Vital Signs
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| Body temperature is the difference between __. | the amount of heat produced by body processes and the amount of heat lost to the external environment.
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| Body surface temperatures fluctuate usually within a range of __. | 36 °C to 38 °C (96.8 °F to 100.4 °F)
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| The balance between heat lost and heat produced. | Thermoregulation
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| The __ controls heat loss, while the ___ controls heat production. | anterior hypothalamus, posterior hypothalamus
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| Heat production can occur through? | Metabolism, Shivering, and Excessive muscle activity (as seen with exercise).
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| Heat loss can occur from? | Radiation, Conduction, Convection, or Diaphoresis and Evaporation.
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| Radiation | Transfer of heat from the surface of one object to the surface of another without direct contact between the two.
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| Conduction | Transfer of heat from one object to another with direct contact.
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| Convection | Transfer of heat away by air movement.
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| Diaphoresis and evaporation | Transfer of heat energy when a liquid is changed to a gas.
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| Celsius to Fahrenheit Formula | C=(F-32 degrees)X.55
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| Name a major disadvantage of a rectal thermometer. | Risk of transferring nosocomial Clostridium infections rectally.
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| Name one disadvantage of a Tympanic Thermometer (ear). | More variability of measurement than other core temperature devices.
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| Which thermometer provides accurate body core temperature? | Tympanic Thermometer
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| Assess for signs and symptoms that may accompany temperature alterations such as __. | Fever, Hyperthermia, Heatstroke, and Hypothermia.
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| In what direction should the nurse pull the pinna of the adult when taking a tympanic temperature? | Up, then backward and out.
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| You remove Mary Helen’s blanket and turn a fan on in the room. By what mechanism will this help lower Mary Helen’s temperature? | Convection – the transfer of heat away by air movement.
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| Vital signs are import indicators of the body's ___. | physiologic status and response to physical, environmental, and psychological stressors.
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| You should always obtain a baseline measurement of vital signs on first contact with a client to provide a means for ___. | comparison with subsequent vital sign measurements.
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| Vital Signs are important indicators of the body’s____. | physiologic status
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| Vital signs consist of ___. | temperature, pulse, respiration, blood pressure, and oxygen saturation.
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| Vital signs reveal sudden changes in a client’s condition, as well as changes that occur ____. | progressively
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| Acceptable Range of Respiration for an adult. | 12-20 breaths per minute.
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| Acceptable Range of Heart Rate for an adult. | 60-100 beats per minute.
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| Normal SpO2 is ___. | 90% to 100%. Between 85% and 89% may be acceptable for certain chronic disease conditions. Less than 85% is considered abnormal.
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| Aortic distention creates a ___ that travels rapidly toward the extremities. | pulse wave
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| The ___ is the palpable bounding of the blood flow. | pulse
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| Pulse rate, rhythm, and strength indirectly evaluate the heart's ___. | cardiac output (CO)
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| The strength or amplitude of a pulse reflects the volume of blood ejected against the arterial wall with each heart contraction, also called ___. | stroke volume (SV)
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| The integrity of peripheral pulses indicates the status of ___ to the area distributed by the pulse. | blood perfusion
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| A decrease in fluid volume will result in an ___ heart rate as the body attempts to increase cardiac output. | increased
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| If the client has been active, wait ___ before assessing the pulse. | 5 to 10 minutes
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| Bradycardia is when a client's heart rate ___. | falls below 60 beats per minute.
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| Tachycardia is when a client's heart rate ___. | is above 100 beats per minute.
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| All excessively fast or slow pulses should be counted for ____ rather than 30 seconds multiplied by two. | 60 seconds/1 full minute
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| Whenever there is abnormality in rate, rhythm, or amplitude, it is best to take an ___. | apical pulse
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| The ___ of the stethoscope is best for transmitting an apical pulse, since the pulse is a high-pitched sound. | diaphragm
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| The ___ is best for transmitting low-pitched sounds, so it is used for other assessments such as detecting heart murmurs. | bell
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| An inefficient contraction of the heart that does not transmit a pulse wave to the peripheral pulse site creates a ___. | pulse deficit.
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| The pulse deficit reflects the number of ____ in 1 minute. | ineffective cardiac contractions
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| The mechanism of ___ exchanges oxygen (O2) and carbon dioxide (CO2) between cells of the body and the atmosphere. | respiration
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| Ventilation | Mechanical movement of gases into and out of the lungs.
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| Diffusion | Movement of O2 and CO2 between the alveoli and the red blood cells.
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| Perfusion | Distribution of red blood cells to and from the pulmonary capillaries.
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| You directly assess ventilation by observing the ___ of respiratory movements. | rate, depth, and rhythm.
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| Expiration is an active process only during __. | exercise, voluntary hyperventilation, and certain disease states.
