Vital Signs Flashcards
(87 cards)
1
Q
Afebrile
A
without fever
2
Q
Febrile/Pyrexia
A
with fever
3
Q
Hyperpyrexia
A
Very high fever
4
Q
Hypothermia
A
body temperature below normal
5
Q
Eupnea
A
normal breathing
6
Q
Apnea
A
absence of breathing
7
Q
Dyspea
A
difficulty/labored breathing
8
Q
Orthopnea
A
difficulty breathing when laying down, but able to breathe better when standing
9
Q
Tachypnea
A
increase respiratory rate
10
Q
Bradypnea
A
decrease respiratory rate
11
Q
Chynes-Stoke Respiration
(who is it usually seen in?)
A
- period of deep/rapid breathing, then period of apnea, and/or regular breathing
- seen in PTs with:
–> heart/kidney (renal) failure
–> increased cranial pressure
–> drug overdose
–> people living in high altitude
12
Q
Kussmaul Respirations
(who is it seen in?)
A
- Increased respiratory rate and depth
- seen in PTs with:
-> Metabolic acidosis
-> Diabetic ketoacidosis
13
Q
Intermittent Fever
A
body temperature fluctuates between normal and fever within 24hr period
14
Q
Remittent Fever
A
temperature does NOT return to normal: may fluctuate, but remains high
15
Q
Continous/Sustained Fever
A
temperature remains above normal; little/no temperature variations
16
Q
Relapsing/Recurrent Fever
A
Series of fevers; normal for few days, the fever comes back
17
Q
Sinus Bradycardia
A
generates slower pulse rate from SA node (pacemaker), but rhythm remains the same
- Common in athletes
18
Q
Hypertension
A
high BP
19
Q
Hypotension
A
low BP
20
Q
Orthostatic hypotension
A
low BP when standing up
- decrease 20 systolic and decrease in 10 diastolic = orthostatic hypotension
- advise for pt to sit up slowly and “hang” from bed before standing
21
Q
White Coat Hypertension
A
a condition where a person’s blood pressure is elevated only when they are in a healthcare setting, such as a doctor’s office
22
Q
Assessing Blood Pressure:
Upper Arm & Special Considerations
A
Upper arm:
- Ask PT if they have smoked, exercised, or caffeine. If yes -> wait 30 minutes. Take blood pressure before eating
- Make sure PT back/legs straight and touch floor; remove any jackets
- Have PT rest for 5 minutes
- Choose the right cuff; width should be 40-50% circumference, and length should wrap 80-100%
Have PT arm rest on one side and arm tested should be on table equal to height of heart - Place cuff 1-2” above elbow bend and make sure it’s snug (2 finger in; snug)
- Make sure tubing is not touching each other
- Place two fingers on radial pulse, feel for pulse, inflate cuff until no longer able to feel pulse. This is your estimated systolic
- Add +30 to estimated systolic
- Place stethoscope on brachial artery and inflate to number. Slowly deflate at 2mmHg and measure systolic and diastolic pressure
Special Considerations
- Avoid extremity with IV or AV shunt
- Avoid arm on side of mastectomy/surgery/cast
23
Q
Assessing Respiratory Rate:
Rate, Depth, Rhythm, Quality, Procedure
A
- Rate
- Depth
-> Deep vs shallow - Rhythm (pattern)
-> Regular
-> Irregular
–> Kussmal Respirations
–> Chynes-Stroke Respirations - Quality
-> Silent (normal) - Procedure
-> Look at chest fall/rise
24
Q
Assessing O2 Saturations
(How do you do it? What are special considerations to take into account when taking O2 stat?)
