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Vital Signs
Module D Lee- 102 Vital Signs -Calhoun
| Question | Answer |
|---|---|
| 96.8-100.4 | Adult Temperature |
| 98.6 | Young Child |
| 96.8 | Older Adult |
| Labor-Delivery: T, P, R, B/P | T=WNL, P=Increased, R=Increased, B/P=Slight Increase |
| Pregnancy: T, P, R, B/P | T and P= Slight Increase, R and B/P= WNL |
| Post-Partum: T, P, R, B/P | Increased up to 100.4, P= Transient, R and B/P= WNL |
| Newborns AX Temperture: | 95.9-99.5 |
| Newborns Pulse: | 120-160 |
| Newborns Respirations: | 30-60 |
| Newborns B/P: | Systolic= 63/70 Diastolic= 40/50 |
| F.H.R. Pulse: | 120-160 |
| Young Child/Pulse: | Average 90 |
| Young Child/Respirations: | 20-30 |
| Young Child B/P | 95/65 |
| Older Adult/Pulse: | >80 |
| Older Adult/Repirations: | 12-20 |
| Older Adult B/P | Sysolic 140/160 Diastolic 80/90 |
| Adult Pulse Pressure: | 30-50 mm Hg |
| When should vital signs be taken? | before, during, & after giving blood, ambulation, & change in mental status |
| If Md orders medications that effect cardiovascular system.. Nurse will need to... | Monitor pulse or B/P & Teach patient how to take V/S & the importance |
| This is an essential ingredient to determine pts health status.. | Vital Signs |
| Who teaches Techs about Vital Signs or other deligatable care for the patient... | Nurse |
| Baseline measurement ... | give us V/S we can compare future V/S with. |
| When would you have another nurse recheck V/S? | If there abnormal |
| Report abnormal V/S to... | MD or Charge Nurse |
| ....cannot shiver!!! | Neonate |
| Radiation | Transfer of heat without direct contact of two surfaces. |
| Conduction | Transfer of heat to another object during contact. |
| Convection | Transfer of heat away by air movement. |
| Evaporation | Conversion of liquid to a gas |
| Core Temperature | Most accurate reading that comes from the deep tissues in the body. |
| Loss 30% of heat through head... | Newborn's |
| Hypothermia Range for older adults ... | 94 degrees & below |
| Vasomotor Controls | Hot flashes, vasoconstriction & vasodialation |
| This can alter temperature set points... | Disease |
| Temperature is lowest at... | 1:00 AM To 4:00 AM |
| Temperature is highest at... | 10:00 AM To 6:00 PM |
| Normally changes 0.9 to 1.8 degrees... | In a 24 hour period |
| Rectal Temperature lubercate... | 1 to 1 1/2" adult |
| Hold in place for 3 minutes.. | Axillae thermometer |
| Tympanic Membrane taken with right hand in.. | right ear or (left handed/left ear)Point speculum toward nose, small figure 8 in ear. |
| Pull ear pinna backward, up, & out... | Adult |
| Pull pinna down & back... | Child 3 or older |
| Pull pinna up & back... | Child older than 3 |
| Don't use Oral Temperature on these patient's.. | Surgery, trauma, Epilepsy, Confused, Unconscious, Uncooperative, Shaking, Chills, Infants & Small children. |
| Temperature affected by theses... | Ingestion of fluids/food, smoke, & oxygen delivery. |
| May lag behind core temperature during rapid temperature changes.... | Rectal, Axillae, Cutaneous Temperatures |
| Not recommended to detect temperature in Infants & Young Children... | Axillae |
| Not recommended to detect temperature in Infants & Young Children... | Axillae |
| Not use for routine V/S in newborns (birth to 8 weeks) | Rectal temperature |
| Axillae can be used for.. | Newborns & uncooperative patients |
| Accurate Core Reading, very rapid measurement (2 to 5 secs), & can be used for tachypnea patients.... | Tympanic Membrane |
| Not accurate core temp. after exercising... | Tympanic Membrane |
| Cannot obtain continuous measurements... | Tympanic Membrane |
| Provides continuous readings & can be used on neonates... | Cutaneous Temp. Site |
| Sweating , environmental temp, chill phase of fever cause it to be unreliable... | Cutaneous Temp. Site |
| Hypothalamus | Controls body temperatures "Set Point" |
