17-Vital Signs Flashcard | Flashcards-library.com

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assessment of vital or critical physiological functions; temp, pulse, respirations, blood pressure, pain

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vital signs

assessment of vital or critical physiological functions; temp, pulse, respirations, blood pressure, pain

although stable vital signs indicate physiological well-being,

they do not guarantee it; may remain stable in the presence of moderately large blood loss

pulse oximetry

assessing oxygenation

common occasions for assessing VS

admission to hospital; vistit to doctor; before, during, after surgery or special procedures; monitor effects of certain meds or activities; changes in patient's condition

frequency of assessing VS

in hospital- once every 4-8 hrs; home health setting- each visit; clinic- each visit; skilled nursing facilities- weekly to monthly

if VS vary from normal assess and document

every 5-15 min

initial measurement of VS is to

establish baseline; reason- a change in VS caused by disease state, effect of therapies, or change in activity/environment; and there are normal variations in VS

if VS not in normal range will be documented on

nurses' notes, along with symptoms; document any intervention as well

body temperature

degree of heat maintained by the body; diff between heat produced by the body and heat lost to the environment

need to knows for assess/support body temp

normal temp range, how heat is produced by and lost from the body, factors that influence body temp

body temp fluctuates w/

age, exercise, environmental conditions

core temperature

adult's internal temp; ususally 1-2 degree higher than surface temp; rectal and tympanic measurements

average temp

98-98.6

normal range

96.2-100.4

surface temp

oral and axillary measurements

degree of temp elevation doesn't always indicate seriousness of the disease or condition

some acute, even fatal infections may cause mild temp elevation; continuously elevated temp even slight always cause for concern

thermoregulation

process of temp regulation; body must balance heat production and heat loss; controlled by the hypothalamus- can recognize small changes

decreasing body temp

activates peripheral vasodilation, sweating, inhibition of heat production

increasing body temp

reacts with shivering and release of epinephrine which increases metabolism; blood vessels constrict

piloerection

goose bumps; not an important heat-conserving mechanism

behavioral control of temp

put on clothes in the cold, remove or take cold shower in the heat

body produces heat by

metabolism, movement of skeletal muscles, and nonshivering thermogenesis

metabolism

uses energy and generates heat; basal metabolic rate (BMR)- energy required to maintain the body at rest, influenced by body size, lean muscle mass, numerous hormones

hyperthyroidism

increases BMR

hypothyroidism

less heat produced; feel cold

shivering

body heat production can rise to about 4X the normal rate injust a few minutes

nonshivering thermogenesis

metabolism of brown fat to produce heat; used by infants- they cannot produce heat through shivering; disappears in the first few months following birth

exchange of hear between the body and the environment

radiation, convection, evaporation and conduction

radiation

loss of heat through electromagnetic waves emitting from surfaces that are warmer than the surrounding air; room warms by radiation when filled with people; accounts for almost 50% of body heat loss

convection

transfer of heat through currents of air or water; immerision in a warm bath may raise body tem; currents of cool fan reduce fever; accounts for 15-20% of all heat loss

evaporation

water is converted to vapor and lost from the skin or mucous membranes

insensible loss

loss by evaporation

conduction

process whereby heat is transferred from a warm to a cool surface by direct contact

influenced on body temp

developmental level, environmental temp, hormones, exercise, emotions and stress, circadian rhythm

developmental level

infants and older adults are most susceptible to the effects of environmental temp extremes; infants lose approx 30% of heat through head; older adults diff maintaining temp because of slower metabolism, decreased vasomotor control, and loss of subcutaneious tissue

common for older adults to have temp of

95 in the morning

environmental temp

warm room, hot bath increase body temp; very high can cause heat stroke; cold lead to hypothermia

hormones

womans body temp varies 1F with menstrual cycle; temp lower when progesterone levels are low, increase when progesterone rise

hot flashes

fluctuations of body temp during menopause

exercise

101-104F temp

emotions and stress

emotional stress, excitement, anxiety adn nervousness stimulat the sympathetic nervous system, producing epinephrine and norepinephrine, these increase metabolic rate and body temp

circadian rhytm

cyclical repetition of certain physiological processes (change in body temp, blood pressure) every 24 hrs; temp lowest early morning, highest late afternoon; fluctuate daily 1-2 degree