A
- Find baseline
- Spot check
- Continous
- Special Considerations
-> Continuous monitoring for: Post-op, high risk, O2 therapy
-> Try to avoid wearing dark nail polish/artifical nails
25
Assessing Temperature:
**Oral**
**Important Considerations**: has PT consumed food/cold water
- if yes -> wait ~30 minutes
- Ask PT to open mouth and lift the tongue
- Cover the probe with disposable probe cover
- Place bulb on either side of frenulum and ask PT to close mouth
- Remove when beeps; throw away probe cover
***RED = RECTAL; BLUE = ORAL/AXILLARY*
**
26
Assessing Temperature:
**Rectal**
- Apply disposable gloves
- Have PT in side lying position and instruct to take deep breaths
- Use lubricant and insert 1.5 inches (in adult) and wait for temp
***NEVER FORCE IF RESISTANCE*
**
27
Assessing Temperature:
**Axillary**
- Pat axilla dry (if moist()
- Place bulb in middle and wait for temp
28
Assessing Temperature:
**Tympanic**
- Pull pinna slightly up and back
- Point probe slightly anteriorly (toward jaw)
- Insert probe slowly using circular motion
29
Assessing Heart Rate:
**Sites, Rate (what type of pt may we see tachycardia in?), Rhythm, Quality/Strength, Important Considerations** (equal?, where do you assess pulse in unconcious adult/infant)
**Sites:**
Count 60 seconds
- Apical
Count 30 seconds (unless abnormal):
- Carotid
- Brachial
- Radial
- Femoral
- Popliteal
- Dorsalis pedis
**Rate:**
- #; BPM
- May see increase HR in those with: COPD, asthma, anemia
**Rhythm:**
- Lub-dub (normal)
- Regular: count 30 sec x 2
- Irregular: count 60 sec
**Quality/strength:**
- 0 - absent
- +1 - weak/thready/feeble
- +2 - normal
- +3 - bounding
**Important Considerations:**
- Make sure HR is Equal bilaterally
- Ask PT what their baseline/normal HR
- Unconcious adult = measure carotid
- Unconcious infant = measure brachial
30
Assessing Pain:
**Scale, Quality, Characteristics**
**Scale:**
- 0 - 10: 0 being no pain, 10 being the worst pain
**Quality:**
- Burning, Sharp, Dull
**Characteristics:**
- Radiating
- Localized
31
List the Situaitons When You Should Assess Vital Signs
- Admission/Discharge
- Pre and Post OP
- Change in condition
- Loss of consciousness
- Meds given that affect cardiac rate/rhythm
- Per MD order/hospital policy
32
Explain how disease/trauma to hypothalamus or spinal cord alters temperature control
Hypothalamus recieves messages from thermal receptors throughout the body, and compares that information with the set point, and initiates a response to either produce/conserve body heat. Damage to the hypothalamus can disrupt the set point and impair the bodys ability to regulate temperature corrcectly. (This could lead to neurogenic fever)
With damage to the spinal cord, information from thermal (sensory) receptors cannot be sent to the hypothalamus, damaging the bodys ability to regulate temperature
33
Body Temperature = __________ - _____________
- Amount of heat produced by body
- Amount of heat lost to environment
34
**T/F:** When documenting temperatures, you shouldn't include sire where temp was taken
**False**, you should always include the site at where it was taken since each site has a different normal range for body temperature
35
T/F: Surface temperature is the most accurate for measuring temperature
False, Core temperature is the most accurate for measuring temperature
36
What areas are used to measure Core Temperature?
- Rectum
- Tympanic Membrane (ear)
- Temporal Artery (prope over forehead temporal artery)
-> Use high resolution infared image of PT temporal artery
-> Swipe thermometer probe across forehead and behind ear
37
What areas are use to measure Surface Temperature?
FAMS
- Forehead (disposable chemical strap)
- Axillae (armpit)
- Mouth (oral)
- Skin
38
________ is the most common way to take temperature in the hospital.
Mouth/Oral
39
List the different type of thermometers
ISTG EC
- Infrared (tympanic)
- Scanning Infrared (temporal artery)
- Temperature-sensitive tape
- Glass mercury
-> DO NOT USE; GLASS BREAKAGE
- Electronic
- Chemical Disposal
40
List the ways body heat is lost:
- Skin
- Evaporation
- Conduction
- Convection
- Radiation
**Describe the Mechanism of Action
Provide an example**
- ***Skin***
-> BV at surface release heat (***PRIMARY AREA WHERE HEAT IS LOST***)
- **Evaporation**: Conversion of liquid to vapor
-> Sweating
- **Conduction**: Transfer heat to cooler object
-> ice pack, cooling blanket, water bath, tepid sponge
- **Convection**: blows cool air to warm body
-> fan
- **Radiation**: Diffusion of heat by electromagnetic waves (no hat)
