Vital Signs Flashcards
(100 cards)
1
Q
Guidelines for obtaining vital signs
A
Measure correctly, understand and interpret the values, communicate findings, document correctly, begin interventions as needed
2
Q
What do vital signs measure
A
Temp, pulse, respirations, blood pressure, oxygen saturation, comfort or pain level. Accuracy of vital signs is critical, vital signs can be used for problem solving = “what’s wrong”
3
Q
When are vital signs assessed
A
Baseline vitals taken on admission, discharge, transfer, change in condition
4
Q
When are vital signs taken more frequently
A
Sicker pt = more vital signs
5
Q
What can low respiratory rate indicate
A
Urgent or emergent problem
6
Q
Temp above 105f
A
Can damage body cells
7
Q
When to not take oral temp
A
On comatose pt
8
Q
What can a rise in temperature of 1 degree do
A
Increase pulse rate by 4 beats per minute. Can also increase bl press and respirations
9
Q
Hemorrhaging causes
A
Decrease in bl. Pressure pulse and respirations increase. Temp usually decreases
10
Q
Norm temperature
A
98.6F. (37C). (Book)Variations from 97 to99.(36.1C to37.5C)
11
Q
2 types of body temp
A
Core temp= deep tissue= constant
Surface temp= skin= changes
12
Q
When does Hypothermia occur
A
Body temp abnormally low below 93.2Fx
13
Q
What temp is considered a fever
A
Above100.4F. Exceeding 105F damages cells
14
Q
Different methods of taking temperature
A
Heat sensitive patches
Electronic thermometer
Tympanic thermometer
Temporal artery method
15
Q
Body temperature is regulated by what part of brain
A
Hypothalamus
16
Q
Parts of the stethoscope
A
DIAPHRAGM =high pitched noise, movement of blood and air
BELL=low pitched noise, heart sounds vascular sounds
EARPIECE = toward nose
TUBING= hold still to minimize noise
17
Q
What does pulse measure
A
Heart rate
18
Q
Peripheral pulse points
A
Temporal, carotid, apical, brachial, radial, femoral, popliteal, pedal, dorsal is pedis
19
Q
Where is apical pulse taken at
A
Mid clavicular line, 5th intercoastal space, apical pulse used for patients w/ heart problems
20
Q
Where is radial pulse taken at
A
Measured in groove of wrist. Thumb/radial side of forearm. Is lateral to flexor tendon
21
Q
Pulse deficit
A
Difference between the radial pulse and the apical. Apical pulse minus the radial pulse = pulse deficit both pulses are taken simultaneously
22
Q
How do you assess respirations
A
Rate counting (12-20), Depth(observe movement of diaphragm), Quality, Rhythm
23
Q
Breathing w/difficulty
A
Dyspnea
24
Q
How many respirations for bradycardia
A
Less than 12
25
How many respirations for tachycardia
Faster than 20 per min
26
How many respirations for Cheyenne stokes
Varying periods of increasing depth /periods of apnea
27
Normal respirations
12-20 breaths per minute
28
Kussmaul breathing pattern
Rapid deep and labored
29
Where do you position lower extremity blood pressure cuff
Above politeal artery at mid thigh
30
Blood pressure is measured by what( metric)
Millimeters of mercury(mmHg)
31
Top number when measuring b/p
Systolic (force against arteries during contraction of the heart)
32
Bottom number when measuring b/p
Diastolic (force arteries when heart is relaxed)
33
What might raise pt. B/p
Fear of dr office, pain, anxiety, smoking, pregnancy, exercise, trauma
34
Vital signs normal limits
Temp= 97.6F-99.6F (36.4C-37.5C)
Pulse rate= 60-100 BPM
Respirations= 12-20 per min
Systolic BP= 100 to 120 mmHg
Diastolic BP= 70 to 80 mmHg
Pulse Ox= 95 to 100%
Slightly different ranges for older adults
35
What factors affect vital signs
Environment, age, stress, smoking, timeof day, pts. state of health, activity levels, pain, bleeding, position change, stage of menstrual cycle, hormones
36
Height and weight are necessary to
Assess growth and development
Drug dosage calculations
Assess efficacy of drug therapy
Weight change- may be sign of under lying desease
37
When should weight be measured
Same time of day
Same scale
Same clothing
38
2.2 lbs also equals
1 liter of fluids, 1 kilogram
39
What does pulse oximeter measure
Oxygen saturation, which is the measurements of how much oxygen is combined with hemoglobin in the red blood cell also provides pulse rate
40
What is hemoglobin
Protein on RBC
41
Body part used to measure pulse ox
Warm finger Can use toes or earlobes depending on probe
Cold hands,thick nails,nail polish,and artificial nails can interfere with measurement
42
Normal range for pulse ox
95-100%on room air(RA)
43
Cardiac output
Amount of blood ejected from heart in 1 min
44
Orthostatic hypertension
Drop in BP with change in position
45
When measuring height
Remove shoes, stand erect
46
Vital sign abbreviations
R next to number=rectal temp
Axnext to number=axillary temp
ap next to number= axillary temp
47
When is use of electronic BPmeasuring device inappropriate
Arrythemias, excessive tremors, inability to cooperate to minimize arm motions, irregular heart rate, obese extremity, older adults, peripheral vascular obstruction(clots, narrowed vessels), seizures, shivering
48
Interventions for abnormal body temperature
Repeat measurement, monitors q4 hours, limit physical activity, encourage fluid intake if not contra indicated( heart failure), give meds, if temp above normal assess for infection, if subnormal, cover pt. with more blankets,close doors-windows
49
Intervention for abnormal pulse
1.Use different pulse sight, use Doppler, 2.Observe for cyanosis of tissue distal to weak pulse/ coldness of extremity, 3. observe for signs of dyspnea, fatigue, chest pain,syncope. 4.assess pulse deficit
50
Interventions for pt. with abnormal respirations
1.Possible effects of meds or anesthesia, 2. Reposition to upright sitting. 3. Respirations below 10 or above 20 require immediate intervention 4. Observe for obstructed airway or snoring respirations
51
Interventions for pts. with abnormal bl. pressure
1Repeat assessment, 2.
