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Foundations Of Patient Care > Vitals > Flashcards

Vitals Flashcards

1
Q

Pulse/heart, blood pressure, respiration, temperature

A

Vital signs

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2
Q

Indirect measurement of heart rate , # of times the heart ventricularly contracts in a given period of time

A

Pulse

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3
Q

Beats per minute

A

Pulse

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4
Q

Manual palpation

A

Pulse

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5
Q

What is the most accurate way to asses resting

A

Pulse

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6
Q

Pulse is an indicator of

A

Peripheral circulation

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7
Q

2 ways to test manual heart rate

A

Radial and carotid pulse

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8
Q

Carotid pulse

A
  • stand on same side you are assessing
  • do not apply significant pressure
  • never palpate both arteries at same time
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9
Q

Antebrachial fossa, medial to the biceps brachii tendon

A

Brachial artery location

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10
Q

placement of stethoscope for assessing BP

A

Brachial

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11
Q

60‐100bpm

A

Children over 10 and adults heart rate

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12
Q

40‐60bpm

A

Well conditioned athletes

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13
Q

Abnormal Responses Exhibited by the Pulse

A

Slowly ↑ or does not ↑ during active exercise

● Continues to ↑ or ↓ as intensity of exercise or activity plateaus
● Slowly ↓ as intensity of exercise or activity declines and terminates \
● Does not ↓ as intensity of exercise or activity declines
● ↓ during exercise before intensity of exercise or activity declines
● ↑ pulse rate or amount of increase exceeds level expected to occur during exercise period ● Rhythm of pulse becomes irregular during or after exercise or activit

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14
Q

Peripheral pulses can also be used to assess how well blood is moving through

A

distal vessels

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15
Q

use of sound waves to assess passage of blood through arterial and venous blood vessels

A

Doppler sonography

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16
Q

f no Doppler is available, manual assessments are a screening tool for

A

Blood circulation

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17
Q

Want to assess bilaterally, start distally

A

Peripheral pulse

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18
Q

Bounding pulse

A

4

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19
Q

Increased pulse

A

3

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20
Q

Normal pulse

A

2

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21
Q

Weak or thready

A

1

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22
Q

Absent or non palpable

A

0

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23
Q

Peripheral pulse

A

Femoral, popliteal, dorsalis pedis, posterior tibial pulse

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24
Q

Start with palpating radial pulse

A

Assessing respiration

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25
Q

Watch for the rise and fall of the thorax, try not to let the patient be aware you are
watching them breathe

A

Assessing respiration

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26
Q

Respiratory rate

A

RR

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27
Q

Normal resting respiratory rate

A

12-20

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28
Q

voluntary (breath holding) vs involuntary (obstruction or damage to respiration
control centers in the brain)

A

Apnea

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29
Q

Labored, difficult, and painful

A

Ease of breathing

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30
Q

Measurement of oxygen in the blood

A

Pulse oximetry

31
Q

“Sp02”

A
  • max 100%
32
Q

Normal pulse ox

A

95-100%

33
Q

HYPOXEMIA suspected if

A

<90%;<85%
severehypoxemia

34
Q

The force exerted by the blood against any unit area of the vessel wall

A

Blood pressure

35
Q

BP at the time of contraction of the left ventricle (systole)

A

Systolic pressure

36
Q

the BP at the time of the rest period of the heart

A

Diastolic

37
Q

Sensors placed directly into the arterial vessels (e.g. arterial lines)

A

Direct

38
Q

Mostcommonsiteisbrachialartery,useleftarm unlessmedicallynotadvisabledueto

A

Indirect

39
Q

Elevated blood pressure

A

120-129, less than 80

40
Q

130-139 80 to 89

A

High blood pressure stage 1

41
Q

Higher than 180

A

Hypertensive case

42
Q

BP Changes during exercise that are serious warnings

A

Systolic reading >250 mm Hg
● Diastolic reading > 115 mm Hg
● ↓ systolic pressure > 10 mm Hg from baseline
● Failure of the systolic pressure to ↑ with ↑ workload

43
Q

physiologic stress related to an upright posture (sitting or standing)

A

Orthostasis

44
Q

once you stand up the gravitational changes on circulation are compensated by
the

A

Circulatory and autonomic nervous systems

45
Q

Venous pooling in the lower limbs, along with decreased filling pressure of the heart and a
reduction in cardiac output lead t

A

fall in arterial BP

46
Q

Decrease in BP of at least 20 mm Hg systolic OR > 10 mmHg diastolic within 3 min of
assuming an upright position

A

Orthostatic

47
Q

Turgor (elasticity/tension) Hair growth Sensation
◦ Light touch/Pressure
◦ Sharp/dull (pain/temp) Pigmentation changes Bruising Odor

A

Integumentary integrity

48
Q

◦ Look at skin
◦ Patient characteristics – e.g. bed ridden or post op?
◦ May need to drape/ undres

A

Visual assessment

49
Q

(redness that does not disappear quickly once pressure is relieved is

A

Stage 1 pressure sore

50
Q

A flat, small (1 centimeter or less) lesion with color change. Seen in rubeola, rubella, scarlet fever, roseola infantum.