-> body gives off waves of heat from uncovered surfaces
41
______ is the primary area where the body loses its heat.
Skin
42
List the ways heat is generated in the body:
**Metabolism
Hormones
Exercise
Epinephrine/Norepinephrine
Tremors
Goosebumps**
Describe the Mechanism of Action
**Metabolism**
- *PRIMARY SOURCE FOR BODY HEAT*
**Hormones**
- thyroid gland -> ↑ metabolism -> ↑ heat production
**Exercise**
- muscle contraction -> ↑ heat production
**Epinephrine/Norepinephrine**
- ↑ heat production
**Tremors**
- cold temp. -> hypothalamus -> cause tremors/shivering -> ↑ muscle contraction -> ↑ heat production
**Goosebumps**
- ↓ surface area -> ↑ heat retentioj
43
List the Expected Temperature Ranges for:
**Oral Temperature
Rectal Temperature
Axillary Temperature
Temporal Temperature**
- **Oral Temperature:** 96.8°F - 100.4° (Average 98.6)
- **Rectal Temperature:** 0.9°F higher than oral/tympanic
- **Axillary Temperature:** 0.9°F lower than oral/tympanic
- **Temporal Temperature:** 1° higher than oral, or 2° higher than axillary
44
List the S/SX of Fever
- Hot, Dry skin
- Flush
- General Malaise
- Increased HR
45
A PT has hot, dry skin, looks flush and is complaining of general discomfort. What nursing interventions should you do?
- VS
- I&O (see how much Fluid in/out, is PT Hydrated?)
- Fluids (IV, Oral)
- Meds (pain meds, antipyretic/fever reducing)
- Oral hygiene, dry clothing, linen
46
CNS
## Footnote
What systems are in the Central Nervous System?
CNS
- SNS (voluntary)
- ANS (involuntary)
-> SANS (increase HR)
-> PANS (decrease HR)
47
What system is responsible for the increasing heart rate and the fight/fight response?
Sympathetic Nervous System (SANS)
48
What system is responsible for the decreasing heart rate and the rest/digest response?
Parasympathetic Nervous System (PANS)
49
List the Pulse Assessment Sites:
**Heart Areas
Other Pulse Sites (Arteries)**
**Heart Areas: APE To Man**
- Aortic area
- Pulmonic Area
- Erb's Point
- Tricuspid Area
- Mitral Area (apical pulse)
**Other Pulse Sites: Arteries**
- Carotid Artery
- Brachial Artery
- Radial Artery
- Femoral Artery
- Popliteal Artery
- Dorsalis Pedis
50
What is systolic pressure? What noise is systolic pressure responsible for?
- Highest pressure
- (Pressure on arteries) during ventricular contraction, Tricuspid/mitral (bicuspid) valve closes
51
What is diastolic pressure? What sound is diastolic pressure responsible for?
- Pressure in arteries when heart RELEAXES
- Pulmonic/aortic valve closes
-> as age ↑ -> ↓ in elasticity of arterial walls -> unable to stretch/dilate -> ↑ BP and poor blood flow
52
How do you calculate pulse deficit?
apical rate - radial rate
53
How long should you measure heart rate if youre measuring apical pulse? radial?
- Apical site MUST be for 60 seconds
- Radial pulse 30 seconds then mulitply by 2
54
How does pulse differ with age?
(Infant vs Teen vs Adult)
- Infants: 120-160/min
- Teen 12-14yo: 80-90
- Adults: 60-100
55
**T/F:** When measuring respirations, you need do it for a whole minute.
False; when getting respiration rate, measure for 30 seconds then mutliply by 2 (unless abnormal)
56
A ________ in CO2 is the most power respiratory stimulent and causing an increase in ____ and ______.
Increase; Respiratory Rate; Depth
57
What is diffusion?
- exchange of O2 and CO2 between alveoli of lungs and blood
58
What is perfusion?
exchange of O2 and CO2 between tissue cells and blood
59
When listening to blood manually, what is the first sound you hear? last sound? What are these sounds generally referred as?
- First sound: Systolic
- Last sound: Diastolic
- Sounds known as Korotkoff sounds
60
What areas are the most commonly used to assess blood pressure?
- Brachial artery
- Popliteal artery
61
What errors can affect the accuracy of blood pressure readings?
- Wrong size cuff - width ~ 40% arm circumference
- Not going high enough
- Distracting noises
- Position of PT
- Time between recheck
62
What does a pulse oximetry measure? What are other names for a pulse oxietry? Why are pulse oximeters so effective?
