Vital Signs Ch 4 Flashcards Preview

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Flashcards in Vital Signs Ch 4 Deck (75):
0

Vital signs include what

Temperature, pulse, respirations, and blood pressure

They are called vital signs because of their importance

1

Vital signs and other physiologic measurements often provide what

The basis for problem-solving

2

Many facilities have begun using the fifth vital sign witch is

Pain level or comfort level

3

Guidelines for obtaining vital signs (4)

Measure vital signs correctly.

Understand and interpret the values.

Communicate findings appropriately.

Begin interventions as needed

4

When do you access vital signs

When a patient is admitted to a facility, and then as prescribed by the physician or as policy dictates

5

Heart rate respiratory rate and blood pressure for a neonate

120-160

36-60

Systolic - 20-60

6

Heart rate respiratory rate and blood pressure for an infant

125-135

40-46

Systolic- 70-80

7

Heart rate respiratory rate and blood pressure for a toddler

90-120

20-30

Systolic 80-100

8

Heart rate respiratory rate and blood pressure for school-age 6 to 10 years

65-105

22-24

Systolic- 90-100
Diastolic- 60-64

9

Heart rate was between rate and blood pressure for Adolescent 10 to 18 years

65-100

16-22

Systolic 100-120
Diastolic 70-80

10

Heart rate respiratory rate blood pressure for an adult

60-100

12-20

Systolic- 100-120
Diastolic - 70-80

11

Heart rate respiratory rate blood pressure for an older adult

60-100

12-18

Systolic - 130-140
Diastolic - 90-95

12

Temperature

A relative measure of sensible hot or cold

13

What temperature is considered normal
What is acceptable variations

98.6 F (37 C)

97- 99.6 F (36.1 C - 37.5 C)

14

Factors that have the potential to cause body temperature variances

Environment, the time of day, the patient state of health and activity level, in the stage of the patients monthly menstrual cycle

15

Regulation of body temperature is the job of the what

And where is it located

Hypothalamus

Located in the brain, form in the floor and part of the lateral wall of the third ventricle.

The hypothalamus helps maintain a balance between heat loss and he produced by the body

16

What are the two categories temperature falls into

Core temperature and surface temperature

17

Core temperature

The temperature of the deep tissues in the body

Remains relatively constant unless a person is exposed to severe extremes in environmental temperature

18

Surface temperature

The temperature of the skin

Austin varies a great deal in response to the environment

19

What is usually the first sign of illness

Temperature elevations.

Pyrexia, febrile, and hypothermia all mean above normal body temp

20

What is fever and what is it do

It's a body defense. Elevated body temperature will destroy invading bacteria

21

Intermittent fevers

Rise and fall

22

Remittent fevers

Similar to intermittent fevers except the temperature does not return to normal at all until the patient becomes well

23

Hypothermia

When body temperature is abnormally low

24

Factors affecting body

Age- neonates 99.5 F, older adult- 95 F

Exercise.- can raise as high as 103.2- 105.8

Hormonal influences.- woman have greater variations

Diurnal daily variations.-change throughout day

Stress.-

Environment .

Ingestion of hot and cold liquids.

Smoking- plus or minus 0.2 F

25

Signs and symptoms of elevated body temperature (10)

Thirst
anorexia
flushed warm skin
Irritability
glassy eyes or photophobia
headache
elevated pules and respiratory rate restlessness or excessive sleepiness increased perspiration
disorientation

26

Heat sensitive patches

To obtain your reading of surface temperature is a possible choice

Place the patch on the area of the skin such as the four head the color change on the patch indicates the temperature

27

Electronic thermometer

Consist of rechargeable battery powered display unit, thin wire cord, and the temperature processing probe with the disposable cover

Separate probes are available for oral temperature measurement (Bluetip )and rectal temperature measurement (red tip)

28

Normal body temperature is according to the measurements site

Oral 98.6
Rectal 99.5
Axillary 97.6
Tympanic 98.6

Make a telephone oral and tympanic 98.6 down the axillary minus one of the butt plus one

29

Oral temperature

Most assessable site
comfortable for patient
necessary no position change. Do not use for patients who are infants or small children, disoriented or unconscious patient

30

Rectal

Most accurate. Do not use a patient after rectal surgery or patients who have a rectal disorder

31

Axilla

Least accurate

32

Tympanic

Excessive your wax has a possibility to interfere with accurate reading

33

Temporal artery

Provides core temperature.
Diaphoresis and airflow across the face may affect the accuracy

