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Module 1 (Intro To Basics) > Vital Signs > Flashcards

Vital Signs Flashcards

(91 cards)

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1
Q

What is the range of normal temperatures?

A

96.8-100.4

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2
Q

What is the normal range of temperatures for an oral/tympanic/temporal thermometers?

A

97.6-99.6

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3
Q

What is the normal temperature range for a rectal thermometer?

A

98.6-100.4

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4
Q

What is the normal temperature range for a axillary thermometer?

A

96.6-98.6

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5
Q

What is the normal range for a pulse?

A

60-100 bpm (Lub-dub = 1 beat)

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6
Q

What are normal levels of O2 Saturation?

A

95-100%

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7
Q

What is a normal blood pressure?

A

120 / 80

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8
Q

What is prehypertension bp?

A

120-139 / 80-89

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9
Q

What is stage 1 hypertension bp?

A

greater than 140 / 90

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10
Q

What is hypotension?

A

less than 90 systolically with symptoms

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11
Q

Normal respiratory rate (Expiration and Inspiration =1)

A

12-20 breaths per minute

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12
Q

When do you measure Vital Signs? (6)

A

admission
pre physician orders
change in patient condition
before/after the procedure
during blood transfusions
after medications that affect VS

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13
Q

Where do you get the core temperature for a patient?

A

Bladder

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14
Q

Where is the regulation of temperature controlled?

A

Neural/Vascular Control : Hypothalamus

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15
Q

The anterior hypothalamus controls the heat _____ by causing the body to ____________.

A

lost; radiation, conduction, convection, evaporation, diaphoresis

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16
Q

The posterior hypothalamus controls the heat _____ by causing the body to ____________.

A

production; BMR and shivering

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17
Q

Radiation

A

transfer heat without direct contact

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18
Q

Conduction

A

transfer of heat with direct contact

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19
Q

Convection

A

transfer heat away by air movement

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20
Q

Evaporation

A

transfer of heat from liquid to gas

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21
Q

Diaphoresis

A

visible persperation

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22
Q

What factors that affect temperature?

A

age
hormonal levels
environment
excercise
circadian rhythm
medication alteration of temp

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23
Q

Pyrexia, Febrile

A

fever

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24
Q

To what degree does a fever turn harmful?