F to C

(F-32)x 5/9

advantages of glass thermometers

flexibility of use: oral, rectal, axillary; inexpensive initial cost; accuracy; easily disinfected

disadvantages of glass thermometers

fragile, slow (3-6 min); difficult for some to read

advantage of electronic thermometers

flexibility of use: oral, rectal, axillary, ease of use, fast (15-45 sec)

disadvantage of electronic thermometers

expensive, requires frequent calibration, conflicting data about accuracy, need to keep charged

advantages of infrared tympanic membrane thermometer

ease of use, fast (2-5 sec), most cost-effective

disadvantages of infrared tympanic membrane thermometer

expensive, less accurate, require frequent calibration, batteries

disposable chemical thermometer

not used very much

to obtain comparative oral temp

axillary reading add .9; rectal reading subtract .9; tympanic membrane reading subtract 1.1-1.5

advantages of oral temp

simple, convenient, comfortable

disadvantages of oral temp

eating/drinking affect accuracy; mouth closed; exposure to body fluids; slow; contraindicated for some clients

advantages of rectal temp

most accurate of core (internal) body temp

disadvantages of rectal temp

injury to rectal mucosa; embarrassing; special positioning; does not reflect changes in core temp as rapid as oral; exposure to body fluids; presence of stool may cause inaccurate reading

contraindication of rectal temp

clients who may be injured by the method; clients with cardiac surgury; can slow the heart rate by stimulating the vagus nerve

advantages of axillary temp

can be used on newborns, children, uncooperative or unconscious clients

disadvantages of axillary temp

least accurate; slow; diaphoresis can affect reading

advantages of tympanic membrane temp

fast

disadvantages of tympanic membrane temp

expensive initial purchase; hearing aids removed; cerumen may affect accuracy

fever

pyrexia; abnormally high body temp >100.4; occurs in response to pyrogens; phagocytes ingest the invaders and secrete pyrogens, pyrogens induce secretion of prostaglandins that reset the hypothalamic thermostat at a higher temp

hyperpyrexia

fever above 105.8

initial phase (febrile episode or onset) of fever

temp is rising but has not yet reached new set point; may be sudden or gradual; feeling of chilly, uncomfortable and shivers

second phase (course) of fever

temp reaches max (set point) and remains fairly constant at the new higher level

third phase (defervescence or crisis) of fever

temp returns to normal; feeling of warmth, appears flushed in response to vasodilation; diaphoresis occurs, fever breaks

4 types of fever

intermittent, remittent, constant, relapsing

intermittent fever

temp alternates regularly between fever and normal/below normal temp

remittent fever

wide fluctuations in temp >3.6, all above normal, during 24 hr period

constant (sustained) fever

temp may fluctuate slightly but is always above normal

relapsing fever

short periods of fever alternating with periods of normal temps, each lasting 1-2 days

high temps up to 102.2 benefit the body by

enhancing the immune response because they kill/inhibit growth of many MO; enhance phagocytosis; cause breakdown of lysosomes and self-destruction of virally infected cells; cause the release of interferon (protects cells from viral infections)

very high temps 106 or greater can

damage cells throughout the body especially the brain, causing agitation, confusion, stupor or coma

death results in body temp

higher than 109-112

hyperthermia

above normal body temp, fatigue, warm, flushed, increased heart rate; >96.8

ineffective thermoregulation

temp fluctuates above/below the normal range

risk for imbalanced body temp

temp is normal but client at risk for failure to maintain body temp w/in normal range

hypovolemia

fluid deficiency

severe hypothermia

body temp drops below 82.4; death usually results body temp <70-75F

ischemia

lack of oxygen

pulse

rhythmic expansion of an artery produced when a bolus of blood is forced into it by contractions of the heart

normal pulse range

60-100 bpm; average 70-80

cardiac monitor to determine

rate, rhythm, and pattern of pulse

stroke volume

quantity of blood forced out by each contraction of the left ventricle; ave 70 mL; if decreases, body tries to maintain same cardiac output b increasing the pulse rate

cardiac output

total quantity of blood pumped per minute

cardiac output=

stroke volume x pulse (heart) rate

pulse rate is regulated by

autonomic nervous system; sympahtetic stimulation increases the heart rate (and thus the cardiac output); parasympathetic stimulation decreases it

pulse changes in response to

changes in teh volume of blood pumped through the heart, variations in heart rate, changes in the elasticity of the arterial walls, or any condition that interferes with the functioning of the heart

conditions that interfere with normal functioning of the nervous system

also affect the pulse

factors that may cause variations in pulse rate, rhythm, or quality include

age; sex; exercise; food; stress; fever; disease; blood loss; position changes; medications

age

newborn rapid pulse rate

sex

females slightly faster

exercise

increase pulse rate but people who exercise regularly have lower heart rates

food

ingestion slight increase for several hours

stress

fight/flight sympathetic nervous system response

fever

increase 10 bpm fore each degree

disease

heart disease, hyperthyroidism, respiratory diseases and infections increase pulse rate; hypothyroidism decreased pulse rate

