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Fundamentals of Nursing > Vital Signs > Flashcards

Vital Signs Flashcards

(122 cards)

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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
what probe is for rectal temp
red
26
what do you apply to the thermometer before inserting the rectal thermometer
lubricant
27
what probe is for the oral/axillary
blue
28
afebrile
without fever
29
febrile
fever/temp
30
pyrexia
temp/fever
31
what are some physical effects of fever
decreased appetite headache hot skin flushed face thirst muscle aches fatigue fever blisters
32
what should we note for fever in elderly
they may show signs of confusion before temp rises
33
what should we do for interventions for patients with a fever
MAXIMIZE HEAT LOSS MINIMIZE HEAT PRODUCTION
34
how do we maximize heat loss
remove heavy blankets keep clothing and linens dry (otherwise could lead to chills) cool compresses ice pack cooling blanket
35
how do we minimize heat production
limit physical activity
36
what is radiation
energy that comes from a source and travels through space at the speed of light
37
what is convection
process by which heat is transferred by movement of a heated fluid such as air or water
38
what is evaporation
liquid into vapor
39
what is conduction
the process by which heat energy is transmitted through collisions between neighboring atoms or molecules
40
can we hear the peripheral artery
NO only palpate
41
what is the only place we can hear the heart
apical
42
lub/dub is a count of
1
43
what are the 3 characteristics of the peripheral pulse
rate rhythm amplitude
44
what is the amplitude 4 point scale
4+ bounding 3+ stong 2+ moderate 1+ weak 0 absent
45
what is the rhythm result
regular/irregular
46
where could you palpate a peripheral artery
temporal carotid brachial radial femoral popliteal posterior tibial dorsalis pedis
47
where do you go to find to ausculate the apical pulse
5th intercostal space/ mid clavicular line
48
why do we not take pulse with thumb
thumb has a vein/artery in it so it has its own pulse
49
tachycardia
fast HR over 100
50
bradycardia
slow HR less 60
51
pulse deficit
difference between apical and peripheral
52
if we have a apical pulse of 88 and a peripheral of 88 what's the pulse deficit
0/none
53
if we have a apical pulse of 88 and a peripheral of 80 what's the pulse deficit
8
54
if we have a apical pulse of 85 and a peripheral pulse of 88, why does that not make sense?
because the heart is the source of pumping so we have to have apical higher or equal to the peripheral
55
how many people do you need to complete a pulse deficit
2
56
when we are inspecting respirations what are we looking for
rate depth rhythm work of breathing symmetry
57
hypoventilation
low rate and shallow depth
58
hyperventilation
fast rate and increase depth
59
dyspnea
difficulty breathing
60
what does DYS mean
difficulty
61
tachypnea
fast
62
orthopnea
difficulty breathing when laying flat
63
apnea
no breathing
64
what does 'a' mean
without
65
blood pressure systolic is the
highest pressure on arterial walls contraction of the ventricles
66
blood pressure diastolic is the
lowest pressure on arterial walls ventricles at rest
67
what numbers are classified as elevated blood pressure
systolic between 120-129 AND diastolic between 80-89
68
what numbers are classified as stage 1 blood pressure
systolic 130-139 OR diastolic 80-89
69
what would be told if you have stage 1 blood pressure
lifestyle changes should begin at 130/80 medication if patient is at risk for CV event
70
what numbers are classified as stage 2 blood pressure
systolic at least 140 OR diastolic at least 90
71
what numbers are classified as hypertensive crisis
systolic over 180 AND/OR diastolic over 120
72
factors that are affecting blood pressure
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
how much should people reduce salt intake to
less than 2300
74
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
11, $18
75
why do we do the 2 step method of blood pressure
so we do not miss the auscultatory gap
76
what is the first korotkoff sound
systolic
77
what is the 5th korotkoff sound
diastolic
78
how do we know where the diastolic sound is at
the point at which all sounds disappear
79
what artery is the most commonly used for the blood pressure
Brachial
80
what arm do we not take a blood pressure in
mastectomy, fistula, lymphedema, amputee, IV
81
what do you do if you take a mobile BP into a isolation room
clean cart
82
what do you do if the reading indicates hypertension or hypotension
take it again in different arm
83
what is the pulse of the fistula called
thrill
84
what is the sound of the fistula called
bruit
85
a bruit sounds like
whoosing
86
a bruit is normal in a fistula because it indicates there is blood flow, where is a bruit abnormal
heart
87
hypotension is classified as
less than 90/60 WITH symptoms
88
orthostatic hypotension is a decrease of how much
20 systolic 10 diastolic
89
what is the proper way to check for orthostatic hypotension
lay down for 5 mins BP and pulse sit for 3-5 mins recheck stand for 3 mins recheck
90
what is primary hypertension
cause is unknown
91
what is secondary hypertension
cause is known, normally secondary to a medical condition
92
what are all of the numbers in when we take blood pressure
2
93
what is one advantage to take an automatic blood pressure
do not need a stethoscope
94
what are the limitations to automatic blood pressure
vulnerable to error in - arrhythmias - older adults - obese extremity may not work with hypotensive
95
you need a MAP of ___ or greater to perfuse vital organs
60
96
what is the normal MAP
70-100
97
how do you find map
2xdiastolic + systolic divided by 3
98
pain is ALWAYS
what the patient says
99
what numbers on numerical scale are mild
1-3
100
what numbers on the numerical scale are moderate
4-6
101
what numbers on the numerical scale are severe
7-10
102
FLACC is used for patients who
cannot communicate
103
what does FLACC stand for
face legs activity cry consolability
104
PAINAD is used for patients with
advanced dementia
105
if the patient has pain what do we ask if the patient if they say they have pain
onset location functional limitations pain interventions patients functional goal
106
how often do you reassess pain
4 hours or sooner
107
why might someone ask for more pain meds
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
SPO2 measures the
amount of hemoglobin saturated with oxygen in arterial blood
109
SPO2 measures NOT ventilation but
oxygenation
110
what does FIO2 stand for
fraction of inspired air
111
why is FIO2 important
because an individual at 88% on oxygen is at more of an emergency than an individual at 88% on room air
112
what percent of SPO2 is abnormal in everyone
less than 85
113
HYPOXEMIA
KILLS
114
if we have a patient who has low SPO2 what is one nursing intervention we can do
raise head of bed which helps lungs expand
115
what are some factors that interfere with light transmission
outside light sources carbon monoxide patient motion jaundice dark skin pigmentation may result in signal loss or over estimation of saturation (false high)
116
why is SPO2 a rough measurement
you could have a 100% SPO2 but only have 6 hemoglobin
117
what are some factors interfere with arterial pulsations
peripheral vascular disease hypothermia at assessment site low cardiac output hypotension perisperhal edema tight probe arrthythmias edema
118
what is the heart rate criteria for rapid response team
over 140/min or less than 40/min
119
what is the respiratory rate criteria for rapid response team
28/min or less than 8/min
120
what is the blood pressure criteria for rapid response team
systolic greater than 180 or less than 90
121
what is the oxygen saturation criteria for the rapid response team
less than 90% despite supplementation
122
what is another reason to call a rapid response team that is not related to vitals
acute change in mental status

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