A

102.2

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25
Fever Characteristics
defensive mechanism taken several times a day results from alter in hypothalamic set point increase in metabolism and O2 consumption increase in heart rate and respiratory rate
26
Hyperthermia
inability to promote heat loss or reduce production
27
Afebrile
no fever
28
FUO
Fever of unknown origin
29
Heatstroke
dangerous heat emergency with a high mortality rate 104 +
30
Heatstroke Signs and Symptoms
*NO SWEATING* dry, hot skin confusion, excess thirst, muscle cramps VS: increase in heart rate with low bp *NO SWEATING*
31
Heat exhaustion
diaphoresis = excess water and electrolyte loss Replace fluids
32
Hypothermia
prolonged exposure to cold, decrease body's ability of heat Temperature lower than 86-96.8
33
Formula F to C
C = (F - 32) x 5/9
34
Formula C to F
F = (9/5 x C) + 32
35
Oral Thermometer
easily influenced by hot/cold food *wait 30 minutes* most used approximately one degree lower than core temperature mercury, glass, or electronic
36
Rectal Thermometer
closest to the core temperature
37
How far should the nurse place the rectal thermometer into an adult, child, and infant?
Adult = 1 1/2 inches Child = 1 inch Infant = 1/2 inch
38
If the rectal thermometer is placed in feces, is it accurate temperature?
no, inaccurate
39
Axillary thermometer
safest and least accurate moisture may reduce temperature
40
How long does the axillary thermometer need to be in place?
5-10 minutes
41
Tympanic thermometer
most rapid unaffected by PO intake remove hearing aides
42
Temporal thermometer
most accurate fast, easy with few errors
43
What can a nurse do during vital signs _______ culture monitor ________ and _______________ conserve _____ and provide _______ bath water is ________ dry ______ ________ meds (tylenol)
blood culture if ordered monitor VS, skin color, temp., turgor, and lab work reduce frequency activities to decrease oxygen maximum heat loss extra fluids tepid bath water oral hygiene dry linens antipyretic meds (tylenol)
44
What are the parts of a stethoscope called?
Earpieces, binaural, tubes, chest piece with bell and diaphragm
45
Pulse definition
palpable/audible bounding of blood flow at various points in the body indirect measure of circulatory status
46
Radial pulse
most common routine used for pt teaching circulation to hand assessed with VS pulse
47
Apical pulse
located 5th intercostal and mid clavicle if abnormal radial pulse, check meds and radial inaccessible
48
Carotid pulse
only if patient suddenly worsens pulse quickly do not measure bilaterally at same time
49
Doralis Pedis
top of foot between 1st and 2nd toes or ankle circulation to foot via doppler if no palpation do both at the same time
50
Pulse Characteristics
Rate (baseline, if abnormal try apical) Rhythm (regular, irregular, dysrhythmia) Strength (4,3,2 (normal), 1, 0) Equality
51
What pulse strength is normal?
2
52
Gas Exchange
moving air in or out (inspiration and expiration)
53
Where is gas exchanged?
Alveoli
54
Ischemia
insufficient oxygen supply leads to cell injury/death
55
Hypoxia
cells don't have enough oxygen
56
Hypoxemia
arterial blood does not have enough oxygen
57
Respiratory Acidosis
carbon dioxide stays and causes no oxygen to enter
58
Perfusion
swapping of gases at alveoli
59
What do you assess during pulse?
rate, rhythm, and depth
60
Eupnea
ventilation of normal rate and depth
61
Factors influencing pulse
exercise, acute pain, anxiety, smoking, body positions, meds, neuro injury, hemoglobin functions
62
Possible Alterations of Respiration Patterns (-pnea(s))
tachypnea bradypnea apnea cheyne-strokes respirations dyspnea orthopnea biot's respiration
63
Tachypnea (bpm rate)
24 bpm or higher
64
Bradypnea (bpm rate)
less than 10
65
Apnea
life-threatening with no breathing for a period of time
66
Cheyne-strokes Respirations
rate and depth increase then apnea
67
Dyspnea
difficult breathing or shortness of breath
68
Orthopnea
positional breathing laying down
69
Biot's respiration
normal 3-4 breaths with apnea
70
What method is an indirect oxygen saturation?
pulse oximetry
71
Pulse Oximetry
light absorption with photodetector SpO2 = SaO2
72
Factors Affecting Pulse Oxygenation
too loose/tight device polished artificial nails temperature of extremities movement lighting skin pigmentation edema peripheral vascular disease
73
Blood Pressure definition
force exerted against blood vessels by blood measured in mmHg
74
Systolic
maximum pulse pressure
75
Diastolic
minimum pulse pressure
76
Physiology Factors of BP
cardiac output (volume of blood) peripheral resistance (plague) blood volume viscosity elasticity
77
Korotkoff Sounds in Phases
1- sharp thump (systolic) 2- blow/whooshing 3-crisp, intense tap 4-soft blowing fades (diastolic) 5-silence
78
Steps of BP
proper cuff size and site position at heart level with palm up wrap cuff around place stethoscope and close valves inflate to 30 mmHg above baseline document
79
Ideal Environment for BP
quiet sitting record both arms initially same arm everytime avoid IVs rest 5 minutes before assessment ask not to speak
80
Factors Affecting BP
age, stress, ethnicity, gender, daily variation, meds, activity, weight, smoking White Coat Syndrome
81
Hypertension effects
major factor in underlying stroke contributes to heart attacks *No symptoms*
82
Hypotension symptoms
skin molting, clammy, confusion, increase heart rate, decrease in urine output
83
Automatic BP machines
frequent assessment needed baseline BP is manually 1st more susceptible to error unable to accurately detect low BP talking during BP will rise by 10-40%
84
Hypertension signs
thicken of walls loss of elasticity family history risk factors
85
Hypotension signs
systolic less than 90 dilation of arteries loss of blood volume decrease in blood flow to organs orthostatic/postural
86
Alternative BP sites
thigh (systolic raises by 10-40, but diastolic is same) Arterial line
87
Pain Mnemonic PQRST
Provokes/palliative: worst or better Quality: type Region/radiation: where Severity/Setting Timing: time of day
88
Pain Severity Scale 0-10 None = Mild = Moderate = Bad to Worst =
0 1-3 4-6 7-10
89
When do you assess pain?
Before procedures, activity, and medication 30 minutes after pain meds After procedures, activity
90
T/F: Always assume what the patient says and don't assume their pain levels.
True
91
When do you assess pain?
Before procedures, activity, and medication 30 minutes after pain meds After procedures, the activity

Module 1 (Intro To Basics) (32 decks)

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