| When measuring vital signs what can happen? | a change in one has the potential to alter the others |
| When measuring vital signs what can happen? | a change in one has the potential to alter the others |
| When measuring vital signs what can happen? | a change in one has the potential to alter the others |
| indication of basic body functioning, it is appropriate to begin the physical assessment by obtaining these data | vital signs |
| ausculate | listen for sounds within the body to evaluate the condidion |
| What should be included in an overall assessment for all patients? | cultural assessment |
| What are the guidelines for obtaining vital signs? | measuring them correctly, understanding & interpreting the values, communicating findings appropriately, beginning interventions as needed |
| High temperature | Body can be fighting off infection |
| High B/P | Patient can be prone to having a stroke |
| What is the 5th vital sign? | Pain or comfort level |
| What do you need to be aware of for patients' vital signs? | The normal range |
| What helps maintain a balance between heat lost & heat produced by the body? | Hypothalamus |
| 2 types of body temperature | core temp & surface temp |
| core temp | deep tissue of the body; remains relatively constant |
| surface temp | temperature of the skin |
| When taking a patient's temp what do you need to remember to always do? | Always note where you took it |
| Hypertension | High blood pressure |
| Fever | a body defense mechanism |
| What happens when the body temp is elevated? | helps destroy invading bacteria |
| Radial Pulse Rate | is obtained at the radial artery thumb |
| What pulse rate will you check the LOC? | Thumb (Radial Pulse) |
| Where will you find a quick pulse? | Carotid |
| Remittent | fluctuates, does not return to normal until feeling better |
| intermittent | rise/falls to normal everyday ex: normal in the morning & spikes in the after noon |
| apical pulse | actual beating of heart |
| Lub-Dub | one cardiac cycle |
| If pulse differs by more than 2 then what exist? | pulse deficit exists |
| internal resperation | gas exchange on tissue level |
| paracentesis | fluid out of the lungs |
| What is considered as a silent killer? | Hypertension |
| Apnea | stopped breathing |
| When taking a patient's vital signs what do you need to be aware of? | The normal Range |
| What do you need to report while doing vital signs? | Abnormalities |
| How frequently are vital signs measured? | Depend on the nurse's judgment of the need |
| Neonate Heart Rate | 120-160 per minute |
| Neonate Resp. Rate | 36-60 per minute |
| Neonate B/P | Systolic 20-60 |
| Infant Heart Rate | 125-135 |
| Infant Resp. Rate | 40-46 |
| Infant B/P | Systolic 70-80 |
| Toddler Heart Rate | 90-120 |
| Toddler Resp. Rate | 20-30 |
| Toddler B/P | Systolic 80-100 |
| School Age Heart Rate | 65-105 |
| School Age Resp. Rate | 22-24 |
| School Age B/P | Systolic 90-100
Diastolic 60-64 |
| Adolescent Heart Rate | 65-100 |
| Adolescent Resp Rate | 16-22 |
| Adolescent B/P | Systolic 100-120
Diastolic 70-80 |
| Adult Heart Rate | 60-100 |
| Adult Resp. Rate | 12-20 |
| Adult B/P | Systolic 100-120
Diastolic 70-80 |
| Older Adult Heart Rate | 60-100 |
| Older Adult Resp. Rate | 12-18 |
| Older Adult B/P | Systolic 130-140
Diastolic 90-95 |
| temperature | a relative measure of sensible heat or cold of 98.6 which is considered normal |
| When the patient reports nonspecific symptoms of physical distress (feeling funny or different) | Take vital signs |
| Before and after administering meds specially those that affect cardiovascular, respiratory, & temperature control function what should you make sure to do? | Take vital signs |
| Normal body temperature for oral | 98.6,37.0 |
| Normal body temperature for rectal | 99.6,37.5 |
| Normal body temperature for axillary | 97.6,36.4 |
| Normal body temperature for tympanic/temporal | 98.6,37.0 |
| Where is the hypothalamus located? | In the brain and forms the floor & part of the lateral wall of the third ventricle |
| Often varies a great deal in response to the environment | surface temperature |
| pyrexia, febrile & hyperthermia | used to describe the condition of having above-normal body temperature |
| Temperatures exceeding 105 | have the potential to damage normal body cells |
| What are fever classified as? | constant, intermittent, & remittent |
| constant fever | remains elevated consistently and fluctuates very little |
| Hypothermia | body temperature is abnormally low |
| when the body temp falls below 93.2 | death is a risk |
| hypothyroidism | produce a subnormal temperature |
| Factors that affect body temperature | Age, exercise, hormonal influences, diurnal (daily) variations, stress, environment, ingestion of food & hot & cold liquids, & smoking |
| What are some signs & symptoms of elevated body temp? | anorexia, disorientation, elevated pulse/respirations, warm skin, headache, irritability,thirst |
| Tympanic | temperature by scanning the tympanic (eardrum) membrane |
| What are the instructions for tympanic probe positioning? | Gently tug ear pinna upward and back for an adult, down and back for a child |
| stethoscope | an instrument that is placed against the patient's chest or back to hear heart & lung sounds |
| cultate | listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones |
| Oral temp | most accessible site; comfortable for patient; necessitates no position change |
| Rectal temp | argued to be more reliable when oral temperature cannot be obtained |
| Axilla temp | safe method because noninvasive |
| Tympanic Temperature | noninvasive, accurate, safe; provides core reading |
| Temporal artery temp | provides core temperature; rapid, noninvasive method; tolerated well by children; lessens need to handle newborns, which aids in preventing heat loss |
| What is the least accurate method to take a temp? | Axilla |
| pulse | a rhythmic beating or vibrating movement |
| what does pulse signify? | the regular recurrent expansion 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 |
