Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Vital Signs > Vital Signs > Flashcards

Vital Signs Flashcards

(132 cards)

Start Studying
1
Q

Factors that affect VS

A

Medications
Illness/infection
Exercise/stresw
Age
Hypovolemia/dehydration
PO intake
Hormones
Circadian rhythm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Medications

A

Antipyretic such as acetaminophen decrease temp
Opioids such as morphine decrease resp rate
Antihypertensives such as atenolol decrease blood pressure and many decrease pulse
Cardiac glycosides such as digoxin can decrease pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Illness/infection

A

Can cause increased pulse, resp rate, bp
Infection causes increased pulse
Sepsis causes increased pulse and decreased bp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Exercise/stress

A

Increased metabolism temporarily increased temp,pulse,resp,bp
Postural changes can increase P and decrease BP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Age

A

Older adults and infants temp regulation is less effective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Hypovolemia/dehydration

A

Hemorrhage caused decreased bp and increased pulse same with dehydration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Environment

A

Visit to health care provider can increase BP, hot/cold environment can impact T

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

PO intake

A

Hot/cold beverages, smoking, etc can alter Temp, smoking, caffeine, heavy drinking can increase BP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Hormones

A

Ovulation can change T
Thyroid hormones cause increase in metabolic rate thus increase T and P

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Circadian rhythm

A

T and BP can slightly fluctuate based on time of day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Why is it important to note VS

A

Important to note both negative and positive changes:
Can tell if a health status is declining or improving
Can tell if an intervention is working

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Interpret

A

Assess in relation to other VS, clinical manifestations S&S, medical history, lab values

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Temp average

A

36-38

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Temp sites

A

Oral, axillary, temporal, tympanic, rectal
Skin tape, non contact
Core temp: pulmonary artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Oral

A

Avg: 37
Most frequently taken
Easily accessible and comfortable
Must wait 20 minutes or chose another site if client has taken hit or cold foods/fluids, chewed gum, or smoked
Do not use on patient who have had oral surgery, facial trauma, very young, unconscious, confused, or uncooperative

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Axillary

A

Avg: 36.5
Second most used
Takes longer to obtain reading
Often used in newborns and children
Accuracy effected by recent bathing, sepsis, surgery and sweating
If client is sweating wipe axilla prior to taking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Temporal

A

Avg: 37
Uses scanner probe to obtain infrared readings of temporal artery blood flow
Non-invasive and fast
Avoid any scar tissue, open abrasions or sores
Readings affected by diaphoresis and air flow across face

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Tympanic

A

Avg: 37
Detects heat radiation from tympanic membrane using infrared sensor
Used less=prone to error such as incorrect straightening of ear canal, gettting a good seal, dirty lens
Affected by patients different sized and shaped ear canals, amount of cerumen as well as if they talk or yawn
Pull pinna down and back for ages 3 or less

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Rectal

A

Avg: 37.5
Rarely used
Considered accurate but not convenient and uncomfortable/may be damaging to rectal tissue
Vagus nerve stimulation can cause bradycardia and synscope fainting
Need to be sure probe is not placed in feces
Contraindicated in infants and children, rectal surgery, disease, diarrhea, hemorrhoid, bleeding disorders, cardiac conditions, spinal injury, uncooperative clients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Skin tape or chemical disposable

A

Rarely used
Not very reliable
Contain liquid crystals that change colour according to temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Non-contact

A

Newest
Used for covid 19

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

True core

A

Measures T of deep tissues
More closely represents T of internal organs
Is most accurate
Invasive, inconvenient, often unavailable
Used only in critical care and intraoperatively
Optimal core temp 36.5-37.5
Pulmonary artery catheter is best
T sensing foley in bladder and probe in esophagus are other methods

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Alterations in temp

A

Pyrexia
Hyperthermia
Fever
Hyperpyrexia
Febrile, afebrile
Hypothermia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Thermoregulation