- Measures % of O2 carried by available Hb
- Arterial Oxyhemoglobin saturation
-> SaO2 or SpO2, "pulse ox"
- Non-invasive, almost instantaneous
63
Describe the parameters for the following vital sign:
**Blood Pressure**
(Normal, Abnormal)
**Normal:**
- 120/80 mmHg
**Abnormal:**
- Stage II Hypertension: ≥140 / ≥ 90
- Stage 1 Hypertension: 130-139 / 80-89 mmHg
- Elevated: 120 - 129 / <80 mmHg
- Hypotension: <90 / 60 mmHg
64
Describe the parameters for the following vital sign:
**Respiration Rate**
(Normal, Abnormal)
**Normal:**
- 12 - 20 breaths/min
**Abnormal:**
- Tachypnea: > 20 breaths
- Bradypnea: < 10 breaths
65
Describe the parameters for the following vital sign:
**Oxygen Saturation**
(Normal, Abnormal)
**Normal:**
- 95 - 100%
**Abnormal:**
- ≤ 90%
- < 85% indicates inadequate
oxygenation
66
Describe the parameters for the following vital sign:
**Temperature**
(Normal, Abnormal)
**Normal:**
Oh, RAT!
- Orally: 96.8°F - 100.4°F
- Rectal: +0.9°F than oral/tympanic
- Axillary: -0.9°F than oral/tympanic
- Tympanic: +1°F than oral, and +2°F axillary
**Abnormal:**
- Hyperpyrexia: ≥106°F (extremly high fever)
- Hyperthermia: >104°F
- Hypothermia: <95°F
67
Describe the parameters for the following vital sign:
**Heart Rate**
(Normal, Abnormal)
**Normal:**
- 60 - 100 BPM
**Abnormal:**
- Tachycardia > 100 BPM
- Bradycardia < 60 BPM
68
Describe the parameters for the following vital sign:
Pain
(Normal)
**Normal:**
- Assess pain based on scale, quality, characteristics on a scale of 0 - 10
-> 0 = no pain
-> 10 = worst pain
**Abnormal:**
- X
69
Describe factors that affect the following vital sign:
**Blood Pressure**
(Identify, Describe)
**Identify:**
- Age
- Circadian rhythm
- Sex
- Eating food
- Weight
- Emotion
- Body position
- Race
- Medications
**Describe:**
- ↑age = ↓elasticity = ↑BP
- BP↑ day, BP↓ during night
- Women ↓BP vs. Men
- ↑Weight = ↑BP
- Strong emotions (fear, pain, anger) = ↑BP
- ↓BP Prone/Supine vs Sitting/Standing
- ↑BP prevalent in African American men and woman
- Oral contraceptives can cause ↑BP
70
Describe factors that affect the following vital sign:
**Respiration Rate/Rhythm**
(Identify, Describe)
**Identify:**
- Age
- Acid-base balance
- C-V disease
- Pain
- Emotions
- Opioid-narcotics
- Anesthesia
- CNS injury
**Describe:**
- ↑age = ↓RR
- ↑acid = ↑RR
- Acute pain = ↑RR
- Opiod-narcotics/Anesthesia = ↓RR
71
Describe factors that affect the following vital sign:
**Oxygen Saturation**
(Identify, Describe)
**Identify:**
- Respiratory Conditions (chronic bronchitis, emphysema)
- Low hemoglobin (anemia)
- Heart conditions/BP
- Skin pigmentation
**Describe:**
- Impair lungs ability to exchange oxygen from the air to bloodstream = ↓spO2
- ↓ hemoglobin= ↓ blood's capacity to carry O2 = ↓spO2
- impairs the heart's ability to pump blood effectively = ↓ oxygen-rich blood is delivered to the body's tissues =↓ oxygen saturation levels
- Deeply pigmented skin can interfere with the passage of light waves used by pulse oximeters, potentially leading to inaccurate reading
72
Describe factors that affect the following vital sign:
**Temperature**
(Identify, Describe)
**Identify:**
**CABIE**
- Circadian Rhythms
- Age
- Biological Sex
- Illness
- Environment
**Describe:**
- Circadian rhythm = peak temperature in afternoon/evening 3-6pm (lowest at 4am)
- ↑ age = ↓temp (lose thermoregulatory control)
-> very old/young sensitive to temp change
- Women ↑fluctuations in temp vs men
-> increase in progesterone during ovulation
- Illness = ↑/↓temp (ex: fever)
73
Describe factors that affect the following vital sign:
**Heart Rate**
(Identify, Describe)