34

Diaphragm

The circular flat surfaced portion of the chest piece covered with a thin plastic disc of the stethoscope it transmits the high pitch sound created by the hive velocity movement of air in blood

35

Auscultate

Listen for sounds within the body to evaluate the condition of heart lungs, pleura, intestines or other organs or to detect fetal heart tones

36

Pulse

A rhythmic beating or vibrating movement
Signifies the regular, recurrent explanation and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts

Adult pules rate is normally between 60-100 beats per minute

37

Tachycardia

>100 beats per min

38

Bradycardia

<60 beats per min

39

Dysrhythmia

If the amount of time between beats varies, there will be an irregular pulse

Any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart

40

Which two arteries are easily palpated pules sites

Radial and carotid artery

41

Pulse volume variations

0- absent pyulse
1+ thready pulse
2+ weak pulse
3+ normal pulse
4+ bounding pulse

42

Factors influencing pulse rates (10)

Age,
exercise,
fever/heat,
acute pain and anxiety,
unrelieved severe pain/chronic pain, medications,
hemorrhage,
postural changes,
metabolism,
pulmonary condition

43

Obtaining for radial pulse

Lightly place tips of first and second fingers in Groove formed along radial side of forearm lateral to flexor tendon of wrist

44

Obtaining for ulnar pulse

Place fingertips along ulnar side of forearm

45

Brachial pulse

Locate groove between biceps and triceps muscles above elbow at antecubital fossa

46

Femoral pulse

With patient supine, place first three fingers over inguinal area below inguinal ligament, midway between pubic symphysis and anterosuperior iliac

47

Popliteal pulse

Slightly flex knee with foot resting on table or bed

48

Dorsalis pedis pulse

Place fingertips between great and first toes and slowly move them along groove between extensor te done of great and first toe

49

Posterior tibial pulse

Slightly extend feel
Place fingertips behind and below medial malleolus (ankle bone

50

Apical

Apex
(The tip, the end, or the top of a structure) of the heart

51

Apical pulse

Represents the actual beating of the heart

52

Pulse deficit

The difference between the radial and apical rates.

To confirm pulse deficit one nurse listens to the apical rate and the second palp area the radial pulse at the same time using same watch for 1 minute

53

Respiration

The taking in of oxygen, it's utilization in the tissues, and the giving off of carbon dioxide; the act of breathibg, I.e, inhaling and exhaling

Both internal and external

54

Internal respiration

Refers to the exchange of gas at the tissue level caused by the process of cellular oxidation as well as the gas exchange that occurs in the alveoli of the lungs

55

Oxidation

Any process in which the oxygen content of a compound is increased

56

External respirations

The breathing movements of the patients that you will observe.

The cycle of external respiration's has two parts: inspiration and expiration

57

Inspiration

Inhaling air with oxygen into the lungs

58

Expiration

Exhaling air with carbon dioxide out of the lungs

59

Factors intending respiration

Disease or illne
STress
Fever
Age
Sex
Body position
Medications
Excercise
Acute pain
Smoking
Brainstem injury
Hemoglobin function

60

Tachypnea

Rapid respiratory rate

61

Bradypnea

Slow respiratory rate, blow 10 per minute

62

Cheyne stokes respirations

Abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing

63

Blood pressure

The pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart

64

Systolic

Pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries

65

Diastolic

The lower number of the blood pressure reading, the second pressure is the diastolic pressure

66

Pulse pressure

The different between systolic and diastolic

67

Cardiac output

The amount of blood discharged from the left or right ventricle per minute

Blood pressure reflects cardiac output

68

Prehypertension

120-139/ 80-89

69

Hypertension

Occurs when elevated pressure is sustained above 140/90

70

Hypotension

Blood pressure below normal

71

Orthostatic hypotension

A drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from lying to a sitting position

Occurs when a person rides too quickly usually from supine position

72

Sphygmomanometer

A device for measuring the arterial blood pressure . Consists of an inflatable cuff and a gauge

Blood pressure readings are taken with sphygmomanometer and a stethoscope

73

Korotkoff

Pulsating sounds

74

Korotkoff phases

Phase 1 - a sharp thump
Phase 2 - a blowing or whooshing sound
Phase 3- a softer think then phase 1
Phase 4- a softer blowing sound that fades
Phase 5- silence