A

Process that allows your body to maintain its internal core temp

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Thermoreceptors
The body’s cold and warm temp receptors, send messages to hypothalamus
26
Hypothalamus
Part of brain responsible for thermoregulation, goal is to restore homeostasis
27
Homeostasis
Bringing internal T back to normal range
28
Too hot
Body increases capillary blood flow through vasodilation which allows blood closer to surface and results in sweating = decreased T Sweating is body’s only mechanism to dissipate heat when environment warmer than core temp
29
Too cold
Body cells increase metabolic rate to increase heat production and blood vessels constrict to keep blood away from surface and core warm to conserve energy Shivering (an involuntary contraction of muscles) occur to generate additional heat
30
Pyrexia
Fever Occurs when the heat-loss mechanisms are unable to keep pace with excess heat production
31
Hyperthermia
T is elevated but it is a result of the body’s inability to promote heat loss or reduce heat production (an overload of the thermoregulatory mechanisms)
32
Febrile
If a client has elevated T they are febrile (above average temp is not called febrile, the client is called febrile Increase T by heat exhaustion, heat stroke, virus, bacterial infection, sunburn Treatment depends on cause and may include fluids, tepid bath, cooling blanket, anti-pyretics
33
Hypothermia
Occurs when core T is 36 or less Can be mild or severe Can be unintentional or medically induced (eg cooling protocol post MI) Treatment can include warm IV, blanket warmer
34
Alterations In temp can indicate
Infection Inflammatory response Deteriorating client Thermoregulatory disorders
35
Pulse
Radial Apical Brachial
36
Radial
Assessed by palpation 30 secs if normal, 60 if abnormal Normal 60-100 per minute, regular rhythm, 2+ equal bilaterally
37
Pulse scale
0 (absent) 1+ (weak/thready) 2+ (strong) 3+ (full/increased) 4+ (bounding, difficult to obliterate) If unequal bilaterally = impaired circulation to one side
38
Apical
Assessed by auscultation Always needs to be assessed for full 60 secs Needs to be assessed at PMI (Erbs points 3rd intercostal space L stern also boarder)
39
Brachial
Assessed by palpation but not usually counted for rate
40
Apical-radial pulse deficit
Difference between apical and radial pulse rates Occurs when the pulse wave is not transmitted such as when someone has an arrhythmia
41
Respiration’s
Act of breathing addition of O2 and removal of CO2 Resp centre in brain stem driven primarily by CO2 levels Ventilation, perfusion, diffusion Mechanical ventilation sometimes used to assist Perfusion involves cardio system ability to pump oxygenated blood to the body’s tissues and return unoxygenated blood to lungs Diffusion responsible for the movement of molecules back and fourth
42
Inspiration
Active process with signals from brain causing diaphragm to contract and ribs to retract upward Main muscles used are diaphragm and intercostal muscles
43
Exhalation
Passive Expelling CO2 Diaphragm, lungs, chest wall return to their relaxed positions
44
Cardio output
HR x SV
45
Average pulse
60-100
46
Alterations in pulse
Tachycardia Bradycardia Arrhythmia/dysrhythmia Pulse deficit
47
What causes pulse
When blood is pumped out of left ventricle that forceful contraction produces a pulse wave that is transmitted through the arteries to the periphery of the body May be palpated where an artery is close to the surface of the skin, and over a bone or firm surface that supports the artery
48
CO
Volume of blood pumped in one minute Approx 5L of blood a minute is pumped
49
HR
Number of beats per minute
50
Stroke volume
Amount of blood that enters the aorta with each ventricular contraction Avg: 60-70ml
51
If pulse significantly increases, decreases or becomes irregular
Alters cardiac output Increasing HR or pulse is the first compensatory mechanism the body used to maintain adequate CO Body can increase SV by pumping more forcefully or increasing amount of blood that fills the left ventricle before it pumps
52
Tachycardia
Abnormally fast HR Greater than 100 bpm Increased pulse can be caused by exercise, fever and heat, anxiety, stress, acute pain, meds such as epinephrine, hemorrhage, postural changes, diseases such as asthma, COPD, CHF
53
Bradycardia
Slow HR less than 60bpm Can be caused by long term exercise, hypothermia, relaxation, medications such as digoxin, lying down , hypothyroidism, cardiac conduction block
54
Arrhythmia/dysrhythmia
