Vital Signs Flashcards
(140 cards)
1
Q
1st part of the physical exam that begins the moment the nurse meets the client
A
General Survey
2
Q
Requires the nurse to use their
observational skills while interviewing + interacting with the client
A
General Survey
3
Q
Outcome will lead to an overall impression of the client’s whole being
A
General Survey
4
Q
Three parts of general survey
A
Appearance, Behavior, Cognition
5
Q
What part of general survey includes age, skin color, and facial features?
A
Appearance
6
Q
What part of general survey includes facial expression, mood/affect, speech, dress, and hygiene?
A
Behavior
7
Q
What part of general survey includes level of consciousness and orientation?
A
Cognition
8
Q
What part of general survey includes any sigs of distress such as facial grimacing and breathing problems?
A
Cognition
9
Q
Stature, nutrition, posture, position, and symmetry refer to what aspect of appearance?
A
Body structure
10
Q
Gait and range of motion refer to what factor of appearance?
A
Mobility
11
Q
What are the 5 levels of consciousness?
A
Alert
Lethargic
Obdundation
Stupor
Coma
12
Q
the patient opens their eyes spontaneously, looks at you when spoken to in a normal voice, responds appropriately to stimuli, and movements are purposeful.
A
Alert
13
Q
the patient appears drowsy but opens their eyes to loud verbal stimuli and looks at you, responds to questions, and then falls back asleep.
A
Lethargic
14
Q
the patient opens their eyes with tactile stimuli and looks at you but responds to you slowly and may be confused.
A
Obdundation
15
Q
the patient awakens only after painful stimuli is applied (i.e., applying pressure to the nailbed). The patient’s verbal responses are slow or absent. The patient will fall into an unresponsive state when the stimuli stops.
A
Stupor
16
Q
patient is unarouseable and their eyes remain closed. There are no purposeful responses to internal or external stimuli. However, nonpurposeful responses to painful stimuli and brain stem reflexes may still be present.
A
Coma
17
Q
Provide the data that reflect the status of several body systems (cardiovascular, neurologic,
peripheral respiratory systems)
A
Vital signs
18
Q
What is the correct order of taking vital signs?
A
Measure the client’s temp. 1st, then pulse, respirations, & blood pressure
19
Q
A core body temp. between _____ orally must be maintained for the body to function on a cellular level
A
96-99.9 degrees Fahrenheit
20
Q
_____ is the most accurate temp. (for infants & unconscious) for core temp.
A
Rectal
21
Q
True or False: Axillary temperature is lower than core temperature
A
TRUE
22
Q
True or False: Temp. tends to be higher in the morning &
lower in the evenings.
A
FALSE. Temp. tends to be lower in the morning & higher in the evenings
23
Q
The radial pulse is also known as an _____.
A
Arterial pulse
24
Q
What are the characteristics assessed for radial pulse?
A
Rate, Rhythm, Amplitude, Contour, Elasticity
25
Refers to how fast a pulse is
Rate
26
Refers to if a pulse is regular/fast/strong
Rhythm
27
Refers to how strong a pulse is
Amplitude
28
What is the measure of a normal pulse?
60-100 beats per minute
29
What is the meaning of 0 in quantifying amplitude?
absent
30
What is the meaning of 1+ in quantifying amplitude?
weak, diminished (easy to obliterate)
31
What is the meaning of 2+ in quantifying amplitude?
normal (obliterate with moderate pressure)
32
What is the meaning of 3+ in quantifying amplitude?
bounding (unable to obliterate or requires firm pressure)
33
How many pulse sites are there?
9
34
What are the pulse sites of the body?
Temporal pulse
Carotid pulse
Apical pulse
Brachial pulse
Radial pulse
Ulnar pulse
Femoral pulse
Popliteal pulse
Posterior tibial pulse
Dorsalis pedis pulse
35
True or False: You should always inform a client if you are going to measure their respiratory rate
FALSE. Don't tell clients you are taking their respiratory rate bc they might change their breathing
36
Characteristics assessed for respiration
Rate, rhythm, depth
37
What is the normal respiration rate?
12-20 breaths per minute
38
Reflects the pressure exerted on the walls of the arteries
Blood pressure
39
Blood pressure varies with the cardiac cycle, reaching a high point with _____ & a low point with ____
Systole; diastole
40
What is the measure for normal blood pressure?
120/80
41
It is a measurement of the pressure of the blood in the arteries when the ventricles
are contracted & when the
ventricles are relaxed
Blood pressure
42
BP when the ventricles are contracted
Systolic BP
43
BP when the ventricles are relaxed
Diastolic BP
44
BP is affected by ____?
