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Fundamentals of Nursing > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

why do vital signs need to be accurate

A

because therapeutic action could be taken from vital signs

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2
Q

what is the order to report vital signs

A

temp
pulse
respiration
BP + mean
pain
O2 (SpO2 & FiO2)

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3
Q

what is elder speak

A

infantilizing communication
ex: sweetie, dearie, honey

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4
Q

why do we not want to use elder speak

A

it conveys a message of incompetence of the receiver and dominance of the speaker over the elder

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5
Q

elder speak leads to what in patients with dementia

A

resistance to care which disrupts nursing care

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6
Q

when to assess vital signs in acute care settings

A

admission
institutional policy
change in a patents condition
before and after surgical or invasive diagnostic procedures
before and/or after certain medications
before and/or after activity in certain cases

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7
Q

why would it be important to assess vital signs before medication

A

some medication can lower or increase certain metabolic functions
EX: some medications lower heart rate and shouldn’t be given if heart rate is already low

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8
Q

why is it important for nurses to know textbook normal and patients normal

A

because somethings that are abnormal may be normal for the patient
EX: a runner could normally have a resting heart rate of 40, that is textbook very bradycardia but for this patient since he is a runner it explains he has a low resting heart rate

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9
Q

nursing process
ADPIE

A

assessment
diagnosis
planning
implementation
evaluation

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10
Q

assessment of VS requires you to make

A

judgments about the means of measurement, equipment, and frequency

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11
Q

you see a nursing student take a blood pressure with gloves on, why would this be wrong

A

unless there is a precaution or bodily fluids present we want to provide touch which shows care

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12
Q

normal oral temp

A

35.8-37.5

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13
Q

normal pulse rate

A

60-100

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14
Q

normal respirations

A

12-20

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15
Q

normal blood pressure

A

lower than 120/80

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16
Q

what are some factors that affect body temp

A

circadian rhythms (lower morning, higher afternoon)
Age (elderly will be less bc of hypothalamus and low amounts of sub)
Gender (men are lower)
physical activity (raises)
environmental temp

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17
Q

what is the primary source of heat production

A

metabolism

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18
Q

what is the primary source for heat loss

A

skin

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19
Q

what are some ways to take core temp

A

rectal
tympanic
temporal artery
pulmonary artery
bladder
esophagus

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20
Q

when you have a rectal temp should you add or subtract a degree

A

subtract

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21
Q

who do you not give a rectal temp to

A

heart problems (stimulates vagus nerve and drops HR)
kids
low WBC (neutropenic)
decrease platelets

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22
Q

surface temp sites

A

oral
axilla
skin surface chemical strips

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23
Q

when you have an axillary temp should you add or subtract a degree

A

add

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24
Q

when you add or subtract a degree do you chart it with that change

A

no chart the actual temp

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25
Q

what probe is for rectal temp

A

red

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26
Q

what do you apply to the thermometer before inserting the rectal thermometer

A

lubricant

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27
Q

what probe is for the oral/axillary

A

blue

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28
Q

afebrile

A

without fever

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29
Q

febrile

A

fever/temp

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30
Q

pyrexia

A

temp/fever

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31
Q

what are some physical effects of fever

A

decreased appetite
headache
hot skin
flushed face
thirst
muscle aches
fatigue
fever blisters

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32
Q

what should we note for fever in elderly

A

they may show signs of confusion before temp rises

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33
Q

what should we do for interventions for patients with a fever

A

MAXIMIZE HEAT LOSS
MINIMIZE HEAT PRODUCTION

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34
Q

how do we maximize heat loss

A

remove heavy blankets
keep clothing and linens dry (otherwise could lead to chills)
cool compresses
ice pack
cooling blanket

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35
Q

how do we minimize heat production

A

limit physical activity

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36
Q

what is radiation

A

energy that comes from a source and travels through space at the speed of light

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37
Q

what is convection

A

process by which heat is transferred by movement of a heated fluid such as air or water