52
Orthostatic bp
53
Procedure for obtaining a manual blood pressure
54
What is objective data
What the nurse sees and feels also laboratory findings, diagnostic imaging
55
Subjective symptoms
Perceived by the pt., reported by pt., or pt. family
Reports of pain, nausea, vertigo, pruritis(itchy skin), anxiety and diplopia (double vision) if no tool is used for measurement, than it is subjective
56
Objective signs
Can be seen, heard, and measured. As in rashes, skin color, altered vital signs, visible drainage or exudate, leakage from bl. Vessels, lab results, diagnostic imaging
57
Disease and diagnosis
Disturbance of structures or function of that system organ/cell
DISEASE IS A PATHOLOGIC CONDITION OF THE BODY
Recognized by a set of signs and systems /clustered in groups
58
Who makes medical diagnosis
Clinician (treats and cures)
59
What are the nurses goals
Holistic treatment (form of healing that considers the whole person)
RNs make nursing diagnosis.
LPNs identity a patient problem
60
Etiology of disease(cause)
Hereditary= transmitted genetically parent (grandparent) to child
Congenital= occurring at birth or shortly thereafter blindness
Infectious= hiv , measles TB
Deficiency= lack of nutrients, iron deficiency as in scurvy(lack of vit C), rickets(lack of vit D)
Metabolic=loss of homeostasis DM
Neoplastic= abnormal growth of new tissues
Inflammatory=hay fever, bronchitis
Degenerative= may be progressive MS, osteoarthritis
Iatrogenic= treatment
Unknown etiology
Traumatic=physical, psychological, any abuse, loss of any kind, weathering ( think of Maslow)
Environmental= CO2, asbestos,
Autoimmune= IBD, Gillian barre, lupus
61
What is a Risk factor
Increase your chances of becoming Ill/accident
62
Some risk factors are
Habits, environmental condition, genetic predisposition, physiologic condition, age, lifestyle( often mechanisms of coping) and social detriments(education,health and healthcare, social and community)
63
Terms used to describe disease
Chronic=slow onset, long effects persist over long period further described as early or late, Terminal, Remission
Acute=sudden onset, severe S/S
Functional disease= no apparent structural origin as in mental illness, nervous system
64
Inflammation
Protective response of the body tissues, healing and defensive response after irritation, injury, or invasion by organisms. S/Sx
65
Infection
Invasion of microorganisms
Bacteria,viruses fungi or parasites
Produces tissue damages/Sx
66
Frequently noted signs and symptoms
Aorexia= no appetite, Cyanosis=deoxygenated blood, Diaphorisis= sweating, Ecchymosis= bruising, Edema=swelling, Erythema= red, Fetid=stinky, Jaundice= yellowing, Sclera icterus=white of eyes are yellowish, Ortopenia=shortness of breath while lying flat. need to change position to breath well, Pallor=pale, Purelant drainage=pus/slough, Sallow=yellowish looking skin
67
For medical assessment you must
First Get consent, evaluation of pt. condition (are the well/unwell)
68
Who conducts physical exam
Clinician= dr., midwife, PA
Follow physicians orders unles they ar unethical, immoral or illegal
Nurse Carrie’s out certain functions
69
What is Nursing assessment
Observation done by senses of touch, smell, sight and hearing
70
During nursing assessment you must
Perform hand hygiene, Document, get consent, assess LOC level of consciousness
71
Items needed for nursing assessment
Penlight, stethoscope, sphygmomanometer, thermometer, watch. W/second hand, gloves, tongue blade
72
What to ask to obtain HPI= history of present illness aka
O=onset
P=precipitation, provocative, palliative
Q=quality/quantity
R=region/radiation
S=severity
T=treatments
U=understanding
V=values goals/expectations
73
What is biographic data
Date of birth, gender, address, marital status, family members names, occupation health insurance benefits
74
What is the chief complaint
It is the reason for seeking health care
75
Nursing physical assessment
Initial assessment is done byRN
Ongoing assessments the responsibility of LPN and RN
76
