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Vital Signs Flashcards

(51 cards)

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1
Q
  • Objective measurement of one’s overall health status
  • Provides important information on the status of the patient
A

Vital Signs Taking

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2
Q

Vital signs consists of?

A
  1. Temperature
  2. Pulse
  3. Respiration
  4. Blood pressure
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3
Q

Often called the 5th sign

A

Pain

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4
Q

Makes the pain worse

A

Aggravating/exacerbating factors

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5
Q

Eases the pain

A

Palliating/remitting factors

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6
Q

Where pain is located?

A

Setting/location

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7
Q

When did the pain start?

A

Onset

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8
Q

How painful on a scale of 0 to 10?

A

Intensity

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9
Q

How does the pain feel?

A

Characteristics

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10
Q

How long do you experience pain?

A

Duration

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11
Q

Determine the severity, 3 scales commonly used are?

A

Visual analog, numeric rating, face pain scale

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12
Q

Describe the pain, how it started, pursue the seven features which are?

A
  1. Location/setting
  2. Quality
  3. Quantity/severity (intensity)
  4. Timing (when did it start)
  5. Setting in which it occurs
  6. Remitting or exacerbating factors
  7. Associated manifestations
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13
Q

Noninvasive measurement of arterial oxyhemoglobin saturation of arterial blood, detects the presence of deficient oxygen in the blood before visible signs develop

A

Pulse oximetry

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14
Q

Percentage of all hemoglobin binding sites occupied by oxygen

A

Oxygen saturation value

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15
Q

Factors in pulse oximetry?

A
  1. Amount of RBC and hemoglobin
  2. Circulation under the sensor is impaired
  3. Patient activity
  4. Acrylic nails and dark nail polish
  5. Moisture and oils on the skin
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16
Q

What are factors indicating the need for monitoring of oxygen saturation?

A
  1. Acute or chronic impaired respiratory functioning
  2. Recovery from any type of anesthesia
  3. Any trauma including surgery
  4. Ventilatory dependency
    Receiving of supplementary oxygen
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17
Q

Best location for a pulse oximeter is based on the ________ and ________, usually the ________ is selected for adults

A

Client’s age and physical condition; finger

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18
Q

How to assess client’s overall condition including risk factors for development of hypoxemia and hemoglobin level?

A
  1. Vital signs, skin color and temperature, nail bed color, and tissue perfusion of extremities as baseline data
  2. Assess for adhesive allergy
  3. Assemble the necessary equipment: nail polish remover as needed, alcohol wipe, sheet or towel, pulse oximeter
  4. Check if the pulse oximeter is functioning normally
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19
Q

When to assess vital signs?

A
  1. Upon admission and before discharge of the client
  2. At the start of every shift
  3. Before, during, and after an invasive procedure
  4. Before and after an intervention,
    therapy or treatment
  5. Before and after medication administration
  6. Whenever a client’s condition changes
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20
Q

Balance between the
body heat produced by the body and the
heat lost from the body

A

Body Temperature

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21
Q

Assessing body temperature can be done through?

Study These Flashcards
A
  1. Oral temperature
  2. Ear temperature
  3. Rectal temperature
  4. Axillary temperature
  5. Temporal artery temperature
22
Q

Types of body temperature?

Study These Flashcards
A
  1. Core temperature
  2. Surface temperature
23
Q
  • Temperature of the inner parts of the body
  • Taken through oral, rectal, or tympanic
  • More accurate than surface
Study These Flashcards
A

Core temperature

24
Q

It gives the most accurate core temperature

25
Temperature of the superficial parts of the body
Surface temperature
26
With fever (pyrexia)
Febrile
27
Without fever (medicine is antipyretic drugs)
Afebrile
28
Temperature control center
Hypothalamus
29
- Controls heat loss. - Nerve sensors send out signals that initiate sweating, peripheral vasodilation and inhibition of heat production
Anterior hypothalamus
30
- Controls heat production. - Nerve sensors send out signals that initiate shivering and vasoconstriction and release epinephrine
Posterior hypothalamus
31
Factors that promote heat production
1. Basal metabolic rate 2. Muscle activity 3. Thyroxine production 4. Epinephrine, norepinephrine, and stress response 5. Fever
32
Factors that promote heat loss
1. Vaporization (evaporation) 2. Radiation 3. Conduction 4. Convection
33
Factors affecting body temperature
1. Age 2. Diurnal variations 3. Environment 4. Exercise 5. Hormones 6. Stress
34
Which factor is affecting the body? -Metabolic rate is higher in a younger person and decreases in age. -Infants and older adults are less able to manage extreme environmental temperature. -Infants and children are not able to shiver. -Uses hats to hep in maintaining body temperature. -Older adults have less subcutaneous fats, slower metabolism, slower motor.
Age
35
Which factor is affecting the body? -Cyclical repetition of various physiological forces throughout 24 hours -Body temperature may increase or decrease as much as 1.8 degrees fahrenheit -Highest temperature: 4-6pm -Lowest temperature: 4-6am
Diurnal variations
36
Which factor is affecting the body? -High environmental temperature and high humidity -Hypothermia, lack of clothing and shelter and etc. (a cold environmental temperature, greater heat loss)
Environment
37
Which factor is affecting the body? - Thyroxine - Epinephrine - Catecholamine
Hormones
38
Functions as nuerotransmitters
Catecholamine
39
Types of thermometers
1. Temporal Scanner 2. Infrared sensors 3. Tympanic Thermometer 4. Electronic Thermometer 5. Electronic Thermometer 6. Skin strip Thermometer
40
Oral route is the ________ and ________; reflects rapid change in core temperature
Most accessible and convenient
41
Most accurate and reliable site for body temperature
Rectal
42
This route can be used for newborns and uncooperative clients, but it is not as accurate
Axillary
43
Approximately how long must be thermometer remain in place for axillary route?
Approximately 8 minutes
44
This route can be used for infants, unconscious, and dyspneic clients
Tympanic route
45
This route can be used for infants, unconscious, and dyspneic clients
Temporal artery
46
Route that is easily accessible for forehead or abdomen
Skin
47
Skin may only indicate ________
Surface temperature
48
Body temperature is < 36 degrees Celsius
Hypothermia
49
Body temp < 28 degrees Celsius
Severe hypothermia
50
If ________ degrees Celsius, cardiac and respiratory functions could cease, cells could still be viable, but death could be possible.
25
51
Temperature > 40.5 degrees Celsius
Hyperthermia

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