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38
Q

what is evaporation

A

liquid into vapor

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39
Q

what is conduction

A

the process by which heat energy is transmitted through collisions between neighboring atoms or molecules

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40
Q

can we hear the peripheral artery

A

NO only palpate

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41
Q

what is the only place we can hear the heart

A

apical

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42
Q

lub/dub is a count of

A

1

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43
Q

what are the 3 characteristics of the peripheral pulse

A

rate
rhythm
amplitude

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44
Q

what is the amplitude 4 point scale

A

4+ bounding
3+ stong
2+ moderate
1+ weak
0 absent

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45
Q

what is the rhythm result

A

regular/irregular

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46
Q

where could you palpate a peripheral artery

A

temporal
carotid
brachial
radial
femoral
popliteal
posterior tibial
dorsalis pedis

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47
Q

where do you go to find to ausculate the apical pulse

A

5th intercostal space/ mid clavicular line

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48
Q

why do we not take pulse with thumb

A

thumb has a vein/artery in it so it has its own pulse

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49
Q

tachycardia

A

fast HR
over 100

50
Q

bradycardia

A

slow HR
less 60

51
Q

pulse deficit

A

difference between apical and peripheral

52
Q

if we have a apical pulse of 88 and a peripheral of 88 what’s the pulse deficit

A

0/none

53
Q

if we have a apical pulse of 88 and a peripheral of 80 what’s the pulse deficit

A

8

54
Q

if we have a apical pulse of 85 and a peripheral pulse of 88, why does that not make sense?

A

because the heart is the source of pumping so we have to have apical higher or equal to the peripheral

55
Q

how many people do you need to complete a pulse deficit

A

2

56
Q

when we are inspecting respirations what are we looking for

A

rate
depth
rhythm
work of breathing
symmetry

57
Q

hypoventilation

A

low rate and shallow depth

58
Q

hyperventilation

A

fast rate and increase depth

59
Q

dyspnea

A

difficulty breathing

60
Q

what does DYS mean

A

difficulty

61
Q

tachypnea

A

fast

62
Q

orthopnea

A

difficulty breathing when laying flat

63
Q

apnea

A

no breathing

64
Q

what does ‘a’ mean

A

without

65
Q

blood pressure systolic is the

A

highest pressure on arterial walls
contraction of the ventricles

66
Q

blood pressure diastolic is the

A

lowest pressure on arterial walls
ventricles at rest

67
Q

what numbers are classified as elevated blood pressure

A

systolic between 120-129
AND
diastolic between 80-89

68
Q

what numbers are classified as stage 1 blood pressure

A

systolic 130-139
OR
diastolic 80-89

69
Q

what would be told if you have stage 1 blood pressure

A

lifestyle changes should begin at 130/80
medication if patient is at risk for CV event

70
Q

what numbers are classified as stage 2 blood pressure

A

systolic at least 140
OR
diastolic at least 90

71
Q

what numbers are classified as hypertensive crisis

A

systolic over 180
AND/OR
diastolic over 120

72
Q

factors that are affecting blood pressure

A

age (older stiffness of vessel increases BP)
race (AA have increased chance of hypertensive)
circadian rhythm (lower in morning, higher afternoon)
exercise
weight
emotional state (increase BP)
body position (lowest BP: supine flat)
drug medications (all ready hypertensive and take cold medication will increase pressure)
disease processes
cigarette smoking (CO2 causes vasoconstriction)

73
Q

how much should people reduce salt intake to

A

less than 2300

74
Q

if people reduce salt intake to less than 2300 this could reduce cases of high blood pressure by _____ million and save _____ billion health care dollars every year

