Vital Signs

Question 1

What are vital signs

Answer 1

• Are clinical measurements that include blood pressure, pulse, body temperature, respiration, and oxygen saturation.
• Provides a baseline of data to compare to future findings
• Identify trends, or patterns, that may indicate a change in a client’s condition.
• Guide treatment decisions and nursing interventions.

Question 2

Blood pressure

Answer 2

A measurement of the force, or pressure, of the circulating
blood on the interior walls of the blood vessels.

Question 3

Pulse

Answer 3

The rhythmic dilation of the arteries that occurs with the beating of the heart.

Question 4

Body temperature

Answer 4

The balance of heat produced by the body and the heat
lost to the environment.

Question 5

Respiration rate

Answer 5

The number of breaths taken per minute.

Question 6

Oxygen saturation

Answer 6

The estimated amount of oxygen bound to the
hemoglobin molecule in red blood cells, indicating the amount of oxygen
being transported to body tissues.

Question 7

Systolic and diastolic

Answer 7

Systolic BP: The maximum amount
of pressure exerted when the
heart contracts and forces blood
into the aorta.
Diastolic BP: The minimum amount
of pressure exerted when the heart
is relaxed.

Question 8

Cardiac output (Exam)

Answer 8

BP is a direct reflection of cardiac output.
* Cardiac output = volume of blood pumped into the circulatory system in 1 minute
Cardiac Output = Stroke Volume x Heart Rate CO = SV x HR
* Stroke volume is amount of blood ejected by the
ventricle during one heart contraction.

Question 9

Equation for cardiac output (Exam)

Answer 9

Cardiac Output = Stroke Volume x Heart Rate CO = SV x HR

Question 10

hypertension (Exam)

Answer 10

• Hypertension is a blood pressure above the expected reference range.
• A client is diagnosed with stage I hypertension when the systolic pressure
  is 130 to 139 mm Hg or the diastolic pressure is 80 to 89 mm Hg.
• When a client’s systolic pressure is greater than 140 mm Hg or the
  diastolic pressure is greater than 90 mm Hg, they have stage II
  hypertension.
• A hypertensive crisis occurs when the systolic pressure is greater than 180
  mm Hg and/or the diastolic pressure is greater than 120 mm Hg.
• Greatly increases risk for heart attack or stroke

Question 11

hypertension can cause (Exam)

Answer 11

increase in: heart issues, drinking caffeine, pain, fever, exercise, Increase in sodium
decrease in: fever

Question 12

nursing interventions for hypertension (Exam)

Answer 12

• Encourage lifestyle changes
• exercise, stress reduction techniques,
  a low-sodium diet, and weight loss if
  needed
• Provide the client with information
  about antihypertensive
  medications, if prescribed by the
  provider, including expected
  adverse effects and when the
  provider should be notified.

Question 13

hypotension

Answer 13

• Hypotension = blood pressure below the expected reference range
• In the absence of baseline data, a systolic pressure less than 90 mm Hg or a diastolic pressure less than 60 mm Hg is typically considered hypotension for an adult.
• Manifestations of hypotension can
  include dizziness, nausea, blurred vision, increased pulse, and fatigue

Question 14

what is a common thing to cause hypotension

Answer 14

sepsis

Question 15

extreme hypotension -> shock manifestations

Answer 15

• cold, pale skin
• rapid breathing (tachypnea)
• weak and rapid pulse

Question 16

treatments for shock

Answer 16

• rapid IV fluid infusion or rapid administration of blood products
• medications that increase contractility of heart muscle and BP

Question 17

orthostatic hypotension

Answer 17

• drop in blood pressure that occurs after standing up from sitting, or sitting up from a lying position.
• Causes include dehydration, general hypotension, heart failure, or disorder of CNS.
• To assess for orthostatic hypotension, check blood pressure while client is lying, sitting and standing with 1 minute between positions.
  * These patients are fall risks

Question 18

nursing interventions for hypotension

Answer 18

• Increase fluids.
• Place in a supine position unless medically contraindicated.
• Evaluate the medications the client is taking.
• Instruct the client about the risk for dizziness and falling.
• Encourage the client to change positions slowly.
• Avoid extremes in temperature.
• Stay well hydrated.

Question 19

pulse

Answer 19

• The pulse is the rhythmic dilation of the arteries and pulsation of blood flow
  that occurs with each contraction of the heart.
• The expected reference range for an adult is 60 to 100 beats per minute.

Question 20

pulse rate is a variable and influences by many factors including?