When to perform admission assessment
As soon as possible
77
Techniques for physical assessment
Non abdomen=inspection. Palpate. Auscultation, Percussion
Abdomen exams only= 1st inspection, 2nd auscultation, 3rd palpation
78
For cultural considerations you should
Focus on humility
79
Head to toe assessment
Neurological. Skin and hair. Head and neck. Mouth and throat. Eyes ears nose. Chest lungs heart and vascular system. Gastrointestinal system. Genitourinary system. Rectum. Legs and feet
80
What neurological assessment entails
Speech: clear, slurred.thick nonverbal
Tongue: midline or deviates
Facial symmetry: symmetrical/droop
Affect: flat right hostile sad
Syncope: faints
Follows commands
81
How skin should appear
Warm dry and intact. Good turgor. No lesions check palms and soles of feet
82
Head and neck assessment
Check eyes. Ears. Nose. Mouth and mucous membranes. Neck(jugular vein distinction is not a normal finding)
83
Cardiovascular assessment
Check apical pulse rate
Check capillary refill it should take less than 3 seconds = brisk can use toe nails or fingers upper/lower extremities
Check Legs and feet
Edema= pitting or non pitting. pitting edema grading scale from 1-4. note location Press against boney prominence for 5 sec
IV fluid= type, rate, site
Pedal and radial pulses=check strength 0= absent, 1= thread, 2=weak, *4=BOUNDING
84
Focused neurovascular assessment (peripheral vascular)
What actions are taken to perform peripheral vascular assessment
Assess radial, brachial, ulnar, femoral, popliteal, dorsalis pedis, and posterial tibial pulses
Assess pulse rate by counting. Check rhythm for regularity. Measure strength by using scale
Begin with the most distal pulse (rate rhythm strength)
Check capillary refill
Check symmetry
85
Expected heart sounds
LUB/S1= 1st sound heard when AV valve closes. Beginning of systole. Listen at the Apex
Dub/s2= 2nd sound heard when semi-lunar valve closes listen at base of heart
86
Ausculatory Landmarks
87
What are Bruit sounds
ABNORMAL SOUNDS. Turbulent blood in blood vessels swishing sounds
88
What are Thrill sounds
ABNORMAL SOUNDS. Felling/palpating turbulent blood in blood vessel. Vibration
This is an expected finding with dialysis access points likeAV fistulas and AV shunts
89
Respiratory portion of physical assessment
Check anterior and posterior.
Check chest wall movement for depth
Pattern=Regular/Irregular; tachypnea; orthopnea; dyspnea
Check O2 sat w/ pulse oximeter
Supplemental oxygen (NC, RA,mask, NRB)
90
During atrial contraction which valves are open/closed
A/V valves are open S/L valves are closed
91
During ventricular contraction which valves are open/closed
A/V valves are closed. S/V valves are open
92
Abdominal assessment
Inspect= distended/non distended. Flat/round
Auscultate bowel sounds=each quadrant for 1 min. Active, hyperactive, hypo active, absent
Palpitation= masses, tenderness/ non tender *REBOUND TENDERNESS
93
Genitourinary assessment
C= color
O= Oder
C= clear/cloudy
A= amount; small, moderate, large(ml)
Catheters= indwelling, nephrostomy, suprapubic, urostomy
94
Assessment of genitals, perineum, and rectum
Assess for= lumps, lesions, lice, discharge moisture, hemorrhoids, bleeding
95
Documentation
Be objective, clear, complete and concise
If you didn’t write it you didn’t do it
96
Priorities of care
1.ABCs=ALWAYS airway, breathing, circulation
2.Safety
3.Prevention
97
Which body system does each belong to
Respitory rate= Respitory
Pedal pulses=cardiovascular
Edema of legs =cardiovascular and lymphatic
awake alert oriented =neuro
BP= cardiovascular Renal?
Lung sounds = Respitory
Heart sounds=cardiac
Bowel sounds=GI system listen 1 min each quadrant
98
lung sounds (abnormal)
Start at apex
**Crackles= wet popping sounds heard in CHF
Wheezes= sibilant(hissing sound) sonorous
Pleural friction rub=sounds like rubbing (caused by pleural membranes)
Ronchi= resembles snoring
Bronchi=loud and harsh midrange pitch
99
Metabolic
Diabetes
100
Stehoscope
Diaphragm= high pitched
Bell= low pitched sound
