- Intermittent - Remittent - Relapsing - Constant

VITAL SIGNS Flashcards by Natalie Abrenica

Are measurements of the body’s most basic functions.
Are the body’s indicators of health.
Common, noninvasive physical assessment procedure that most clients are accustomed to.

*First step in physical assessment.

VITAL SIGNS

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VITAL SIGNS also called

“Cardinal Signs”

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the four main vital signs routinely monitored by medical professionals and health care providers including the following:

body temperature
pulse rate
respiratory rate
blood pressure

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*is a measurement of our body’s ability to make or expel heat.

THERMOREGULATION CENTER: Hypothalamus

BODY TEMPERATURE

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— number of calories you burn as your body performs basic life-sustaining function

BMR

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Types of Body Temperature

-Core
- Surface

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— deep tissues of the body
— constant

Core

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— transfer of heat from one molecule to a molecule of lower temperature through physical contact.

Conduction

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— skin, subcutaneous tissue
— rises and falls in response to the environment

Surface

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— transfer of heat without contact between the two objects (infrared rays).

Radiation

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Types of Heat Transfer

Radiation
Conduction
Convection
Evaporation

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— continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.

Evaporation

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formula:

C= ?
F= ?

C= (Fahrenheit temperature - 32) * 5/9

F= (Celsius temperature * 9/5) + 32

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— dispersion of heat by air currents.

Convection

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Assessing Body Temperature

Oral
Rectal
Axillary
Tympanic
Temporal Artery

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Normal Range: 35.9’C- 37.5’C

Client type: Older children and adults who are awake, cooperative, alert, and oriented.

*Do not use if client has just consumed very cold or very warm food or drink.

Advantage: Easy and accurate

Disadvantage: Cannot be used if client has had oral surgery, if the client is a smoker, or if the client is mouth breather.

ORAL

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Normal Range: 36.3’C- 37.9’C

Client type: Adults who require a very accurate core temperature

*Use with caution because there is a higher risk of exposure to body fluids.

Advantage: Most indicative of core body temperature (when compared to other routes)

Disadvantage: Cannot be used with clients who have had rectal surgery, abscesses, diarrhea, low WBC, or cardiac disease

RECTAL

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Normal Range: 35.4’C- 37’C

Client type: Infants, young children , and anyone with an altered immune system, because this technique is noninvasive.

Advantage: Easy to take

Disadvantage: Takes a very long time while nurse holds thermometer under client’s arm. Not as accurate as oral or rectal

AXILLARY

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Normal Range: 36.7’C- 38.3’C

Client type: All clients, except with ear infection or ear pain

Advantage: Easy and quick to obtain

Disadvantage: There is no research to support the accuracy of this method (Mayo Clinic, 2018). Only one size of thermometer is available, and it is very difficult to use in children under 3 years of age

TYMPANIC

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Normal Range: 36.3’C- 37.9’C

Client type: All clients, unless sweating profusely

Advantage: Easy and quick to obtain

Disadvantage: Sweating can interfere with accurate reading

TEMPORAL

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FACTORS AFFECTING BODY TEMPERATURE

AGE
EXERCISE
HOMONAL LEVEL
CIRCADIAN RHYTHM
ENVIRONMENT
ILLNESS OR INFECTION

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Types of Fevers

Intermittent
Remittent
Relapsing
Constant

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alternates at regular intervals between periods of fever and periods of normal/subnormal temperatures.

Intermittent

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wide range of temperature fluctuations all of which are above normal

Remittent

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fluctuates minimally but always remain above normal

Constant

short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature

Relapsing

Nursing Interventions During Fever * Monitor vital signs and skin color * Encourage fluid intake * Tepid sponge bath * Dry clothing and linens * Antipyretics * Monitor lab values

PROCEDURE: Count the rate for a full minute, noting the regularity (rhythm). *When an irregular peripheral pulse is present, the nurse needs to assess for a pulse deficit.

* A shock wave produced by the contraction of the heart and forceful pumping of blood out of the ventricles into the aorta * Is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point. * A normal pulse rate for adults is between 60 and 100 beats per minute

PULSE

PULSE commonly called

arterial or peripheral pulse

* Condition in which the apical pulse rate is greater than the radial pulse rate * A ____________ results from the ejection of a volume of blood that is too small to initiate a peripheral pulse wave.

Pulse Deficit

assessment of pulse *assessed using a stethoscope

temporal carotid brachial femoral dorsalis pedis apical ulnar radial popliteal posterior tibial

Amplitude can be quantified as follows: 3+ Bounding (requires firm pressure) 2+ Normal (obliterate with moderate pressure) 1+ Weak, diminished (easy to obliterate) 0 Absent

characteristic of pulse

rate rhythm strength equality

-is the regularity of the heartbeat -there are regular intervals between beats

* Pulse Rhythm

-irregular heart beat

* Dysrhythmia

-Artery feels straight, resilient, and springy

* Arterial Elasticity

-is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction

* Pulse Volume

normal respiratory rate

12-20 breaths/min

normal respiratory rate ranges AGE: - NEWBORN TO 6 WEEKS - INFANT (6 WEEKS TO 6 MONTHS) - TODDLER (1-3 YEARS) - YOUNG CHILDREN (3-6 YEARS) - OLDER CHILDREN (10-14 YEARS) - ADULTS

normal respiratory rate ranges BREATHS/MIN: - 30-60 - 25-40 - 20-30 - 20-25 - 15-20 - 12-20

is a heart rate less than 60 beats per minute in an adult may be normal in well – conditioned clients