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| Orthopnea | Labored breathing that occurs when lying flat and is classic symptom of left ventricular heart failure. Rapid resp. rate.
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| ______ (position) promotes full ventilation movement and lung expansion. | Standing or sitting erect
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| Decreased ___ levels lower the amount of oxygen carried in the blood, which results in increased respiratory rate to increase oxygen delivery. | hemoglobin
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| Pulse oxygen saturation (SpO2) less than ___ is often accompanied by changes in respiratory rate, depth, and rhythm. | 85%
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| CBC measures red blood cell count, volume of red blood cells, and concentration of hemoglobin, which reflects the client's capacity to carry __. | O2
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| Hemoglobin values | Males: 14 to 18 g per 100 mL and Females: 12 to 16 g per 100 mL.
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| Hematocrit values | Males: 40% to 54% and Females: 38% to 47%.
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| Red blood cell count | Males: 4.6 to 6.2 million per mm3 and Females: 4.2 to 5.4 million per mm3.
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| Human pH values | 7.35 to 7.47
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| Arterial carbon dioxide saturation | 35 – 45 mm Hg.
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| Cheyne-Stokes | Varying periods of increasing breathing depth interspersed with apnea.
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| Kussmaul's | Rapid, deep, labored breathing
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| Systolic | The force exerted against he wall of the artery when the ventricles contract.
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| Diastole is a ___ process. | passive
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| The five different sounds heard over an artery are called ___ phases. | Korotkoff
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| The difference between ____ pressure is called the pulse pressure. | systolic and diastolic.
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| Hypertension is defined as systolic BP (SBP) of ____, diastolic BP (DBP) of ___ or greater. | 40 mm Hg or greater, 90 mm Hg
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| Hypotension is generally considered present when the systolic BP falls to ___ or below. | 90 mm Hg.
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| Orthostatic hypotension, also referred to as postural hypotension, occurs when ___. | a normotensive person develops symptoms (e.g., light-headedness or dizziness) and low BP when rising to an upright position.
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| A noninvasive method of estimating arterial blood oxygen saturation by measuring oxyhemoglobin in arterial blood. | Pulse oximetry - a light-emitting diode (LED), two wavelengths of light determine oxygenated and deoxygenated hemoglobin.
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| When arterial oxygen tension falls below ___, oxygen saturation falls. | 50 mm Hg
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| To prevent ___, you should assess the skin integrity underneath the probe used for continuous monitoring every 2 hours. | tissue ischemia
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| Why is it necessary to take vital signs preoperatively? | To use for comparison during and after surgery and make sure client is not experiencing any complications such as a high fever that may contraindicate surgery or require intervention.
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| Average body temperature approximately ___. | 36 °C (96.8 °F)
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| The apical pulse it taken at the __ | .5th Intercostal Space (ICS) at the left Mid-Clavicular line (MCL).
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| Bradypnea—rate is regular but less than __ breaths per minute. | 12
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| Tachypnea—rate is regular but greater than __ breaths per minute. | 20
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| Hyperpnea—respiration is __ than normal, usually during exercise. | deeper
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| Kussmaul's—deep regular respiration, common with ___. | diabetics
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| Respiratory rate may increase when the client is in pain, but breathing becomes ___. | shallow
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| Repeating a BP too quickly will result in a false ___ reading. Wait 1 to 2 minutes to repeat a measurement, or measure the pressure in the opposite arm. | high systolic
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| The ___ controls body temperature the same way a thermostat works in the home. | hypothalamus
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| When nerve cells in the __ hypothalamus become heated beyond the set point, impulses are sent out to reduce body temperature. | anterior
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| How does hypothalamus reduce body temperature? | Induces sweating, vasodilation , and inhibition of heat production.
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| How does posterior hypothalamus induce heat conservation? | Vasoconstriction, shivering.
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| BMR | Basal metabolic rate – depends on body surface area and accounts for the heat produced by body at absolute rest.
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| What hormone affects BMR? | Thyroid – promotes breakdown of glucose and fat and increases chemical rxn in body cells.
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| Shivering increases body heat production by __. | 4-5 times greater than normal.
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| Applying an ice pack to lower body temperature is what kind of heat loss? | Conductive heat loss.
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| Peripheral vasodilation increases blood flow from the internal organs to the skin to increase heat loss. What kind of heat loss is this? | Radiation/radiant heat loss.
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| Diaphoresis is what kind of heat loss? | Evaporation
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| Which population is at most risk of heat loss or gain due to behavioral control?Infants and older adults. | (blank)
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| What factors affect body temp? | Age, exercise, hormone level, circadian rhythm, environment, and temperature alteration (fever, hyperthermia, heatstroke, hypothermia).
