Vital Signs Flashcards
(46 cards)
1
Q
Vital signs
A
- assessing vital or critical physiological functions
- measurements include temperature, pulse, respiration, and blood pressure. Also pain and oxygen saturation are consider vital signs as well
- one of the most frequent assessments you will make as a nurse
- for a patient, don’t always go by the original vital sign, go with their baseline if they run lower then normal temp usually it’s okay
- make sure vitals are correct and documented
2
Q
Monitoring vital signs
A
- performed on regular basis
- in hospital it’s usually every 4 to 8 hours
- home health setting: each visit; 1 or 2 a week
- clinic: each visit
- skilled nursing facility: this person is function able, they aren’t there for illness so they get checked less often like weekly to monthly
- frequency can be determined by the clients condition, facility standards, and providers prescription, or nursing judgement( certain medications more often)
3
Q
Core temperature
A
- normal range: 97 F to 100.8 F (36.1 C to 38.2 C) with some variation
- rectal/tympanic is 1 degree higher
- axillary/temporal is 1 degree lower
- stress increases body temperature and older patients temp decreases with age
- oral: best one taken
- rectal: most accurate, infant or older adults if unable to follow directions
- axillary: not as accurate neither is tympanic(ear) or surface(forehead)
4
Q
Convection
A
- transfer of heat through currents of air or water
- example would be a fan, wind blowing across exposed skin
5
Q
Conduction
A
- transfer of heat from a warm to a cool surface by direct contact
- example could be when the body is immersed in cold water or it’s been a hot day and you get in the car and the seat belt burns you
6
Q
Radiation
A
- Loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air
- examples would be heat lost from the body to a cold room baby’s also lose 30% of their heat through heads
7
Q
Evaporation
A
- water is converted to vapor and lost from the skin( as perspiration) or the mucous membranes (though the breath)
- examples would be sweating
8
Q
Fever
A
- pyrexia, febrile- also referred to as a fever
- abnormally high body temperature over 100 F or 37.8 C
- occurs in response to pyrogens (bacteria)
- pyrogens raise body temperature and tell it to get hot which occurs in the hypothalamus
- fever increases pulse- so if a patient comes in with high temp and the pulse is high you’re not going to be worried about the pulse you will treat temp first by giving them antipyretics (Tylenol, ibuprofen)
- afebrile means no temperature
9
Q
Hypothermia
A
- core temperature below normal so below 95 F or 35 C
- associated with extended exposure to cold
- babies can have trouble regulating temperature because it escapes though their head
- if you get weird reading, take it somewhere else
- also you can protect brain function by hypothermia and make them cold
10
Q
Pulse
A
- the wave that begins when the left ventricle contracts and ends when the ventricle relaxes
- 60-100 bpm
- average- 70-80 bpm
- newborns way faster pulse rate
- older adults slow down
- athlete or in good shape and exercise frequently have a slow heart rate
11
Q
Obtaining pulse rate
A
- apical is the most accurate
- full minute is most accurate especially if irregular, if regular you can also count 30 seconds and x2
- use a stethoscope to auscultation the number of heartbeats at the apex of the heart
- LUB- S1
- DUB- S2
12
Q
Common pulse points
A
- apical: at the apex of heart, 5th inter coastal
- carotid: between midline/ side of neck- don’t take this pulse on each side of the neck could cut off pressure
- brachial: medically in the antecubital space- infants other side of elbow
- radial: laterally on anterior wrist/ thumb side
- femoral: in the groin fold
- popliteal: behind the knew
- pedal: top of feet- one way to catch circulation issue, clots or anything wrong with legs
13
Q
Taking a pulse
A
- lightly compress artery against the underlying cone with the index and middle finger of one of your hands
- do not use thumb, pulse in thumb can cause you to count your own
14
Q
Variances in pulse rates
A
- bradycardia: rate is below 60 bpm
- tachycardia: rate is above 100 bpm
- for assessments assess if that rate is regular or irregular- pattern
- what is the quality of the pulse
- thready: barley pick up- weak pulse could mean fluid volume deficit
- bounding: strong
Rates of pulse
-0: absent: pulse cannot be felt
-1: weak/thready: pulse barley felt
-2: normal: pulse easily palpated, not weak or bounding
-3: bounding/full: pulse easily felt with little pressure
15
Q
Digitalis/digoxin
A
- take apical pulse for whole minute
- if pulse is below 60 then hold this medicine and don’t give it because digoxin lowers pulse
- compare radial pulses for assessment put fingers on both pulse and feel that they line up
- before meds make sure you have up to date vitals, current info
16
Q
Cardiac efficiency
A
- stroke volume: volume of blood during each contraction and is usually on average 70 mL
- cardiac output: stroke volume X pulse rate
- take pulse and multiply by 70
17
Q
Inadequate circulation
A
- if circulation is compromised, pallor(pale) or cyanosis( blue/grey) and cyanosis can happen due to excessive carbon dioxide and deficient oxygen in the blood
18
Q
Respiration
A
- the exchange of oxygen and carbon dioxide in the body
- 2 separate processes:
1. Mechanical: lungs/taking air in pushing air out so its physical
2. Chemical: exchange- air in alveoli oxygen in blood stream then pull carbon dioxide out- exhale so this is exchange in gases
19
Q
Mechanical
A
- pulmonary ventilation; breathing
- active movement of air in and out of the respiratory system
20
Q
Chemical
A