| Anterior Hypothalamus controls.. | heat loss |
| Posterior Hypothalamus controls.. | heat production |
| Hyperpyrexia | Fever (not harmful if stays under 102.2 F)Pulse & Respirations increase |
| Malignant Hyperthermia: | Hereditary, Uncontrolled heat production when susceptible people receive certain anestetics. |
| Heat Exhaustion: | Environmental heat exposure, profuse diaphoresis excess loss of H20/Electrolytes, S/S:Increased heart rate, dry mucous membranes, thirst, lethargy, poor skin turgor, & confusion; Place in cooler environment, give fluids/elctrolytes. |
| Heat Stroke: | Emergency!!! Treat Immediately!! S/S: hot, dry skin, confusion, delirium, incoherent, may be unresponsive; Place them out of the sun, fan person, pour cool water on them & PO fluids Call 911 |
| Heat Stroke: | Emergency!!! Treat Immediately!! S/S: hot, dry skin, confusion, delirium, incoherent, may be unresponsive; Place them out of the sun, fan person, pour cool water on them & PO fluids Call 911 |
| Pulse | Palpable bounding of blood flow in the peripheral arteries. Indicates circulatory status. |
| Assess pulse for... | Rate, Rhythm, Strength, & Equality |
| Rate | Beats per minute |
| Rhythm | The pattern of the beats & the intervals between the beats (Regular or Irregular) |
| Strength | The force of blood against the arterial wall with each beat. |
| Equality | Compare one side to the other side (should be the same (Symmetrical) |
| Pulse site used in children when radial not accessible.. | Temporal pulse |
| Pulse site used during physological shock or Cardiac arrest... | Carotid pulse & (Femoral Pulse if Carotid not palpable) |
| Pulse site best for infants or young children up to age 3.... | Brachial & Apical |
| This Pulse site is used to determine discrepancies with radial pulse.... | Apical Pulse |
| If abnomal/intermittent, or inaccessible use this pulse site... | Apical Pulse |
| Assessment of these two pulse sites reveal heart rate variations.... | Peripheral & apical Pulse |
| This pulse site provides a more accurate assessment of heart functions when patient takes medications that effect the heart rate... | Apical Pulse |
| Provides a more accurate assessment of cardiac contraction... | Apical Pulse |
| Pulse sites used to Assess circulation to hand ... | Radial & Ulnar Pulse |
| Pulse site routinely used... | Radial Pulse |
| Pulse sites used to Assess circulation to hand ... | Radial & Ulnar Pulse |
| Pulse site routinely used... | Radial Pulse |
| How do you get a childs heart who has sinus dysrhythmia to become regular? | Have child hold breath |
| Some Drugs, Anxiety, Fear, Stress, Fever, Heat, emotions, Hemorrhage, COPD, acute pain & standing or sitting cause the heart rate, cardiac output, Peripheral vascular resistance & Pulse to.... | Increase |
| Some Drugs, Hypothermia, chronic pain & lying down causes the heart rate & pulse to... | Decrease |
| Regular Pulse: | is when a regular interval occurs between each pulse or heart beat (count for 60 sec or 30 sec x 2) |
| Tachycardia: | Abnomally elevated heart rate, >100 beats per minute in adults |
| Bradycardia: | Slow rate, < 60 beats per minute in adults |
| Pulse Deficit: | is an inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site.(Frequently associated with dysrhythmias) |
| Nurse does what if there is a pulse deficit? | Compare apical & radial rates simultaneously to determine if a pulse deficit exists (two nurse assessing at same time) |
| An Irregular heart rhythm has been detected what should the nurse do next no one else is available to help her... | One examiner technique- Auscultate the apical pulse first & then the radial pulse immediately after. Report abnormal pulse rate to physician immediately! |
| Apical rate 90 & Radial rate is 70 what is the pulse deficit? | 20 is the pulse deficit (90-70=20) |