Irregular heart rhythm Places individuals at risk as it may cause an inadequate cardiac output
55
Pulse deficit can be caused by
Cardiovascular disease Atrial fibrillation Aflutter Heart block Premature ventricular contractions
56
Assessment of resps include
Rate: if regular count 30 secs 12-20 Depth: normal deep or shallow Rhythm: regular or irregular Quality: effortless/silent, or dyspnea/orthopnea
57
Eupnea
Normal breathing 12-20, effortless, automatic, quiet and regular Resp rate strong predictor of adverse events
58
Newborn resp
30-60 RR gradually slows fill the normal adult rate
59
Factors affecting resp
Exercise, age, acute pain, anxiety, smoking, body position, meds, neurological injury, hemoglobin function, fever
60
Tachypnea
Fast rate of breathing over 20 breaths per minute
61
Bradypnea
Slow rate of breathing under 12 breaths per minute
62
Hyperventilation
Rapid and deep respiration’s which may result in hypocarbia (decreased CO2)
63
Hypoventilation
Slow and usually shallow breathing which may result in hypercarbia (increased CO2)
64
Dyspnea
Difficult/laboured breathing, breathlessness, an unsatisfied need for air. Clinical manifestation of hypoxia
65
Orthopnea
Ability to breath only upright, standing or in tripod position, need serval pillows to sleep at night or need head of bed to be elevated
66
Oxygen saturation
Avg adult 95-100% Under 70% life threatening Sensor placed on finger, toe, nose, earlobe
67
Pulse oximetry
Measures the ratio of oxygen in the blood combined with hemoglobin to the total amount of oxygen that the hemoglobin molecule can carry
68
Things that affect o2 measurement
Nail polish Impaired circulation Movement such as shivering Severe anemia (may have good readings however as their amount of hgb is inadequate they are still hypoxia) Carbon monoxide can trick into providing a good reading because co attached to Hgb in oxygens spots and the oximeter is unable to differentiate between the two molecules
69
Hypoxia
Inadequate tissue oxygenation at the cellular level Can be caused by anemia
70
Hypoxemia
Below normal level of oxygen in your blood, specifically in your arteries From COPD
71
What is bp
Pressure exerted on arterial walls by the force of the hearts contraction Pressure rises and falls during the cardiac cycle
72
Where is pressure highest
In the ventricles and decreased as the distance from the heart increases
73
Why is adequate bp required
For perfusion of all the body tissues with oxygenated blood, transportation of essential nutrients, and removal of waste materials by the liver, kidneys, and lungs
74
Systole/systolic bp
Top or bigger number, highest pressure on the arterial walls and occurs during heart contraction
75
Diastole/diastolic
Lower or smaller of the two numbers, the lowest pressure in the arteries during the brief rest period
76
Pulse pressure
Difference between systole and diastole and is normally 30-50mmHg
77
Consistently high/wide pulse pressure
Can be a result of arteriosclerosis, increased ICP, fever, pregnancy, anxiety, endocarditis, heart block, anemia
78
Consistently low/narrow pulse pressure
Can result from blood loss, low stroke volume, heart failure, shock
79
Procedure of measuring BP
1. Position client 2. Find brachial artery 3. Measure bp cuff and apply 4. Preform palpatory 5. Place stethoscope over brachial 6. Obtain reading 7. Document and inform client
80
Cuff is inflated
To a pressure greater than the arterial blood flow, blood returns to brachial artery and produces sounds
81
Bp sounds
Korotkoff sounds
82
Phase 5
Diastolic value Absence of sound
83
Position
In order to determine future treatment in relation to BP important to compare values in a consistent position and on the same arm
84
Apply bp cuff
2.5-3cm above antecubital fossa 40/80 rule
85
Auscultatory gap
Temporary disappearance of sound often between first and second phase, can occur and may last up to 40mmHg may cause systolic reading to be underestimated Why we do palpatory Often occurs with hypertensive clients as a result of arteriosclerosis and can lead to a missed diagnosis of hypertension
86
Last sound
Take last sound heard and subtract 2mmHg
87
Why not use arm in bp
If client has had a mastectomy on same side may cause lymphedema leading to aching, discomfort Also cannot use are that has a dialysis fistula or graft, an iv infusion, if arm is painful or swollen and if there is a cast or injury
88
Alternative sites for bp
Radial artery Posterior tibial artery Popliteal artery
89
Bladder length
Covers 80%-100%
90
Bladder width
40%
91
Cuff too small
False high
92
Cuff too big