blood loss

large loss stimulates the sympathetic nervous system; stable pulse and blood pressure do not by themselves guarantedd that there has been no blood loss

position changes

standing/sitting temporary increase in pulse rate and decrease in blood pressure as a result of blood pooling in the veins of the feet and legs, this decreases blood return to the heart, decreasing blood pressure and subsequently increasing heart rate

medications

stimulant drugs increase pulse rate; cardiotonics and opioids or sedatives decrease pulse rate

bell of stethoscope

hear low-frequency sounds

diaphragm of stethoscope

hear high-frequency sounds

apical pulse

apex of heart; use when radial pulse is weak or irregular, less than 60 or higher than 100 bpm; patient taking cardiac meds, assessing infants and child up to 3 yrs

peripheral pulses

radial, brachial, dorsalis pedis, posterior tibial, carotid, femoral, popliteal, temporal arteries

radial artery

most common; for routine assessment of VS

brachial artery

when performing CPR of infants

carotid artery

CPR of adults and assessing circulation to the brain

femoral artery

infants and children to determine circulation to the legs, and in cases of cardiac arrest

dorsalis pedis (pedal pulse) and posterior tibial arteries

assessing peripheral circulation

popliteal artery

assessing circulation to the lower leg

finding apical pulse

anterior chest 3" or less to the left of the sternum, 4,5,6th intercostal space at the midclavicular line

pulse deficit

difference between apical and radial pulse; not all apex beats are being transmitted or felt at the radial artery

rate

beats/min; if irregular count for full minute

bradycardia

rates below 60 bpm

tachycardia

rates above 100 bpm

rhythm

pulse pattern between heartbeats

dysrhythmia

abnormal rhythm; too early, too late, or group of irregular beats

regularly-irregular rhythm

irregular rhythm that forms a pattern

irregularly-irregular rhythm

unpredictable rhythm

electrocardiogram

traces the electrical pattern of the heart

quality

pulse volume and bilateral equality of pulses

pulse volume

amount of force produced by the blood pulsing through the arteries 0-3

0 pulse volume

absent; pulse cant be felt

1 pulse volume

weak, thready; pulse barely felt

2 pulse volume

normal quality; easily palpated, not weak or bounding

3 pulse volume

bounding or full; easily felt with little pressure; not easily obliterated

bilateral equality

used to determine whether the blood flow to a body part is adequate

pallor

paleness of skin compared to another part of the body

ineffective tissue perfusion (peripheral)

absent/weak pulse, cool, pale skin is present

respiration

exchange of O2 and CO2

pulmonary ventilation (breathing)

active movement of air into and out of the respiratory system

external respiration

exchange of O and CO2 between the alveoli and the pulmonary blood supply

gas transport

transport of these gases throughout the body

internal respiration

exchange of gases between capillaries and the body tissue cells

how does body regulate respiration

centers in the medulla oblongata and pons, nerve fibers of teh ANS, regulate breathing in response to minute changes in teh O and CO2 in the arterial blood

primary stimulus for breathing

leve of CO2 tension in the blood

central chemoreceptors

located int eh respiratory centers; sensitive to CO2 and pH concentrations

peripheral chemoreceptors

in carotid and aortic bodies stimuate respiration; Partial pressure of O in arterial blood falls below 100 Hg

inspiration

diaphragm contracts, drawing air into the lungs; 1-1.5 sec

expiration

diaphragm relaxes; passive, 2-3 sec

influences on breathing

age, exercise, pain, stress, smoking, fever, pulse rate, hemoglobin, disease, meds, position

infant respiration

40-90 breaths per minute

adult respirations

12-20 breaths per minute

pain and breathing

acute pain increases respiration but a decreased depth

fever and breathing

for every 1F increase, breaths increase up to 4 per minute

respiratory rate: pulse rate

1:4

hemoglobin and breathing

respiratory rate and depth increase as a result of anemia, sickle cell anemia, high altitudes

meds and breathing

CNS depressants such as morphine or general anesthetics cause slower, deeper respirations; caffeine and atropine cause shallow fast breathing

position and breathing

respiratory depth is max by standing, hampered by lying flat

apnea for more than 4-6 min

brain damage and even death occurs

tachypnea (polypnea)

abnormally fast breathing

eupnea

respirations that fall within normal parameters

tidal volume

amount of air taken in on inspiration; 300-500 mL normal

respiratory depth described as

deep, shallow, normal

rhythm

normal/abnormal; period between each respiratory cycle is the same, regular breathing pattern