| Scale for measuring pulse Volume 0-4+ | 0- absent,not discernible, 1+ Pulse diminished, barely palpable, 2+ Normal, easily palpable, 3+ Full pulse, increased, 4+ Strong, Bounding, Cannot be obliterated |
| Respiration | The exchange of Gases between the atmosphere & the blood, & the blood & the cells. |
| Diaphragmatic | Abdominal or normal pattern of exhalation & inhalation in which the ventilatory works done in the diaphragm. |
| Dyspnea | Breathing is difficult characterized by increased effort to inhale & exhale. (uses intercostal & accessory muscles) |
| Hyperpnea | Increase in depth & rate >20/min |
| Bradypnea | Regular, decreased < 12/min |
| Tachypnea | Regular, > 20/min |
| Hyperventilation | Increased depth & rate, (excessive intake of 02 & blowing off of Co2, seen with increased anxiety.) |
| hypoventilation | rate is abnormally low & depth depressed |
| Kussmaul | Abnormally deep, but regular, increased rate |
| Biot's | Shallow breathing interrupted by irregular periods of apnea, condition of CNS, increased intracranial pressure followed by irregular period of apnea. |
| Cheyne Strokes | Irregular rate, alternating periods of apnea & hyperventilation. |
| End of life breathing also known as... | Cheyne stokes |
| Depth | Deep or Shallow |
| Systolic | Maximum pressure |
| Diastolic | Minimum pressure |
| Systolic pressure 120 minus diastolic pressure 80 what is the pulse pressure? | 40 mm/Hg (120-80= 40) |
| Peripheral Resistance | The smaller the lumen the greater peripheral vascular resistance to blood flow. As resistances rises, arterial blood pressure rises. As vessels dilate & resistance falls, blood pressure drops. |
| Blood Volume | If blood volume increases, more pressure is exerted against arterial walls & B/P increases. |
| Example of Blood Volume: | Rapid infusion of IV fluids elevates blood pressure. When circulating blood volume falls, as in hmorrhage or dehydration, blood pressure falls. |
| Viscosity | thickness of blood affects the ease with which blood flows thru small vessels. The hematocrit (HCT), or % of RBC's in the blood, determines blood viscosity. |
| Elasticity | Normal wassl of the artery are elastic & easily distensible. As pressure within the arteries increases, the diameter of the vessel walls increase to accommodate the pressure changes. |
| Cardiac Cycle Consist of two phases.. | Systole & Diastole |
| Systole | The ventricles contract & eject blood from the left ventricle into the aorta & from the right ventricle into the pulmonary artery. |
| Diastole | The ventricles relax & the atria contract to move blood into the ventricles & fill the coronary arteries. |
| Events on the.... of the heart have the most dramatic effect on assessment findings. | left side |
| Body size & age would be considered with respect to... | B/P level |
| Advancing age in adults causes B/P to... | Increase |
| Hypertension is higher, genetically & environmentally related in.. | African Americans |
| This med lowers B/P... | Antihypertensive & Narcotic analgesics |
| Diural variation | B/P gradually rises & falls throughout the day & night. No two persons have the same pattern or degree of variation. |
| Purberty & Menopause cause B/P readings to be... | Higher |
| Most common B/P problem & considered the silent killer... | Hypertension 140/90 & above |
| Prehypertension B/P... | 128/84 |
| Hypotension B/P... | systolic 90 mm/Hg or below |
| S/S of Hypotension: | Pallor, skin mottling, clamminess, confusion, increased heart rate, decreased urine output, Report to doctor immediatly |
| Orthostatics or (TILTS) | measure B/P between each position change & document each. (1 to 3 minutes between each)LYING, SITTING, & STANDING |
| Stroke value times Heart Rate = Cardiac output | 60x72= 4320 |
| The amount of blood ejected from the left ventricle each minute at adult rest.. | Cardiac Output |
Created by:
maliakaye5
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