**Identify:**
**FISH PEA**
- Fever
- Illness
- Stress
- Hemorrhage
- Pain
- Exercise
- Age
**Describe:**
- Fever = ↑HR bc ↑metabolic demands
- ↑stress = ↑HR
- Hemmorhage = ↓BV = ↓BP = ↓SV = ↓CO = ↑HR
- Pain = stressor = ↑HR
- ↑Age = ↓HR
74
Describe factors that affect the following vital sign:
**Pain**
(Identify)
**Identify:**
- -algia
**Describe:**
- X
75
Describe Basic Nursing Responsibilities:
**Role of Nurse**
- Assess
-> Assess upon admission to healthcare setting, meds that affect VS, before/after invasive diagnostic/surgical procedure, emergency situations
- Evaluate
- Normal v abnormal
- Recognize trends
- Supervise
76
Describe Basic Nursing Responsibilities:
**Documentation**
- Timely
- Accurate
- Comapre/Trend
- Note significant changes & report
77
Describe Basic Nursing Responsibilities:
**Communication/Teamwork**
- Communicate findings to other nursing/healthcare professionals through written and spoken words
-> Written actual/potential health problem/need IS NOW permanent part of patients health record
78
Describe Basic Nursing Responsibilites:
**Safety**
- PPE, sanitizating devices
- PT education on use adn rationale
79
Describe Methods to Maintain Adequate Oxygenation:
**Positioning**
(Technique, Who uses it?, Misc)
**Technique:**
- Raise HOB (Head of Bed)
- Use pillows
- Leaning over bedside table (orthopneic)
**Who uses it?**
- Dyspnea
- Orthopnea
**Misc:**
- refer to notes for visual of orthopneic position
80
Describe Methods Maintain Adequate Oxygenation:
**Deep Breathing**
(Technique, Who uses it?)
**Technique:**
- Breathe slowly
**Who uses it?**
- Hypoventilation
**Misc:**
- X
81
Describe Methods Maintain Adequate Oxygenation:
**Incentive Spirometry**
(Technique, Who uses it?, Misc)
**Technique:**
- Direct teh pt to inhale to lift light balls/disks
**Who uses it?**
- Post op (pvt atelectasis)
- Dyspnea
- Secretions
**Misc:**
- refer to notes for visual of incentive spirometry
82
Describe Methods Maintain Adequate Oxygenation:
**Pursed Lip Breathing**
(Technique, Who uses it?)
**Technique:**
- Inhale slowly through nose, hold, and slowly exhale through pursed lips
**Who uses it?**
- Dyspnea/panic
- COPD
**Misc:**
- X
83
Describe Methods Maintain Adequate Oxygenation:
**Diaphragmatic Breathing**
(Technique, Who uses it?)
**Technique:**
- PT sits upright with knees bent.
- One hand placed on the stomach, and the other on the middle of the chest.
- PT breathes in slowly through the nose to allow the abdomen to fill, while keeping the chest as still as possible.
- PT breathes out through pursed lips while contracting the abdominal muscle, while keeping hand on chest as still as possible
**Who uses it?**
- Asthma
- COPD
**Misc:**
- X
84
Describe Methods Maintain Adequate Oxygenation:
**Splinting with Pillow**
(Technique, Who uses it?)
**Technique:**
- Split pillow and place pressure on painful area (to reduce pain)
**Who uses it?**
- Post-op pt who have pain when breathing
**Misc:**
- X
85
Describe Methods Maintain Adequate Oxygenation:
**Nasal Cannula**
(Technique, Misc)
**Technique:**
- Place nasal cannula prongs into the PT nose and wrap around the ears. Check ear for skin breakdown
**Who uses it?**
- X
**Misc:**
- Supplemental O2 on doctor order only
86
Describe Methods Maintain Adequate Oxygenation:
**Mask**
(Technique, Misc)
**Technique:**
- Place mask snugly around PT mouth/nose
- Assess for pressure injuries/skin breakdown
**Who uses it?**
- X
**Misc:**
- Supplemental O2 on doctor order only
87
Describe Methods Maintain Adequate Oxygenation:
**Oxygen Tent**
(Technique, Who uses it?, Misc)