infant rhythm more irregular

than adult rhythms

Biot's respirations

periods of respirations of equal depth, alternating with periods of apnea

Cheyne-Stokes respirations

gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea

respiratory effort

degree of work required to breath

dyspnea

labored breathing

orthopnea

inability to breathe when in a horizontal position

wheezes

high-pitched, narrowing of the airways

rhonchi

low-pitched, caused by secretions in teh large airways; cleared by coughing

crackles

discontinuous sounds; high-pitched, popping sounds, or low-pitched, bubbling sounds

stridor

piercing, high pitched sound in infants who are experiencing respiratory distress

stertor

labored breathing that produces a snoring sound

intercostal retraction

visible sinking of tissues around and between the rigs that occurs when the person needs to make additional effort to breathe

substernal retraction

tissues are drawn in beneath the sternum

suprasternal retraction

tissues are drawn in above the clavicle

arterial blood gas

sampling directly measures the partial pressures of O and CO2 and blood pH

noninvasive monitoring respiratory status

pulse oximeter- measures oxygen saturation

hyperventilation

rapid deep breathing, excess loss of CO2 (hypocapnia)

hypoventilation

rate and depth of respirations are decreased and CO2 is retained or alveolar ventilation is compromised

blood pressure

important indicator of overal CV health

systolic pressure

peak pressure

diastolic pressure

trough pressure; at rest

pulse pressure

difference between systolic and diastolic pressures; ex 120/80, pulse pressure 40 mm Hg; indication of the volume output of the left ventricle, shouldnt be more than 1/3 of the systolic pressure

blood pressue influenced by

cardiac function, peripheral vascular resistance, and blood volume

change in either stroke volume or heart rate alters

cardiac output

conditions taht increase cardiac output by increasing stroke volume include

increased blood volume, more forceful contraction of teh ventricles

conditions that decrease cardiac output by decreasing stroke volume include

dehydration, active bleeding, damage to the heart, very rapid heart rate

peripheral resistance

arterial and capillary resistance to blood flow as a result of friction between blood and the vessel wall; friction depends on viscosity and arterial size and compliance (elasticity)

viscosity

determined by percentage of red blood cells in plasma (hematocrit)

arterial size and compliance

constricted arteries prevent the free flow of blood, increase BP; dilated arteries allow unrestricted flow of blood, decrease BP; sympathetic nervous system controls vasoconstriction and vasodilation

arteriosclerosis

common contributor to increased BP in middle-aged and older adults

normal volume of blood in the body

5000 mL

some factors that affect BP

age, sex, family history, lifestyle, exercise, body position, stress, pain, race, obesity, diurnal variations, meds, disease

sex and BP

men slightly higher, in women slight increase after menopause (due to increased estrogen)

lifestyle and BP

increased Na consumption, smoking, alcohol (3 or more/day); all increase BP; caffeine may raise BP for a short time

body position and BP

higher when standing; readings higher if taken with arm above heart or if arm is unsupported at the client's side; dangling feet higher

pain and BP

increase, severe pain can decrease BP

race and BP

AA higher rate of hypertension

obesity and BP

increase

diurnal variations and BP

BP varies according to person's daily schedules and routines

aneroid manometers

dials that register BP by pointers attached to a spring

mercury manometers

use calibrated upright tube containing mercury; most accurate

electronic blood pressure monitors

less accurate; so auscultate a baseline BP prior to initating automatic monitoring

width of the bladder fits

2/3 the length fo the upper arm, entire arm of a child

systolic pressure may be

20-30 mm Hg higher in teh lower extremities than in the arms, but diastolic pressures are similar

Korotkoff sounds

1st- tapping sound corresponds to the pulse (systolic BP); 2nd- soft, swishing sound caused by blood turbulence; 3rd- begins midway through BP, sharp, rhythmic tapping sound; 4th- like 3rd but softer, fading; 5th- silence, diastole

inflate cuff rapidly to 70 mm Hg

then palpate radial pulse slowly increasing 10 mm Hg increments

auscultatory gap

loss of sound for as much as 30 mm Hg followed by the return of sound

hypotension

systolic blood pressure is less than 100 mm Hg; problem if with dizziness, fatique, concentration problems, activity intolerance or shortness of breath or if of sudden onset

causes of hypotension

hemorrhage and heart failure

orthostatic or postural hypotension

BP drops suddenly on moving from a lying position to a sitting or standing position; decrease of 10 mm Hg w/ dizziness and/or fainting; postural hypotension results from peripheral vasodilation w/o a compensatory increase in cardiac output, more in older adults, pregnant women, prolonged bed rest, decreased blood volume

hypotension is a

medical diagnosis

primary or essential hypertension

no know cause for the BP elevation; accounts for at least 90% of all cases of hypertension

hypertension is realted to

thickening of the arterial walls and decreased elasticity of the arteries

secondarey hypertension

occurs when there is a clearly identified cause for the persistent rise in BP

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