False low
93
Optimal bp
120/80
94
Normal bp
Less than 130/85
95
Hypertension
135/85
96
Hypotension
Systolic less than 90
97
Bp value
One bp alone does not give enough data , needs to be several bp’s to diagnose something like hypertension
98
Factors that affect bp
Age Sex Stress Ethnicity Daily variations Medications Activity Weight Smoking Pyrexia Diabetes White coat syndrome
99
Hypertension
Significant risk factor for CVA, CAD, CHF, PVD, renal failure
100
Clinical manifestations HTN
Often silent killer May get headache, ringing in ears, flushed face, nosebleeds, fatigue
101
Hypotension
May occur due to hemorrhage, MI
102
Clinical manifestations hypotension
Pallor, mottling, clamminess, confusion, increase hr, decreased urine output
103
Orthostatic hypotension
Postural hypotension Important to assess as it leads to falls Drop of 20mmHg or more in systolic or 10mmHg or more in diastolic within 3 mins of the client rising
104
Direct vs indirect bp
Indirect = non invasive sphygmomanometer or automated bp machine Direct = invasive obtained by using an arterial line needle or catheter into brachial, radial, or femoral artery and the reading is displayed on a monitor Only in ICU
105
Shivering
Monitor when reducing heat not to cause shivering as it increased core temp
106
Hyperthermia symptoms
Decreased skin turgor Dry mucous membranes Tachycardia Hypotension Decreased venous filing Concentrated urine
107
Heatstroke symptoms
Body temp of 40 or more Hot Dry skin Tachycardia Hypotension Excessive thirst Muscle cramps Visual disturbances Confusion Delirium
108
Hypothermia symptoms
Pale skin Skin cool or cold Bradycardia Dysrhythmias Shallow respiration’s
109
Older person temp
At lower end 36 Temps considered within normal range often reflect fever in an older person
110
Pulse sites
Temporal (above and lateral to eyebrow) Carotid ( along medial edge of sternocleidomastoid in neck) Apical Brachial Radial Ulnar Femoral Popliteal Posterior tibial Dorsalis pedis
111
Risk factors for pulse alterations
History of heart disease Cardiac dysrhythmia Onset of sudden chest pain or acute pain Invasive cardiovascular diagnostic tests Surgery Sudden infusion of a large volume of iv Internal or external hemorrhage Meds
112
Signs and symptoms of altered cardiac function
Dyspnea Fatigue Chest pain Orthopnea Syncope Palpitations Edema Cyanosis Pallor
113
Symptoms of peripheral vascular disease
Pale Cool extremities Thin shiny skin Decreased hair growth Thickened nails
114
If pulse count differs by more than 2
A deficit exists
115
S1 S2
S1 is sound of tricuspid and mitral valves closing at the end of ventricular filling S2 is sound of pulmonic and aortic valves closing at end of systolic contractions
116
Diffusion
Movement of o2 and CO2 between alveoli and rbc
117
Risk factors for resp alterations
Fever Pain Anxiety Diseases of lungs or chest wall Constructive dressings Abdominal incisions Gastric distension Chronic pulmonary disease Traumatic injury to chest Presence of chest tube Resp infection Pulmonary edema and emboli Head injury Anemia
118
Symptoms of resp alterations
Cyanosis of skin nail beds lips mucous membrane Restlessness Irritability Reduced levels of consciousness Pain during inspiration Laboured breathing Orthopnea Use of accessory muscles Adventitious breath sounds Inability to breath spontaneously Thick frothy blood tinged or copious sputum
119
Apnea
Resps cease for several seconds, resistant cessation results in resp arrest
120
Biots respiration
Irregular resps varying in depth followed by periods of apnea (associated with CNS disorders)
121
Bradypnea
Rate of breathing is regular but abnormally slow (less than 12)
122
Cheyne-stokes resps
Rate and depth irregular characterized by alternating periods of apnea and hyperventilating
123
Hyperpnea
Resps increase in depth and rate over 20 (occurs during exercise)
124
Hyperventilation
Resp increase Hypocarbia may occur
125
Hypoventilation
Rate is abnormally low Hypercarbia may occur
126
Priority abc
Airway, breathing, circulation
127
Radiation
Transfer of heat from the surface of one object to the surface of another without direct contact
128
Conduction
Transfer of heat from one object to another through direct contact
129
Convection
Transfer of heat away from the body by air movement
130
Diaphoresis
Visible perspiration
131
Pyrogens
Such as bacteria and viruses can rise temp
132
Fever causes
Cellular metabolism to increase and oxygen consumption to rise HR and resp rate increase

Vital Signs (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions