range

If patient has high BP and you take it and it’s normal means they are adhering to med regimen

Question 22

BP assessment

Answer 22

Stethoscope
BP cuff

Correct size for patient
Cuff width be 40% of arm circumference
Inflatable bladder of cuff should encircle 80% of upper arm

Cuff too big - low readings
Cuff to small - high readings

Question 23

Precautions for BP readings

Answer 23

Avoid extremities with; dressing, cast, IV, and fistula

If lower extremity chosen the BP will be increased by 10 or more mm Hg

Question 24

Safety guidelines for nursing skills

Answer 24

Clean devices between each patient for decrease risk of infection

Rotate sites of repeated measurements of BP and pulse to decrease skin breakdown

Analyze trends for VS and report abnormal findings

Determine baseline for patients vital signs

Determine patient status before delegating

Question 25

Documenting vital signs

Answer 25

Document only your findings If VS abnormal document in narrative charting along with additional assessment findings - document condition, assessment findings, medications given, stress, pain, fever etc. Document interventions initiated on basis of VS measurement Document plan of action Document follow up/ reassessment of vitals with appropriate assessment

Question 26

Pain

Answer 26

Considered 6th vital sign Often under recognized, misunderstood, and inadequately treated Subjective finding Nurses legally and ethically responsible for assessing and managing pain Pain management should be patient centered

Question 27

Scientific knowledge of pain

Answer 27

Pain stimulus is sent to cerebral cortex then interpreted by brain Brain interprets the quality of pain and also process info from past experiences, knowledge and cultural associations in perception of pain Person becomes aware of pain and reacts Person can react physiological or behavioral responses

Question 28

Physiological response with pain

Answer 28

Body’s stress response from pain stimulates autonomic nervous system Low to moderate intensity and superficial pain will elicit SNS (increased HR, BP, respitory rate) Continuous, severe, or deep pain (organs ex. Kidney stones) elicit the PNS All patients respond differently to pain VS may or may not change with pain

Question 29

Acute/Transient pain

Answer 29

Protective Identifiable cause Short duration Limited tissue damage and emotional response Common after acute injury, disease, surgery Acute pain treated aggressively (with interventions) bc of predictable ending by managing pain successfully patient becomes involved in self care, increases mobility, promotes healthy sleep habits, and reduces pulmonary complications Unrelieved acute pain can go to chronic

Question 30

Chronic pain

Answer 30

Affects more than 50 million American adults Serves no purpose Frantic effect on a persons quality of life 3 to 6 months Can impact psychological and physical ability Symptoms: fatigue, insomnia, anorexia, weight loss, apathy, hopelessness, depression anger

Question 31

Factors influencing pain

Answer 31

Physiological: Age, fatigue, genes, neurological function Social: Previous experience, family and social network, Spiritual factors Psychological: Attention, anxiety and fear, coping style Cultural: Meaning of pain, ethnicity Impacted by pain Quality of life, self care, work, social support

Question 32

Health promotion

Answer 32

Maintaining use of different types of pain relief measures Be willing to use more than one type of pain relief Use measurements patient believes are effective Keep open mind about ways to relieve pain Don’t give up on relieving pain May not be totally eliminated but can be improved for function

Question 33

Non pharmacological pain relief interventions

Answer 33

``` Relaxation and guided imagery Distraction Music Repositioning Cutaneous stimulation -heat/cold Massage Breathing techniques Reducing noise dimming lights ```

Question 34

Pharmacological pain therapies

Answer 34

Need order from provider Analgesics most common and effective for pain relief can use this and non pharmacological interventions to reduce pain Must know medication ordered, indication of use, effects and addiction risk Route of med determine onset and duration Analgesic med for around clock or schedule time is better than prn help maximize pain relief May need less meds bc body at constant therapeutic level Response to it is highly individualized

Question 35

Analgesics: non opioids

Answer 35

Acetaminophen (Tylenol) Safe Action of med is to inhibit enzyme required to make prostaglandins ; they are responsible for causing pain Can be combined with narcs Max 24 hours 4g for healthy adult 3g for older adult or patient with liver disease cause hepatotoxicity if more than that (liver disease) NSAIDS ( non steroidal anti-inflammatory drug) Aspirin, ibuprofen, naproxen Aspirin higher doses of 325 mg is for pain relief 81 mg for cardiac related purposes Reduce inflammation Increase gastrointestinal irritation Can reduce blood flow to kidneys and have kidney problems avoid giving to older adults

Question 36

Analgesics : opioids

Answer 36

Moderate to severe pain Reduction of pain intensity to a level of acceptable comfort Tramadol, oxycodone, hydrocodone, morphine, fetanyl Labeled based on potential of abuse Some in long acting for (8-12 hours) Given during episodes of acute pain for short durations to aggressively treat issue Longer than a week stay on longer Manage chronic pain Depress CNS Must assess the patient thoroughly before and after administering opioid med -VS before and after HR, BP, RR, O2, pain level, mental status Many common and dangerous side effects When given older adults special considerations must be taken due to age

Question 37

Barriers to effective pain management

Answer 37

Physical dependence: Body becomes physical dependent drug bc has adapted to Withdraw syndrome when drug is abruptly decreased Physical dependency does not mean addiction Drug be tapered Drug tolerance: Increased dose for pain control Rotate drug type if tolerance develops as increasing dose can contribute to hyperalgesia (extreme response to pain, increase sensitivity to feeling pain) Addiction: Behavior from a drive to obtain and take substances for reasons other than the prescribed therapeutic value

Question 38

Documentation of pain

Answer 38

Details of the pain, ask appropriate and detailed questions Location Severity Quality Duration Offer interventions (30 min to hour for reassess) Follow up on pain at least every 2 hours if not sooner

Question 39

Reminders

Answer 39

Assess previously used for pain remedies Invasive therapies first Actions and side effects of meds Monitor for and respond to adverse responses Lack of pain expression don’t mean they don’t have it Pain is subjective