Answer 20

body position
age
activity level
health conditions
body temperature

Question 21

auscultate and palpating at the apex

Answer 21

Apical pulse - auscultated and palpated at the apex of the heart
- Auscultation = should hear S1 and S2 (“lub dub”)
Apex of the heart heard (in adults and children over 7) at:
- left side of chest
- 5th intercostal space
- midclavicular line
Rhythm regular or irregular?
- listen and count for 1 full minute if irregular

Question 22

grading pulses via palpation

Answer 22

• 0 = pulse that is absent/nonpalpable (none)
• +1 = pulse that is weak/diminished (weak)
• +2 = pulse that is normal
• +3 = pulse that is increased/strong (fast)
• +4 = pulse that is bounding (racing)

Question 23

tachycardia

Answer 23

pulse greater than 100, some clients may experience no symptoms.
some may feel a “racing” feeling in the chest

Question 24

possible causes of tachycardia

Answer 24

exercise
anxiety
certain medications
caffeine and nicotine
abnormality in the electrical system of the heart

Question 25

nursing interventions for tachycardia

Answer 25

* Educate on possible causes to prevent it (use of nicotine or caffeine) * provide resources/pamphlets * Encourage relaxation techniques * meditation * yoga * guided imagery * Valsalva maneuver * Bearing down as if having a bowel movement

Question 26

bradycardia

Answer 26

pulse less than 60 beats per minute - there are often no symptoms in physically fit individuals. others may report, dizziness, fatigue, SOB, chest pain, or confusion

Question 27

possible causes of bradycardia

Answer 27

expected in physically fit individuals congenital cardiac abnormalities heart failure heart muscle damage hypothyroidisim

Question 28

nursing interventions for bradycardia

Answer 28

* Instruct client to change positions slowly * Take all medications as prescribed * Keep all scheduled medical appointments * Notify provider of any changes in health status

Question 29

body temp

Answer 29

* The measurement of the balance of heat produced by the body and the heat lost to the environment. * Measured in degrees * degree celsius (common for charting) * degree fahrenheit * Expected body temperature is between 36° C and 38° C (96.8° F and 100.4° F). * Average temperature for most clients is 37° C (98.6° F).

Question 30

ways of measuring body temp

Answer 30

oral tympanic membrane temporal artery axillary rectal

Question 31

hyperthermia

Answer 31

* A fever is an increase in body temperature above the expected reference range of 38° C (100.4° F). * Commonly caused by infection. * Symptoms may include a flushed face, diaphoresis, skin that feels “hot,” tachycardia, and increased respiratory rate.

Question 32

nursing interventions for hyperthermia

Answer 32

* Encourage sips of cool fluids. * Remove excess clothing. * Administer medications as ordered. * Antipyretics to reduce or prevent fever * Antibiotics or antivirals if an infection is present * Place the client in a cooler environment. * Give a tepid bath.

Question 33

hypothermia

Answer 33

* Abnormally low body temperature * Early symptoms include: * shivering * decreased motor skills * impaired peripheral perfusion * Later symptoms: * confusion * poor concentration * dilated pupils * loss of consciousness (LOC)

Question 34

nursing interventions for hypothermia

Answer 34

* Warming mats/blankets * Bair Hugger * Increase room temperature * Layers of clothing/blankets * Warmed IV fluids

Question 35

respiratory rate

Answer 35

* Respiration consists of inspiration and expiration. * Inspiration is the intake of air by the lungs in order to oxygenate body tissues and support cellular function. * Expiration expels carbon dioxide from the lungs. * Expected reference range is 12 to 20 breaths per minute for adults.

Question 36

eupnea

Answer 36

normal breathing

Question 37

tachypnea

Answer 37

faster than normal

Question 38

bradypnea

Answer 38

slower than normal

Question 39

cheyne-stokes

Answer 39

end of life - rapid and shallow, deep breaths, apnea and repeat

Question 40

kussmual

Answer 40

deep and rapid

Question 41

apnea

Answer 41

absence of breathing

Question 42

what is tachypnea

Answer 42

* Respiratory rate above the expected reference range (greater than 20 breaths per minute). * Possible causes * Physical activity * Anxiety * Pain * Health conditions (e.g., asthma) * Common symptoms * Dizziness * Tingling in the hands

Question 43

what is bradypnea

Answer 43

* Respiratory rate that is below the expected reference range (less than 12 breaths per minute). * Possible causes * Health conditions * Medications: opioids, sedatives * Common symptoms * Dizziness * Fatigue * Weakness * Confusion * Impaired coordination

Question 44

oxygen saturation

Answer 44

* Oxygenation saturation is the estimated amount of oxygen bound to the hemoglobin. * Expressed as a percentage * Direct reflection of a client’s respiratory status * Expected reference range is 95% to 100%

Question 45

alterations in oxygenation

Answer 45

* Decreased oxygen saturation is a level below 95%. * Possible causes * Health condition (e.g., pneumonia, chronic lung disease, pulmonary edema, poor cardiac output). * Common symptoms * Decrease in mental alertness * Confusion

Question 46

nursing interventions for hypoxia

Answer 46

Depends on underlying cause or etiology. Some routine interventions to increase oxygen saturation include: * Sitting client in upright position * Take deep breaths/cough * Apply oxygen as prescribed * Flow rate depends on severity of hypoxia * Give medications as prescribed Impending respiratory arrest = notify doctor and prepare for intubation.