- cardiac output
- distensibility of the arteries
- blood volume
- blood velocity
- blood viscosity
- time of day
- caffeine/nicotine
- exercise
- emotions
45
It is the difference between systolic and diastolic pressure
Pulse pressure
46
True or False: You should determine pulse pressure before measuring the bp b/c it reflects the stroke volume
FALSE. You should determine pulse pressure after measuring the bp because it reflects the stroke volume
47
the volume of blood ejected with each heartbeat
stroke volume
48
How do you calculate BMI
BMI = weight (kg) / height (m)²
49
provide information about cerebral cortex function
Mental status examination
50
______ disturb the client’s intellectual ability, communication ability, or emotional behaviors.
Cerebral abnormalities
51
Mental status examinations are often performed at the beginning of what type of examination?
often performed at the beginning of the head-to-toe examination because it provides clues regarding the validity of the subjective information provided by the client.
52
A personal & subjective experience w/ few or no objective measurements.
Pain
53
Whatever the experiencing person says it is, and existing whenever the person says it does.
Pain
54
Unpleasant, subjective sensory & emotional experience assoc. with actual or potential tissue damage, or described in terms of such damage.
Pain
55
Viewed as an experience, not merely a symptom and not a disease entity.
Pain
56
What is the process of pain?
Pain transduction
Pain transmission
Pain modulation
57
stimulation of the nociceptors
Pain transduction
58
discharged impulse travels as electric activity to spinal cord
Pain transmission
59
variation in the way clients perceive similarly painful stimuli.
Pain modulation
60
larger and carry other sensory info. such as touch
A-beta
61
transmit pain fast
A-delta
62
transmit pain more slowly / no myelin sheath
C fibers
63
lowest perceivable intensity of stimuli that is transmitted as pain.
Pain threshold
64
amount of pain the client is willing to endure.
Pain tolerance
65
Three phases of pain experience
Anticipation
Sensation
Aftermath
66
allows a person to learn about pain & its relief
Anticipation
67
pain is felt. Gauging tolerance level of pain.
Sensation
68
pain is reduced or stopped
Aftermath
69
Behavioral Indicators of Effects of Pain
Vocalizations
Facial expressions
Body movement
Social Interaction
70
Refers to moaning / crying / screaming / gasping / grunting
Vocalizations
71
Refers to grimace / clenched teeth / wrinkled forehead / tightly closed or widely opened eyes or mouth / lip biting / tightened jaw
Facial expressions
72
Refers to Restlessness / immobilization / muscle tension / hand & finger movements / pacing activities / rhythmic or rubbing motions / protective movement of body parts.
Body movement
73
Refers to Avoidance of conversation / focus only on activities for pain relief / avoidance of social contact / reduced attention span.
Social Interaction
74
Factors influencing pain
a. Age
b. Sex
c. Culture
d. Meaning of pain
e. Previous experience
f. Coping style
g. Family & social support
h. Attention
i. Anxiety
j. Fatigue
75
To assess pain, you should assess for ____.
L-Location
I-Intensity
Q-Quality
U-Usual Chronology
I-Ideal Relief
D-Duration
76
localized, radiating, referred
Location
77
pain scale
Intensity
78
sharp, dull, aching…
Quality
79
pattern of onset, frequency & character
Usual chronology
80
rest, meds, immobility
ideal relief
81
Types of Pain
Acute Pain
Chronic Pain
Cutaneous or superficial pain
Deep somatic pain
Visceral pain
Referred pain
Malignant pain
Pain of Psychological origin
82
Two types of Pain of Psychological origin
Pretended pain
Psychogenic pain
83
Four types of chronic pain
Nociceptive, Neuropathic, Mixed, Visceral
84
Post-surgical pain, headache, trauma
Acute pain
85
Osteoarthritis, rheumatoid arthritis
Nociceptive pain
86
Two types of neuropathic pain
Central, peripheral
87
Post-stroke, multiple sclerosis, spinal cord injury, phantom pain
Central pain
88
Post-herpetic neuralgia, Diabetic neuropathy, HIV related neuropathic pain
Peripheral pain
89
Lower back, cancer, fibromyalgia
Mixed pain
90
Internal organs, pancreatitis, inflammatory bowel syndrome
Visceral pain
90
is an “execution of physical force used so
as to injure or abuse”
Violence
90
“a situation in which one family member causes physical or emotional harm to another family member. At the center of this violence is the abuser’s need to gain power and control over the victim”
Family violence
91
slapping, hitting, kicking, punching, burning
Physical abuse
92
threats of physical harm, financial harm, harm to child or pet, or suicide; harassment; insults and other verbal abuse; isolation; intimidation; mind games; throwing objects
Emotional abuse
93
incest or rape
Sexual abuse
94
5 Theories related to domestic violence for why men batter women
Psychopathology theory
Social learning theory
Biologic theory
Family systems theory
Feminist theory
94
violence is a
learned behavior from childhood
Social learning theory
94
batterers suffer personality disorders
Psychopathology theory
94
physiologic changes from childhood trauma, head injuries, or through heredity cause violent behavior
Biologic theory
95
violence grows through family system function, but some criticize this theory as blaming the victim
Family systems theory
96
male/female inequity in patriarchal societies lead to violence
Feminist theory
97
5 Distinctive elements of observable behavior that indicate the potential for violence
1. Staring and eye contact
2. Tone and volume of voice
3. Anxiety
4. Mumbling
5. Pacing
97
TYPES OF FAMILY VIOLENCE
1. Physical Abuse
2. Psychological Abuse
3. Economic Abuse
4. Sexual Abuse
97
CATEGORIES OF FAMILY VIOLENCE
1. Intimate Partner Violence (IPV)
2. Child Abuse
3. Elder Mistreatment
98
“the process of conducting a self-examination of one’s own biases towards other cultures and the in depth exploration of
one’s cultural professional background”
Cultural awareness
99
Stages of cultural awareness
Unconscious incompetence
Conscious incompetence
Conscious competence
Unconscious competence
100
Not aware that one lacks cultural knowledge; not aware that cultural differences exist
Unconscious incompetence
101
Aware that one lacks knowledge about another culture; aware that cultural differences exist but not knowing what they are or how to communicate effectively with clients from different backgrounds
Conscious incompetence
102
Consciously learning about the client's culture and providing culturally relevant interventions; aware of differences; able to have effective transcultural interactions
Conscious competence
103
Able to automatically provide culturally congruent care to clients from a different culture; having much experience with a variety of cultural groups and having an intuitive grasp of how to communicate effectively in transcultural encounters
Unconscious competence
104
refers to one's ability to understand and respect people. This includes respecting beleifs, cutoms, norms, and values of people from different backgrounds.