* Bradycardia

* The act of breathing * Rate and character are additional clues to the client’s overall health status

Respirations

-is a heart rate in excess of 100 beats per minute in an adult -may be normal in clients who have just finished strenuous exercise

* Tachycardia

movement of breathing * normal amount od inhaled air (tidal volume) =500 mL

- inspiration - expiration

* breath/minute * can be influenced by activity and age, as well as by illness, injury, or disease

respiratory rate

* deep, normal, shallow

ventilatory depth

* regular / irregular

ventilatory rhythm

factors influencing character of respirations

- exercise - acute pain - anxiety - smoking - body position - medication - neurological injury - hemoglobin function

< 12 breaths/minute

bradypnea

> 20 breaths/minute

tachypnea

> 20 breaths/minute; labored breath, increased rate and depth

hyperpnea

no respiration for several seconds

apnea

increased rate and depth of respiration

hyperventilation

decreased rate and depth of respiration

hypoventilation

2-3 abnormally shallow breaths followed by an irregular period of apnea

bio't respiration

alternating patterns of depth separated by periods of apnea and hyperventilation

cheyne-strokes

deep and labored, increased rate

kussmaul's

normal blood pressure

120/80 mm Hg

is the force exerted on the walls of an artery by the pulsing blood under pressure when pumped by the heart.

arterial blood pressure

maximum peak pressure during ventricular contraction

systolic pressure

minimum peak pressure during ventricular contraction

diastolic pressure

mm Hg in bp is

millimeter of mercury

The American College of Cardiology and the American Heart Association______________ define normal blood pressure as systolic less than 120 mmHg and diastolic less than 80 mmHg

(Cifu & Davis, 2017)

Arterial blood pressure is the result of several factors:

- Pumping action - Peripheral vascular resistance - Blood volume - Blood viscosity

A ________________ (e.g., less than 25 mmHg) occurs in conditions such as severe heart failure.

low pulse pressure

systolic >160 mm Hg diastolic >100 mm Hg

stage 2 hypertension

systolic stage of hypertension according to the american heart association

* stage 2 hypertension * stage 1 hypertension * prehypertension * normal

systolic 120-139 mm Hg diastolic 80-89 mm Hg

prehypertension

systolic <120 mm Hg diastolic <80 mm Hg

normal

systolic 140-159 mm Hg diastolic 90-99 mm Hg

stage 1 hypertension

When taking a blood pressure using a stethoscope, the nurse identifies phases in the series of sounds called

Korotko sounds.

An ________________ is the temporary disappearance of sounds normally heard over the brachial artery when the cu pressure is high followed by the reappearance of the sounds at a lower level.

auscultatory gap

A drop in BP of 20 mmHg systolic or 10 mmHg diastolic or increase in pulse of 20 bpm indicates

Orthostatis/Postural Hypertension

Factors Affecting Arterial Blood Pressure

Age Stress Ethnicity Gender Daily variation Medications Activity, weight Smoking Diet High salt/sodium diet Processed foods High amounts of caffeine Excessive alcohol intake

Peripheral vasculature tone decreases and lessens blood return to the heart. Central cardiac tone decreases, which lowers the force of contraction

Age

Genetic and environmental factors are often contributing factors

Ethnicity

Direct alteration: antihypertensives Indirect alteration: opioid analgesics (↓blood pressure and volume), vasoconstrictors († blood pressure)

Medications

Causes sympathetic stimulation, which increases heart rate, cardiac output, and vascular resistance

Stress

Higher blood pressure in men after puberty and in women after menopause

Gender

Blood pressure lowest between hours of sleep: ↑ blood pressure when waking up

Daily variation

Modifiable risk factors blood pressure:

Obesity Smoking Alcohol/caffeine consumption High sall/sodium intake

Nonmodifiable risk factors blood pressure:

Age Gender Ethnicity Family history

Exercise can reduce blood pressure for several hours: obesity can trigger hypertension

Activity, weight

Directly affects vessels and leads to vasoconstriction, which causes ↑ blood pressure

Smoking

detects the amount of oxygen bound to RBCs and calculates the oxygen saturation (SpO₂)

Photodetector:

What Can Affect Oxygen Saturation?

Infection Disease Peripheral perfusion Activity

normal Oxygen saturation

95%-100%

The amount of oxygen that is in t the blood carried to the extremities of the body (fingers, ears, nose, toes) Usually between 95% and 100%

oxygen saturation (SaO2)

Pulse Oximeter Levels 95%-100% Normal blood oxygens levels 91%-95% "Concerning" blood oxygen levels <90% Low blood oxygen levels 80%-85% When low oxygen saturation affects the brain < 67% Cyanosis no oxygen perfusion to extremities

Types of Oxygen Saturation Probes

Finger Nose Ear Forehead

VITAL SIGNS Flashcards

(90 cards)