Vital Signs Flashcards

(63 cards)

1
Q

Heat produced - heat lost

A

Body temperature

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2
Q

Acceptable temp for Fahrenheit

A

96.8° F to 100.4° F

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3
Q

Acceptable temp for Celsius

A

36° C to 38° C

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4
Q

What controls body temp like a thermostat?

A

Hypothalamus

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5
Q

What 5 things regulate body temperature?

A
Neural and vascular control
Heat production
Heat loss (radiation, conduction, convection, evaporation)
Skin temperature regulation
Behavioral control
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6
Q

7 Factors that affect body temperature

A
Age
Exercise
Hormone level
Circadian rhythm
Stress
Environment
Temperature alterations
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7
Q

Heat-loss mechanisms are unable to keep pace with excessive heat production

A

Fever (pyrexia)

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8
Q

Have fever

Do not have fever

A

Febrile

Afebrile

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9
Q

hypothalamus isn’t working correctly

A

Hyperthermia

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10
Q

Acceptable pulse rate

A

60-100bpm

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11
Q

Acceptable respirations

A

12-20bpm

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12
Q

Acceptable blood pressure

A

120/80 mm Hg

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13
Q

Risk for Imbalanced Body Temperature
Hyperthermia
Hypothermia
Ineffective Thermoregulation

A

Examples of nursing diagnosis for pt with body temperature alterations

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14
Q

How to reduce fever (6)

A
Antipyretics (meds)
obtain blood cultures
minimize heat production
Maximize heat loss 
increase metabolic rate (oxygen levels)
pt comfort
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15
Q

When do you want to draw a culture?

A

Before starting antibiotics

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16
Q

Palpable bounding of blood flow noted at various points on the body
The indicator of circulatory status

A

Pulse

HR (same thing as pulse)

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17
Q

Number of pulsing sensations in 1 minute

A

Pulse rate

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18
Q

Electrical impulses

A

originate from the sinoatrial (SA) node

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19
Q

Characteristics of Pulse (4 things)

A

Rate (# per minute)
Rhythm (intervals)
Strength (0-4) volume of blood ejected
Equality (compare sides)

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20
Q

Factors that affect pulse (7 things)

A
Exercise
Temperature
Emotions
Medications
Hemorrhage
Postural changes
Pulmonary conditions
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21
Q

difference b/w peripheral & apical pulses

A

pulse deficit

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22
Q
0
1
2
3
4
strength of pulse is recorded as
A
0= absent
 1= weak or thready
2=normal
3 =full or strong
4= bounding
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23
Q

Sites for pulse (10 sites)

A
Temporal
Carotid
Apical
Brachial
Radial
Ulnar
Femoral
Popliteal
Post. tib
Dorsal pedis
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24
Q

7 things that determine what the pulse will be like

A

Activity intolerance

Anxiety

Acute Pain

Decreased cardiac output

Deficient/excess fluid volume

Impaired gas exchange

Ineffective peripheral tissue perfusion

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25
Movement of gases into and out of the lung.
Ventilation
26
Movement of oxygen and carbon dioxide between alveoli and red blood cells.
Diffusion
27
Distribution of red blood cells to and from the pulmonary capillaries.
Perfusion
28
What is involved with respiration?
Ventilation, Diffusion, Perfusion
29
During the mechanics of inspiration what happens?
abdomen moves downward & forward | Chest wall moves up
30
During the mechanics of expiration what happens?
diaphragm relaxes abdomen returns to normal position chest wall relaxed position
31
When assessing respiration you need to assess
diffusion & perfusion
32
Assessing ventilation
Respiratory Rate: breaths/minute Depth: deep, normal, shallow Rhythm: regular/irregular
33
Assessment of diffusion & perfusion
Measure: oxygen saturation of blood & arterial oxygen saturation
34
8 Factors affecting respiration
``` exercise acute p! anxiety smoking body position medications neurological injury Hemoglobin function ```
35
Force exerted on the walls of an artery by pulsing blood under pressure from the heart
BP
36
Maximum peak pressure during ventricular contraction, squeezing ventricle to get blood out
Systolic
37
Minimal pressure during ventricular relaxation
Diastolic
38
Difference between systolic and diastolic pressures
pulse pressure
39
Physiology of Arterial BP
``` Cardiac output Peripheral resistance Blood volume Viscosity Elasticity ```
40
is the resistance to blood flow determined by the tone of the vascular musculature and diameter of the blood vessels
Peripheral Resistance (PVR)
41
8 factors influencing BP
``` Age Stress Ethnicity Gender Daily Variation Meds Activity, weight Smoking ```
42
Thickening of walls Loss of elasticity-makes it ridged Family history
Hypertension
43
6 Risk factors for hypertension
``` obesity cigarette smoking heavy alcohol consumption high sodium intake sedentary life-style stress ```
44
Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs
Hypotension
45
Korortkoff phase 1
sharp thump
46
Korortkoff phase 2
blowing or whooshing sound
47
Korortkoff phase 3
crisp, intense tapping
48
Korortkoff phase 4
softer blowing sound that fades
49
Korortkoff phase 5
silence
50
when do we need to do BP manually? (7 things)
``` Hyper & hypotensive pt irregular HR Peripheral vascular obstructions (clots) Shivering Seizures Excessive tremors Inability to cooperate ```
51
Characteristics of pain
Quality Aggravating and precipitating factors Relief measures
52
Effects of pain on the patient
Behavioral effects | Influence on activities of daily living (ADLs)
53
Concomitant (secondary) symptoms
Usually increases pain severity
54
ABCDE of P! assessment
``` Ask Believe Choose Deliver Empower ```
55
Type of pain scales
Wong-Baker Faces | Oucher
56
Cuff is too small, release to slow
will cause a high reading
57
If the arm is low
high reading
58
Cuff is too big, above the heart
low reading
59
Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs
Hypotension
60
The measure of HR & rhythm
Pulse
61
Bodys mechanism for exchanging oxygen & carbon dioxide
Respiration
62
Core temp sites
``` rectum tympanic membrane temporal artery pulmonary artery esophagus urinary bladder ```
63
``` Pulses for infants toddler preschooler school age child adolescent adult ```
``` Infants 120-160 toddler- 90-140 Preschooler- 80-110 School age child- 75-100 Adolescent- 60-90 Adult - 60-100 ```