Cultural competence
105
The Four Cs of Culture model Asks questions about what the patient ______
➢ Considers to be a problem
➢ Cause of the problem
➢ Coping with the problem
➢ Concerned they are about the problem.
106
Characteristics of religion
➢ Formal
➢ Organized
➢ Group oriented
➢ Ritualistic
➢ Objective, as in easily measurable (e.g.,
church attendance)
106
is defined as the rituals, practices, and experiences shared within a group that involve a search for the sacred (i.e., God, Allah, etc.).
Religion
106
is defined as a search for meaning and purpose in life
Spirituality
107
Characteristics of spirituality
➢ Informal
➢ Nonorganized
➢ Self-reflection
➢ Experience
➢ Subjective, as in difficult to consistently measure (e.g., daily spiritual experiences, spiritual well-being, etc.)
107
it seeks to understand life’s ultimate questions in relation to the sacred.
Spirituality
108
Active and ongoing conversation that assesses the spiritual needs of the client.
SPIRITUAL ASSESSMENT
109
Characteristics of spiritual assessment
➢ Formal or informal
➢ Respectful
➢ Non-biased
109
Addressing the spiritual needs of the client
as they unfold through spiritual
assessment.
Spiritual care
110
One popular acronym tool is the _____.
FICA Model
110
Characteristics of spiritual care
➢ Individualistic
➢ Client oriented
➢ Collaborative
111
FICA stands for _____.
F-Faith or beliefs
I-Importance and influence
C-Community
A-Address
112
FICA: What are your spiritual
beliefs? Do you consider yourself spiritual? What things do you believe in that give meaning to life?
F-Faith or beliefs
112
FICA: Are you connected with a faith center in the community? Does it provide support/comfort for you during times of stress? Is there a person/group/leader who supports/assists you in your spirituality?
C-Community
113
FICA: Is faith/spirituality important to you? How has your illness and/or hospitalization affected
your personal practices/beliefs?
I-Importance and influence
114
FICA: What can I do for you? What support/guidance can health care provide to support your spiritual beliefs/practices?
A-Address
115
Helps uncover actual and potential imbalances
Evaluating nutritional status
116
Includes data from nutritional screening, medical history, physical examination, laboratory tests
Evaluating nutritional status
116
refers to complex processes by which nutrients are ingested, digested, absorbed, transported, used, and then excreted.
Nutrition
116
is the current body status of a person or a population group, related to their state of nourishment.
Nutritional status
117
The consumption and utilization of nutrients.
Nourishment
118
Two factors that determine nutritional status
Internal/constitutional environmental factors
External environmental factors
119
Age, sex nutrition, behavior, physical activity, diseases
Internal/constitutional environmental factors
120
Food safety, cultural, social, and economic circumstances
External environmental factors
121
Direct methods of nutritional assessment
Anthropometric methods
Clinical methods
Dietary evaluation methods
Biochemical, laboratory methods
121
Non-invasive quantitative measurements of the body (height, weight, head circumference, BMI, body circumstance, skinfold thickness
Anthropometric measurements
121
Used to assess nutritional by measuring: albumin, creatinine, lipid profile, hemoglobin, ferritin, and electrolytes.
Biochemical parameters
122
A systematic way to obtain and document information about an individual's medical and psychiatric conditions and symptoms, function, behavior, personal history, values, preferences, goals, and other relevant information, which is then analyzed using clinical reasoning to identify underlying conditions
Clinical assessment
123
Structured interview method consisting of questions about habitual intake of foods from the core food groups and dietary behaviors.
Dietary history
