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Funda > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

Acceptable Ranges for Adults
(Temperature, Pulse, Blood Pressure, Respiration, O2 Saturation)

A

Temp: 36C - 38C (96.8F - 100.4F)
Pulse: 60 - 100 Beats/min
BP - Systolic: less than 120
- Diastolic: less than 80 mmhg
Pulse Pressure: 30-50 mmhg
Respiration: 12-20 breaths/min
O2 Sat: SPO2 95-100

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2
Q

When to Measure Vital Signs (BASSH)

A

Before during after
- blood products transfusion
- medication administration
- nursing intervention
Admission
Status Changes
Symptoms that are non-specific
Hospital Routine Schedule

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3
Q

General Preparation WIPE

A
  • Wash hands before and after procedure
  • Identify Information patient abt procedure
  • Provide privacy and position patient accordingly
  • Explain procedure and evaluate
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4
Q

detects signals from receptors and sends signals to effectors to regulate body temperature.

A

Hypothalamus

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5
Q

Low body Temperature preserves heat by limiting blood flow to surface

A

Vasoconstriction

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6
Q

High body temperature increase blood flow to surface to promote

A

Heat loss

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7
Q

4 types of heat loss

A
  • Radiation - transfer of heat from an object to another without direct contact
  • Conduction – transfer of heat from one object to another with direct contact.
  • Convection – heat loss through air movement.
  • Evaporation – transfer of heat via evaporation
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8
Q

Factors Affecting Body Temperature

A
  • Age
  • Exercise
  • Hormone level
  • Circadian rhythm
  • Stress
  • Environment
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9
Q

Fever vs Hyperthermia

A

Fever: pyrexia; infection
Hyperthermia: Nausea and vomiting
- Fainting
- Moderately increased temperature

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10
Q

When the temperature drops the usual range of body temperature

A

Hypothermia

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11
Q

How to measure body temperature

A
  • Oral 37C or 98.6F
  • Axillary 36.5 or 97.7F (armpit)
  • Tympanic 37C or 98.6F (ear)
  • Rectal 37.5C or 99.5 F(Butt but recommended for babies)
    1.5 inches for adults
    0.5 inches for babies
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12
Q

Celsius to fahrenheit

A

(C x 1.8) + 32

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13
Q

Fahrenheit to celsius

A

(F - 32) x 5/9

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14
Q

Nursing Intervention for Hyperthermia AILMENT

A

Antipyretics
Limit physical activites
Increase rest
Monitor skin color and temp
Monitor blood count
Excess blankets when patient feels warm
Nutrition and fluids
Tepid sponge bath

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15
Q

Nursing intervention for hypothermia CCAKES

A

Cover patient scalp with cap
Clothes are dry
Apply warming pads
Keep limbs close to body
Environment warm
Supply warm oral and IV fluids

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16
Q

Amount of blood ejected per heartbeat

A

Stroke Volume

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17
Q

Amount of blood ejected within 1 minute

A

Cardiac output

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18
Q

Sites of Pulses

A

Radial - circulation of hand (near thumb)
Apical - 5th ICS at left clavicular line (for infants)
Brachial - for blood pressure

19
Q

Irregular rhythm of pulse

A

Dysrhythmias

20
Q

Phases of Fever (Pyrexia)

A
  1. Cold/Chill Phase
  2. Plateau Phase (warm skin)
  3. Fever Abatement/Flush Phase (Sweating)
21
Q

Types of Fever SIRR

A
  1. Sustained - elevated temp above 38C
  2. Intermittent - temp spiked and returned to acceptable range after 24 hrs
  3. Remittent - temp spiked and fluctuated but with no return to normal temp
  4. Relapsing - returns to normal but recus
22
Q

Chracteristics of pulse

A

Infant - 120-160 bpm
Toddler - 90-140
Preschooler - 80-110 bpm
School aged - 74-100 bpm
Adolescent 60-90 bpm
Adult - 60-100

23
Q

Less than 60 beats/min

A

Bradycardia

24
Q

Greater than 100 beats/min

A

Tachycardia

25
Q

Tachypnea

A

RR over 20

26
Q

Bradypnea

A

RR below 12

27
Q

Absence of Breathing

A

Apnea

28
Q

Overexpansion of lungs

A

Hyperventilation

29
Q

Underexpansion of lungs

A

Hypoventilation

30
Q

alternating periods of
apnea and hyperventilation; cardiac failure, increased
ICP, or brain damage.

A

Cheyne-Stokes breathing

31
Q

shallow respiration of the same depth
followed by a period of apnea.

A

Biot’s

32
Q

abnormally deep, regular, increased
rate; hyperventilation commonly seen in patients with KDA.

A

Kussmaul’s

33
Q

Blood Pressure

A

Systole - Peak of maximum heart ejection
Diastole - Ventricular relaxation
Millimeters of mercury - mmhg

34
Q

Difference between systole and diastole

A

Pulse pressure

35
Q

Cardiac output

A

Stroke volume x heart rate

36
Q

Loses elasticity; cannot compensate for the increased vascular resistance.

A

Arteriosclerosis

37
Q

Ranges of BP

A

Normal - lower than 120 systolic and lower than 80 diastolic
Prehypertension - systolic: 120-139 ; diastolic: 80-89
Stage 1 Hypertension - systolic: higher than 140 ; diastolic: higher than 90
Stage 2 Hypertension - systolic: higher than 160 ; diastolic: higher than 90

38
Q

Hypotension

A

Lower than 90mmhg or below

39
Q
  • Also known as postural hypotension, occurs when a normotensive person develops symptoms.
  • Drop in blood pressure at least 20 mmHg for either systolic or diastolic pressure due to sudden movement or change in position.
A

Orthostatic Hypotension

40
Q

Korotkoff’s sound Phases

A

Phase 1: First sound: Onset of Systolic Pressure. (Tapping)
Phase 2: Blowing or swishing sound occurs.
Phase 3: Blood flows freely through open artery, more intense. (Crisp)
Phase 4: Sounds become muffled and low pitched.
Phase 5: The last sound is heard: Diastolic pressure.

41
Q

an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage, or both (IASP).

A

Pain

42
Q

Types of Pain

A
  1. Referred pain - arising in different areas or other parts of body
  2. Visceral Pain - arisings from organs
  3. Acute Pain - lasts through recovery period
  4. Chronic Pain - prolonged over 6 months
43
Q

Concepts associated with pain

A
  • Hyperalgesia/Hyperpathia – increased sensation of pain in response to a normally painful stimulus.
  • Allodynia – sensation of pain from a stimulus that normally does not produce pain (e.g., light touch).
  • Dysesthesia – unpleasant abnormal sensation that can either be spontaneous or evoked.
44
Q

Pain Assessment PQRST COLDSPA

A

Provocation (what)
Quality (how does it feel)
Radiation (where pain)
Severity (pain scale)
Time (when)

Character
Onset
Location
Duration
Severity
Pattern
Associated factors

Funda (12 decks)

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