A

Macule

51
Q

An elevated, sharply
circumscribed, small (1
centimeter), colored lesion. May
be pink, tan, red, or any
variation. Seen in ringworm and
psoriasis.

A

Papule

52
Q

A bulging, small (under 1 centimeter), sharply defined lesion filled with clear, free fluid. Seen as groups in herpes simplex, varicella, poison ivy, and herpes zoster.

A

Vesicle/blister

53
Q

An elevated, sharply circumscribed lesion (less than 1 centimeter) filled with pus. Seen in impetigo, acne, and staphylococcus infections.

A

Pustule

54
Q

An elevated, white to pink edematous
lesion that is unstable and associated
with pruritus. Wheals are evanescent –
they appear and disappear quickly.
Seen in mosquito bites and hives.]

A

Wheal

55
Q

Tiny, reddish purple, sharply circumscribed spots of hemorrhage in the superficial layers of the skin or epidermis. Petechiae may indicate severe systemic disease such as meningococcemia, bacterial endocarditis, or non-thrombocytopenic purpura and must be reported immediately

A

Petechiae

56
Q

Fresh blood that comes from a recent wound, bright red color, seen in partial thickness and full thickness wounds, bloody

A

Sanguineous drainage

57
Q

Thin, clear and a little thicker than water, occurs during the healing process of the wound

A

Serous

58
Q

Drainage is cloudier and can be slightly yellow or tan in appearance, means wound has infection and will need further treatment

A

Seropurulent drainage

59
Q

Being “milky” in appearance , almost always a sure sign of infection, thick

A

Purulent

60
Q

There is also a lack of smell when the dressing has been removed.

A

No odor

61
Q

An odor is only detectable at close proximity to the patient and when the dressing is removed.

A

Slight odor

62
Q

Similar to the above ranking, except that the dressing remains on the patient.

A

Moderate odor

63
Q

This is when an odor is discernible within 6 to 10 feet of the patient and the dressing is removed.

A

Strong odor

64
Q

An odor that’s also noticeable within 6 to 10 feet, but the patient’s dressings remain fully intact.

A

Very strong odor

65
Q

Sweet smell =

A

pseudomonas

66
Q

Pressure Injuries aka

A

Pressure ulcers

67
Q

localized damage to the skin and/or underlying soft
tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”

A

Pressure injury

68
Q

Five classic locations
Pressure injuries

A

• Sacrum/coccyx
• Greater trochanter
• Ischial tuberosity
• Heel
• Lateral malleolus

69
Q

Purple or maroon localized area of discolored, in tact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear

A

Deep tissue pressure injury

70
Q

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Area may be painful, soft, warmer or cooler as compared to adjacent tissue.
May be difficult to detect in individuals with dark skin tones

A

Stage 1

71
Q

Partial thickness loss of dermis Presents as a shallow, open ulcer with a red/pink wound bed without slough
Can also present as an intact or open/ruptured serum-filled blister Should not be used to describe skin tears, maceration or excoriation

A

Stage 2

72
Q

Full thickness tissue loss Subcutaneous fat may be visible, but bone, muscle or tendon are not. Slough may be present but does not obscure the depth of the tissue loss May include undermining and tunneling, epidermal rolling/ridging/epibole Varies by anatomical location
◦ (bridge of nose, occiput do not have subcutaneous fat
and can have a shallow stage 3) ◦ Areas of high fat tissue content may have very deep
stage 3

A

Stage 3

73
Q

Full thickness tissue loss Exposed bone, tendon or muscle (visible and palpable)
Slough or eschar may be present Often includes undermining and tunneling Depth varies by anatomical location

A

Stage 4

74
Q

Full thickness skin loss Base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or by eschar (tan, brown, black)
Until enough slough/eschar is removed to expose the base of the wound, no stage can be determined Stable, dry, adherent eschar in heels should be left alone

A

Unstageable

Foundations Of Patient Care (7 decks)

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