A

11, $18

75
Q

why do we do the 2 step method of blood pressure

A

so we do not miss the auscultatory gap

76
Q

what is the first korotkoff sound

A

systolic

77
Q

what is the 5th korotkoff sound

A

diastolic

78
Q

how do we know where the diastolic sound is at

A

the point at which all sounds disappear

79
Q

what artery is the most commonly used for the blood pressure

A

Brachial

80
Q

what arm do we not take a blood pressure in

A

mastectomy, fistula, lymphedema, amputee, IV

81
Q

what do you do if you take a mobile BP into a isolation room

A

clean cart

82
Q

what do you do if the reading indicates hypertension or hypotension

A

take it again in different arm

83
Q

what is the pulse of the fistula called

A

thrill

84
Q

what is the sound of the fistula called

A

bruit

85
Q

a bruit sounds like

A

whoosing

86
Q

a bruit is normal in a fistula because it indicates there is blood flow, where is a bruit abnormal

A

heart

87
Q

hypotension is classified as

A

less than 90/60 WITH symptoms

88
Q

orthostatic hypotension is a decrease of how much

A

20 systolic
10 diastolic

89
Q

what is the proper way to check for orthostatic hypotension

A

lay down for 5 mins BP and pulse
sit for 3-5 mins recheck
stand for 3 mins recheck

90
Q

what is primary hypertension

A

cause is unknown

91
Q

what is secondary hypertension

A

cause is known, normally secondary to a medical condition

92
Q

what are all of the numbers in when we take blood pressure

A

2

93
Q

what is one advantage to take an automatic blood pressure

A

do not need a stethoscope

94
Q

what are the limitations to automatic blood pressure

A

vulnerable to error in
- arrhythmias
- older adults
- obese extremity
may not work with hypotensive

95
Q

you need a MAP of ___ or greater to perfuse vital organs

A

60

96
Q

what is the normal MAP

A

70-100

97
Q

how do you find map

A

2xdiastolic + systolic divided by 3

98
Q

pain is ALWAYS

A

what the patient says

99
Q

what numbers on numerical scale are mild

A

1-3

100
Q

what numbers on the numerical scale are moderate

A

4-6

101
Q

what numbers on the numerical scale are severe

A

7-10

102
Q

FLACC is used for patients who

A

cannot communicate

103
Q

what does FLACC stand for

A

face
legs
activity
cry
consolability

104
Q

PAINAD is used for patients with

A

advanced dementia

105
Q

if the patient has pain what do we ask if the patient if they say they have pain

A

onset
location
functional limitations
pain interventions
patients functional goal

106
Q

how often do you reassess pain

A

4 hours or sooner

107
Q

why might someone ask for more pain meds

A

because they have built up a tolerance
(EX: someone with sickle cell might have built up a tolerance and will need more when in sickle crisis)

108
Q

SPO2 measures the

A

amount of hemoglobin saturated with oxygen in arterial blood

109
Q

SPO2 measures NOT ventilation but

A

oxygenation

110
Q

what does FIO2 stand for

A

fraction of inspired air

111
Q

why is FIO2 important

A

because an individual at 88% on oxygen is at more of an emergency than an individual at 88% on room air

112
Q

what percent of SPO2 is abnormal in everyone

A

less than 85

113
Q

HYPOXEMIA

A

KILLS

114
Q

if we have a patient who has low SPO2 what is one nursing intervention we can do

A

raise head of bed which helps lungs expand

115
Q

what are some factors that interfere with light transmission

A

outside light sources
carbon monoxide
patient motion
jaundice
dark skin pigmentation may result in signal loss or over estimation of saturation (false high)

116
Q

why is SPO2 a rough measurement

A

you could have a 100% SPO2 but only have 6 hemoglobin

117
Q

what are some factors interfere with arterial pulsations

A

peripheral vascular disease
hypothermia at assessment site
low cardiac output
hypotension
perisperhal edema
tight probe
arrthythmias
edema

118
Q

what is the heart rate criteria for rapid response team

A

over 140/min or less than 40/min

119
Q

what is the respiratory rate criteria for rapid response team

A

28/min or less than 8/min

120
Q

what is the blood pressure criteria for rapid response team

A

systolic greater than 180 or less than 90

121
Q

what is the oxygen saturation criteria for the rapid response team

A

less than 90% despite supplementation

122
Q

what is another reason to call a rapid response team that is not related to vitals

A

acute change in mental status

Fundamentals of Nursing (23 decks)

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