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1080 Holistic Health Assessment > Vital Signs > Flashcards

Vital Signs Flashcards

(82 cards)

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1
Q

Clinical Indicators for Vitals Assessment

A
  • Newly admitted (obtain baseline)
  • As per MD order or facility’s routine (no order needed as a nurse)
  • Pre- and post-surgery or certain procedures
  • Before, during, and after administration of specific drugs
  • As indicated by client condition/response: “I feel dizzy, weird, funny, different”
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2
Q

Pulse

A
  • Slow/fast heartbeat
  • Each ventricular contraction 60mL of blood (stroke volume)
  • Waves travel from aorta through distal artery ends
  • Accesses rate (bpm), rhythm, strength & symmetry
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3
Q

Bradycardia

A
  • heart rate below 60bpm
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4
Q

Tachycardia

A
  • Heart rate above 100bpm
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5
Q

Pulse Deficit Discrepancy

A
  • Difference of bpm in different pulse locations
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6
Q

Asystole

A
  • No heart contractions
  • Dead?
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7
Q

Arrhythmia

A
  • Heart rate outside regular range
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8
Q

LUB Heart Sound

A
  • signals beginning of systole contraction (blood pushed out of heart)
  • Loudest at apex or lower left sternal boarder
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9
Q

DUB Heart Sound

A
  • Signals beginning of diastole relaxation phase (heart fill with blood)
  • Loudest at base (top of heart)
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10
Q

Heart Sounds

A
  • Blood movement is silent
  • Listen to sounds of valve closing after blood passes
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11
Q

Palpation of Heart Rate

A
  • Best heard at 5th intercostal space at mid clavicular line
  • Below nipple (men) & above bra wire line (female)
  • Apex, point of maximum impulse (PMI)
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12
Q

Apical Pulse

A
  • above heart apex
  • Check if radial pulse is irregular, uncertainty or pulse deficit
  • Difficult to check in children
  • Always check in infants <2
  • Monitor during administration of drugs that alter heart rate (digoxin/lanoxin)
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13
Q

Auscultation of Heart Rate

A
  • Use diaphragm of stethoscope
  • Apex of heart 4/5th intercostal space
  • Listen for LUB & DUB
  • Count LUB sounds for 60 seconds
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14
Q

Distal Pulse Sites

A
  • Temporal
  • Carotid (side of neck)
  • Brachial (inner side of biceps)
  • Radial (inner wrist under thumb line)
  • Femoral (near pelvic bone)
  • Popliteal (behind knee)
  • Posterior tibial (lower limb calf)
  • Dorsalis pedis (over instep of food)
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15
Q

Radial Pulse

A
  • Take on adults & children 3+
  • Most accessible
  • Located inside wrist on thumb line
  • Excess pressure will obliterate pulse
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16
Q

Rhythm of Radial Pulse

A
  • Count for 30 seconds multiple by 2 for bpm
  • Unexpected finding at radial listen to apical site for 30 seconds
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17
Q

Newborn Pulse

A
  • 120bpm
  • Range 70-190
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18
Q

Toddler Pulse

A
  • 110bpm
  • Range 80-130
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19
Q

Child Pulse

A
  • 95bpm
  • Range 70-115
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20
Q

Preteen Pulse

A
  • 90bpm
  • Range 65-110
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21
Q

Teen Pulse

A
  • 80bpm
  • Range 55-105
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22
Q

Adult Pulse

A
  • 70-75bpm
  • Range 60-100
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23
Q

Elite Athlete Pulse

A
  • 50-60bpm
  • Range 50-100
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24
Q