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| Pyrexia | Fever
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| A fever is usually not harmful if it says below __. | 39 C (102.2 F)
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| Pyrogens | bacteria and viruses that act as antigens and trigger immune system responses.
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| When a fever breaks, a client becomes __. | afebrile
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| During a febrile episode, white blood cell production is __. | stimulated
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| Increased temp reduces concentration of ___ in the blood. | iron
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| The duration and degree of fever depends on what 2 factors? | Pyrogen’s strength and the ability of the individual to respond.
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| Myocardial hypoxia produces __. | angina (chest pain)
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| Cerebral hypoxia produces __. | confusion
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| Why is oxygen therapy important during a fever? | Because increased metabolism requires addition oxygen, leaving possibility open for hypoxia.
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| Heat exhaustion occurs when __. | profuse diaphoresis results in excess water and electrolyte loss.
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| At what temp does a client suffer uncontrolled shivering? | 35 C or 95 F.
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| At what temp does skin become cyanotic? | 34.4 C or 94F – heart rate, respiratory rate, and blood pressure fall.
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| ICU measures what temperature in clients? | Core – through continuous invasive devices placed in body cavities or organs.
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| Temporal artery measurements detect temp of? | Cutaneous blood flow.
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| How long must you wait for an oral temperature is someone has eaten? | 20-30 minutes
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| What are 2 internal temperature sites? | Pulmonary artery and bladder
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| Antipyretic | Drugs that reduce fever.
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| How do nonsteroidal drugs like acetaminophen reduce fever? | through increasing heat loss.
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| The pulse is a __. | palpatable place on the body in which to measure heart beat.
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| Electrical impulses for the pulse originate from where? | the Sinoatrial (SA) node.
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| What is cardiac output? | Volume pumped by the heart in 1 minute.
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| If CO is low, pulse will be? | weaker or more difficult to palpate
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| If CO is high, pulse will be stronger, “bounding”. | (blank)
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| What factors regulate ventricular contraction and stroke volume? | Mechanical, neural and chemical factors.
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| Where is the brachial pulse? | Grove between biceps and tricepts muscles at antecubital fossa.
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| Where is the carotid pulse? | Along medial edge of sternocleidomastoid mucle in neck.
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| Where is the Posterior tibial pulse? | Inner side of ankle, below medial malleolus.
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| Where is the Dorsalis pedis pulse? | ”Pedal Pulse” – Along top of foot, between extension tendons of great and first toe.
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| Which pulses are easiest to palpate? | radial or carotid arteries
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| Where is PMI (point of maximal Impulse) in an adult? | Apical impulse – at the apex of heart.
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| Pulse deficits are often associated with ___. | abnormal rhythms.
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| A __ threatens the heart’s ability to provide adequate cardiac output, particularly if it occurs respectively. | dysrhythmia
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| To document a dysrhythmia, a __ is needed. | electrocardiogram, Holter monitor, or telemetry.
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| Peripheral resistance | Determined by vasculature tone – how elastic.
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| Name factors that influence blood pressure. | Age, stress, ethnicity, gender, daily variation, medications, activity, weight, smoking.
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| Stage 2 hypertension occurs above __. | 160 systolic or 100 diastolic.
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| Assessment of BP and pulse evaluates __. | the general state of cardiovascular health.
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| What does a drop in respiration after a head injury indicate? | significant injury to the brain stem.
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| What can abdominal trauma due to affect respiration? | damage phrenic nerve which is responsible for diaphragmatic contraction.
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| The usual range of respiratory rate __ throughout life. | declines
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| Biot’s respiration | Abnormally shallow for 2-3 breaths, followed by apnea periods.
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| What affects Sa02? | Factors that interfere with ventilation, perfusion, or diffusion.
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| Why is SvO2 lower? | Because tissues have removed some of the oxygen from hemoglobin molecules.
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| What is typical value of Sv02? | 70%.
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| What determines hematocrit? | Percentage of RBCs in blood.
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| What is preferred position for blood pressure? | sitting
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| Client's temperature is 36.1° C (97° F) and remaining vital signs are in the normally acceptable range. What should the nurse do next? | If everything seems satisfactory, the nurse should chart the temperature and check the client for signs of hypothermia.
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| The ___ are usually used to assess a client in shock. | carotid or femoral pulses
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| The ___ pulse gives the nurse the most information and accuracy when assessing irregular cardiac rhythm. | apical
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| With a fever, therapies such as tepid water or alcohol sponge baths should be avoided because they lead to ___, which stimulates body heat. | shivering
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| ___ respiration is an irregular respiratory rate and depth w/alternating periods of apnea and hyperventilation; it begins with slow breaths and climaxes in apnea before respiration resumes. | Cheyne-Stokes
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Created by:
Ladystorm