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Health Assessment Theory > Vitals 2 > Flashcards

Vitals 2 Flashcards

1
Q

When is a good time to take vital signs

A 
on admission 
When clients health status changes 
Before and after surgery
Before and after administration of medications
Before and after nursing interventions
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2
Q

What are some things that can interfere with oral temperature readings

A

just eating hot/cold foods/drinks

just smoked

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3
Q

What are considerations with tympanic membrane readings

A

Excess cerumen can interfere

Must contact with all sides of ear canal

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4
Q

What are considerations with axillary measurements

A

Less accurate, infants and children only

One degree below normal oral temp

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5
Q

What are considerations with rectal measurements

A

Accurate
Adult and Child Positioning
Lubricant, insert in rectum 1-1.5 inches
One degree higher then oral

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6
Q

What are the average pulse rates

A 
adults and elderly-- 60-100
newborns-- 80-180
1 year-- 80-140
5-8-- 75-120
10-- 50-90
teens-- 50-90
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7
Q

What are the 9 sites to measure pulse

A 
temporal 
carotid
radial
brachial
femoral
apical popliteal
psterior tibial
dorsalis pedis
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8
Q

Whatshould the nurse be aware of while assessing the RR

A

normal breathing patterns
health probs that could influence it
meds that could influence it
the relationship of the clients respirations to the cardiovascular system

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9
Q

What are the factors that increase RR

A

exercise
stress
increased environmental temp
lower oxygen concentration

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10
Q

What are the factors that decrease RR

A

decreased environmental temp
meds like narcotics
increased ICP

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11
Q

Normal tidal volume is

A

500 ml

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12
Q

the depth of respirations are usually described with what words

A

normal
deep
shallow

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13
Q

What is assessed for respiration assessment

A 
rate 
depth
rhythm
quality
effectiveness
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14
Q

What are the altered breathing patterns for rate

A

tachypnea
bradypnea
Apnea

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15
Q

What are the altered breathing patterns for volume and what are their defs

A

Hyperventilation- rapid deep breaths

Hypoventilation- shallow respirations

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16
Q

What are the altered breathing patterns for rythm and what are their defs

A

cheyne-stokes breathing- random breathing between very deep to very shallow to periods of apnea

17
Q

What are the altered breathing patterns for effort and what are thire defs

A

dyspnea- labored and difficult with an unsatisfied need for air
Orthopnea- ability to breathe only in an upwright position

18
Q

What are the altered breathing patterns for sounds and what are their defs

A

stridor- shrill, harsh sounds heard during inspiration with a laryngeal obst
Wheeze- high pitched sounds coming from the lobes during expiration or inspiration
Crackles- can be fine or course, fine sounds like sticky surfaces pulling apart, course sounds like low rumbling

19
Q

What are the altered breathing patterns for chest movements

A

Use of excessory muscles like the external intercostals and neck muscles

20
Q

What are the altered breathing patterns for secretions and coughing and what are their deffs

A

Hemoptysis- presence of blood in the sputum
Productive cough-
Non-productive cough

21
Q

What are the average changes in RR over the lifespan

A

15-25 for ages 5-10

15-20 for teens and older adults

22
Q

How to assess for orthostatic hypotension

A

place client in supine for 10mins
record BP
slowly have the client sit up or stand and immediately record BP
repeat in 3 minutes

23
Q

What is indicative of ortho htypo

A

20 mmhg drop in systolic

10mmHg drop in diastolic

24
Q

What are the sites to take the BP

A

upper arm and thigh

25
Q

What is the recommended length of the bladder of a BP cuff

A

80% of the arms circumference

26
Q

Whta tis the recommended width of the bladder of the BP cuff

A

40 of the arms circumference

27
Q

What are some things that can cause an error in a BP reading with BP cuffs

A 
incorrect size of bladder
deflating to fast or slow 
unsupported arm 
repeating the assessment too quickly 
assessing immediately after a meal, during pain, or smoking
28
Q

What are some factors that affect O2 sat readings

A

low hemoglobin
circulation
shivering/excessive movement
carbon monoxide poisoning

29
Q

What are some lifespan considerations for pulse ox’s

A

infants— levels may be preset differently and may need to use a forehead or earlobe sensor if size probs
children— instruct the child it doesnt hurt
elderly— bx of meds, poor ciculation or thick nails you may need to use a forehead or earlobe sensor

30
Q

If the client can be weighed on a scale standing what can the nurse use

A

a chair or bed scale

31
Q

How should infants heights be taken

A

supine until age 2

32
Q

What should the nurse include in the documentation of height and weight for infants

A

head circumference until age 2

Health Assessment Theory (15 decks)

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