| tachycardia | pulse is faster than 100 beats per minute |
| bradycardia | pulse slower than 60 beats per minute |
| hypovolemia | an abnormally low circulating blood volume |
| What may cause tachycardia? | shock, hemorrhaging, exercise, fever, medication, or substance abuse, and acute pain |
| What may cause bradycardia? | unrelieved severe pain; stimulates the parasympathetic nervous system, which slows the heart rate |
| dysrhythmia | any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart |
| imperceptible | a pulse you are unable to feel at all |
| What do you do when taking the pulse? | Note the rate, the rhythm, and the volume or strength of the pulse |
| Factors that influence pulse rates | acute pain/anxiety, age, exercise, fever/heat, hemorrhage, medications, metabolism, postural changes, pulmonary conditions, unrelieved severe pain/chronic pain |
| absent pulse (0) | none felt |
| Thready pulse (1+) | Difficult to feel; not palpable when only slight pressure applied |
| weak pulse (2+) | somewhat stronger than a thready pulse but not palpable when light pressure applied |
| normal pulse (3+) | easily felt but not palpable when moderate pressure applied |
| bounding pulse (4+) | feels full & springlike even under moderate pressure |
| What does a pulse deficit signifies? | the pumping action of the heart is faulty or there is a peripheral vascular issue |
| What are all the pulse sites? | temporal, carotid, apical, brachial, radial, femoral, popliteal, dorsalis pedis |
| pulse deficit | a difference between the radial and the apical rates |
| respiration | the taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; act of breathing is internal & external |
| internal respiration | refers to the exchange of gas at the tissue level caused by the process of cellular oxidation |
| external respiration | breathing movements of the patient that are observed |
| what is the rate of respiration controlled by? | medulla oblongata |
| Two parts of external respiration | inspiration & expiration |
| inspiration | inhaling air with oxygen into the lungs |
| expiration | exhaling air with carbon dioxide out of the lungs |
| tachypnea | a rapid respiratory rate |
| bradypnea | slow respiratory rate, below 10 per minute |
| when assessing respirations what do you note? | the rate, depth, the quality, & the rhythm |
| dyspnea | breathing with difficulty |
| Cheyne-Stokes respirations | an abnormal pattern of respiration characterized by alternating period of apnea and deep rapid breathing |
| point of maximal impulse | is at 5th intercostal space. MCL, midclavicular line; PMI, point of maximal impulse |
| Hypoventilation | occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs |
| Factors that influence respiration | acute pain, age, body position, brainstem injury, disease or illness, exercise, fever, gender, hemoglobin function, medications, smoking, stress |
| blood pressure | the pressure exerted by the circulation volume of blood on the arterial walls, the veins, and the chambers of the heart |
| systolic pressure | the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries |
| diastolic pressure | lower number represents the pressure within the artery between beats, that is, between contractions of the atria or the ventricles, when blood enters the relaxed chambers from the systemic circulation and the lungs |
| pulse pressure | difference between the two readings systolic/diastolic |
| cardiac output | the amount of blood discharged from the heart per minute |
| prehypertension | values of 120-139/80-89 mm Hg |
| hypertension | occurs when the elevated pressure is sustained above 140/90 mm Hg |
| kussmaul | rapid, deep labored respirations |
| what are the patterns of respiration? | normal, hyperventilation, bradypnea, sighing, tachypnea, Cheyenne-Stokes, Kussmaul |
| Hypertension is | most common form |
| Risk factors for hypertension | history of hypertension, obesity, smoking, heavy alcohol consumption, elevated blood cholesterol level & stress |
| hypotension | blood pressure below normal |
| orthostatic hypotension | a drop of 25mm Hg in systolic pressure and a drop of 10mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position |
| factors that influence blood pressure | age, alcohol & tobacco use, anxiety, diet, diurnal (happening daily), gender, hormones, medications, obesity, race |
| sphygmomanometer | device for measuring the arterial blood pressure |
| Korotkoff sounds | pulsating sounds from brachial artery |
| Stage 2 hypertension | 160 or higher -100 or higher |
| hypertensive crisis | higher than 180-higher than 110 |
| Lowers pressure | hemorrhage, general anesthesia, & postural change |
| Raises pressure | increased intracranial pressure, acute pain, end-stage renal disease, primary essential hypertension, exercise, & smoking |
| why is height and weight determination important? | it helps assess normal growth and development, aids in proper drug dosage calculation, and often is used to assess the effectiveness of drug therapy such as diuretics |
| When weighing a patient what should you do? | weigh them at the same time of day, same scale, & the same type of clothing |
| how should you approach patient while setting up for vital signs? | calm and caring manner |
| when are vital signs best measured? | inactive (at rest) and the environment is controlled for comfort |
| What is no longer in use because of the danger of mercury toxicity? | use of in-glassmercury thermometers |
| who should you not perform rectal temp measurements on? | newborns, infants, or adults with rectal alterations |
| tympanic route | most accessible and acceptable site for measuring core body temperature |
| why would you assess presence & character of peripheral pulses | to determine the adequacy of peripheral blood flow |
| When is the automatic blood pressure cuff useful? | for home use if the patient or caregiver has hearing difficulties |
| When measuring vital signs what can happen? | a change in one has the potential to alter the others |