Pulse Influencing Factors

A
  • Age, younger = faster
  • Gender, men faster
  • Exercise, increased oxygen needs = faster
  • Medications faster/slower
  • Fever, increased metabolic need = faster
  • Hemorrhage, loosing blood = faster
  • Stress, increased fight/flight = faster
  • Body position change, pump blood further = faster
  • Pain, SYN response = faster
  • Heart/respiratory contractions faster/slower
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25
Pulse Documentation
- Strength (amplitude) 0-4 - 4 bounding, 3 full & increased, 2 normal, 1 diminished, 0 absent - Rhythm (different volumes) - Rate, bpm (2x30secs) - Symmetry/location
26
Blood Pressure
- Pressure within arteries while pumping blood (how hard heart is working) - Forced exerted on walls of artery under pressure from heart - Indicator of cardiovascular health - Access same time as pulse - Measured in mmHg on sphygmomanometer
27
Systolic Blood Pressure
- peak of maximum pressure with ejection/contraction - top number
28
Diastolic Blood Pressure
- minimum pressure exerted with relaxation - bottom number
29
Contributing Factors of Blood Pressure
- Cardiac output - Peripheral vascular resistance - Viscosity - Elasticity of vessel walls
30
Hypertension (HTN)
- High blood pressure - 140+
31
Diurnal Rhythm
- Varies throughout day - Higher in AM
32
Hypotension
- Low blood pressure - Below 90/60
33
Orthostatic Postural Hypotension
- Caused by change in body position - Sustained drop in blood pressure
34
Pulse Pressure
- Difference between systolic & diastolic pressure
35
Shock
- Heart failure - Decreased/narrow pulse pressure
36
Assessment of Blood Pressure
- Use cuff - 2/3 circumference of upper arm - Too tight, artificially increase reading - Too loose, artificially decrease reading
37
Technique of Blood Pressure Assessment
- calmly seated for 5 minutes - Back supported with chair - Bare arm/thing clothing - Arm supported at level of heart - Feet on floor - Uncrossed legs - No talking prior to or during procedure
38
Measurement of Blood Pressure
- Palpitate brachial artery - Systolic over diastolic - Inflated cuff stops arterial blood flow - Silent blood flow when artery no longer compressed - 1st beat systolic - Last beat diastolic
39
Newborn Blood Pressure
- 73/55mmHg
40
Infant Blood Pressure
- 85/37mmHg
41
Toddler Blood Pressure
- 89/46mmHg
42
Child Blood Pressure
- 95/57mmHg
43
Preteen Blood Pressure
- 102/61mmHg
44
Teen Blood Pressure
- 112/64mmHg
45
Adult & Elite Athletes
- <120/80mmHg
46
Risk Assessment for Blood Pressure
- Low risk 120/80 - Medium risk 121-139/80-89 - High risk 140+/90+ - Hypotension <90/<60
47
Influencing Factors of Blood Pressure
- Age up/down - Stress up - Medications up/down - Ethnicity (up for Asian, indigenous & black) - Gender up men after puberty & women in menopause - Diurnal variations (daily fluctuations, higher in morning)
48
Temperature
- Result of difference between heat produced by metabolism & lost through skin - Normal body temp 37C
49
Rectal Temperature
- Core temperature - Red probe - 37-37.5C - Under 6 months
50
Tympanic (ear)
- Core temperature - 36-37.5C
51
Temporal (forehead)
- Surface temperature - 36.5-37.5C
52
Oral Temperature
- Surface temperature - Blue probe - 36.5-37.5
53
Axilla (armpit)
- Surface temperature - 35.9-37.2
54
Temperature Accuracy
- Hot/cold drink in last 30 mins - Chewing gum or smoking in last 30 mins - Wait 10-15 minutes for accurate reading - Posterior mouth, under tongue near back molars
55
Influencing Factors of Temperature
- Age - Exercise - Hormone levels - Circadian rhythm - Environment - Stress
56
Temperature of Fever
- 37.8C
57
Febrile
- fever
58
Afebrile
- absence of fever
59
Pyrogen
- bacteria/virus causing fever
60
Antipyretic
- fever treatment medication
61
Diaphoresis
- Movement of air between lung passages - Access rate, rhythm, depth & effort
62
Diffusion
- gas exchange in body
63
Perfusion
- flow of air in & out of bronchi
64
Assessment of Respirations
- Rate, # of inspirations/expirations per 30 seconds - Rhythm, regularity of inspirations/expirations - Depth/effort, degree of movement of chest wall - Count ins/exps for 30 secs multiple by 2 (60 secs for children/abnormal)
65
Tachypnea
- Faster than 20 breaths per minute
66
Bradypnea
- Slower than 12 breaths per minutes
67
Dyspnea
- Difficulty breathing - No pain
68
Apnea
- Lack of breathing - Irregular rhythm
69
Newborn Respirations
- 30-40 per minute
70
Infant Respirations
- 20-40 per minute
71
Toddler Respirations
- 25-32 per minute
72
Child Respirations
- 20-26 per minute
73
Preteen Respirations
- 18-26 per minute
74
Teen Respirations
- 12-22 per minute
75
Adult Respirations
- 12-20 per minute
76
Elite Athlete Respirations
- 10-20 per minute
77
Influencing Factors of Respirations
- Young age, up - Exercise, up - Hypothermia, down - Anxiety, up - Smoking, up - Upright body position, down - Opioid/narcotic use, down - Medical conditions (anemia), up
78
Oxygen Saturation (SpO2)
- Indirect measurement of O2 in blood - Infrared light passes through tissues to read blood cells - Determines amount of red blood cells stock with O2 in % - Reveals oxygenation issues - Also measures pulse (inaccurate)
79
Regular Oxygen Saturation
- 95%+
80
Underlying Lung Disease Oxygen Saturation
- 92%
81
Measuring Oxygen Saturation
- Finger fully in probe - Light against nail bed - Hand steady (hold if shakey)
82
Influencing Factors of Oxygen Saturation
- Carbon monoxide poisoning - Smoke inhalation - Restless, agitated, moving - Nail polish/artificial nails - External light sources - Intravascular imaging dyes - Jaundice - Peripheral edema (fluid swelling in hands/fingers)

1080 Holistic Health Assessment (5 decks)

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