- exchange of oxygen and carbon dioxide
- transport of oxygen and carbon dioxide throughout the body
- exchange of gases between capillaries and tissues
21
Q
Inspiration
A
- drawing air into the lungs
- involves the ribs and diaphragm, creating negative pressure and allowing air to flow into the lungs
22
Q
Expiration
A
- relaxation of thoracic muscles and diaphragm, causing air to expel from the lungs
23
Q
Rate- assessment findings
A
- 12-20 min a rage respirations
- apnea: not breathing
- bradypnea: abnormally slow
- tachphea: abnormally fast
- while getting patients pulse, also watch their chest because if you tell them what you’re doing they will change the way they are breathing
- gently put hand on abdomen, feel it in and out which equals 1 rate
- also look for depth, deep or shallow
24
Q
Rhythm
A
- patterns of respirations
- cheyne-stokes: increase depth of respirations followed by gradual decrease- apnea- may be dying
- kussmauls: regular but abnormally deep and increased in rate- diabetic kidoacidosis
- biots: irregular, shallow, alternating with apnea- brain damage
- effort: work of breathing
- dyspnea: labored breathing
- orthopnea: inability to breathe when horizontal, left patient up to help them breathe
25
Smokers
- smokers are going to have a faster respiratory rate because airway is not as elastic as it used to be and they have to breathe more times
26
Wheeze
- high pitches continuous musical sounds, usually heard as soon as you approach patient
27
Rhonchi
- low pitched continuous sounds caused by secretions in large airways so like mucous
28
Crackles
- discontinuous sounds usualky heard on inspiration(inhaling), may be high pitches popping sounds or low pitches bubbling sounds and this is usually caused by water in the lungs
29
Stridor
- piercing, high pitched sound heard without a stethoscope, primary heard through inspiration, heard in babies in respiratory distress and people with obstructed airways
- respiratory distress- condition in which fluid collects in the lungs or air sacs
30
Stertor
- labored breathing that sounds like snoring
31
Hyperventilation
- rapid and deep breathing resulting in excess loss carbon dioxide (hypocapnea)
- client may complain of feeling light headed and tingly
32
Hypoventilation
- the rate and depth of respirations are decreased and carbon dioxide is retained
33
Tools to measure oxygenation
- arterial blood gases (ABG)
- directly measure the partial pressures of oxygen, carbon dioxide, and blood pH
- draw blood and better then venous labs
34
Measuring oxygenation
- pulse oximetry: noninvasive method of monitoring respiratory status
- uses an external device that measures oxygen saturation
- oxygen 95%-100%
- good for healthy person and also make sure there’s no nail polish or fake nails
- not good for critical care, could stop breathing and still says there’s oxygen so it can be delayed
35
Counting respiratory rate
- nurse should count the respiratory rate after taking the radial pulse
- that patient can after the rate and pattern of respirations
- RR must be accurate, especially in older adults
36
Blood pressure
- pressure of the blood as it is forced against arterial walls during cardiac contraction
- systolic (top number): peak pressure exerted against arterial walls as the ventricles contract and eject blood
- diastolic(bottom number): minimum pressure exerted against arterial wall between cardiac contractions when the heart is at rest
37
Blood pressure
- measures in millimeters of mercury (mm Hg)
- recorded as systolic pressure over diastolic pressure (120/80 mm Hg)
- pulse pressure is the difference between the systolic and diastolic pressures
38
BP regulation
Influenced by 3 factors:
- cardiac function (cardiac output)- stoke volume X pulse
- peripheral vascular resistance ( blood viscosity: thickness- hemotcrit HCT), arterial size, arterial compliance
- blood volume: more volume, more pressure; less volume, less pressure
39
Measuring BP
- noninvasive because you’re not entering the body and its direct
- invasive means you’re entering the body
- brachial is the most common artery for blood pressure
40
Korotkoffs sounds
- first sound: systolic BP
| - last sound: diastolic BP
41
Hypotension
- systolic blood pressure is below 100, some clients normally have a low BP, ask if client is feeling light headed or dizzy
- orthostatic hypotension or postural is a sudden drop in BP on moving from a lysine to a sitting or standing position- have patients dangle feet and slowly get up
42
Hypertension
Prehypertension
- systolic: 120-140 mm Hg
- diastolic: 80-80 mm Hg
- don’t medicate yet, just talk to them around life style changes
- obtain with two readings, taken 6 min apart
43
Hypertension
- diagnosed when BP is persistently higher then normal
| - diagnosed when BP is over 140 systolic or over 90 diastolic on two or more separate occasions
44
Hypertension
- major cause of illness and death in the United status
- it increases the stress on the heat and blood vessels
- increases stress on heart and blood vessels
- if untreated, it can lead to heart, renal, cerebral, or respiratory complications
- probably have history of high blood pressure
- headache with elevated BP could indicate stroke
45
Primary or essential hypertension
- diagnosed when there is a no known cause for the increase
- accounts for at least 90% of all cases of hypertension
- mist diagnosed with this and not related to something else
46
Delegation
Nurses can delegate the activity of taking vital signs, but the nurse is responsible for interpretation of vital signs, vital sign trends, and decisions based on abnormal vital sign findings
- delegate all vital signs if it is possible, responsible for abnormal vital findings
