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clinical 2 ch 11

vital signs

during initial screening pt should be observed for the following appearance, odor, gait, level of awareness,emotional state
patient intake should include chief complaint(CC); patient hx; height and weight; VS
values that are obtained through measuring mensuration
mensuration values include height, weight, circumference, vital signs
BMI body mass index
BMI less than 18.5 is underweight
BMI greater than 30 is obese
standard VS are considered temperature, pulse, respiration and blood pressure (TPR and BP)
what is considered to be the 5th VS? pain
VS provide an overall picture of the patients general state of health
temperature regulator of the body hypothalmus
structures that help regulate body temperature blood vessels, skin, neuromuscular system
to be without a fever afebrile
with fever febrile
temperature in early morning has a tendency to be lower
temperature in evening has a tendency to be higher
normal value 98.6 and most common method for temp oral
normal value 97.6 least accurate axillary
normal value 99.6, most reliable and core temp rectal
normal value 99.6 temporal artery
factors that affect accuracy of the oral temp eating, drinking, smoking, dental issues, sinus congestion, unconsciousness, lack of understanding
temporary elevation of body temperature fever
low grade fever starts at 100.4
causes of fever include infection, injury, neoplasm,connective tissue disease
pulse points temporal; carotid; apical; brachial;radial; femoral; popliteal; posterior tibial; dorsalis pedis
pulse on side of head temporal artery
pulse on side of neck carotid artery
pulse found in antecubital space used for blood pressure brachial artery
pulse on inner side of wrist, most common used radial artery
pulse found in groin femoral artery
pulse found behind the knee popliteal artery
pulse found behind the ankle posterior tibial artery
pulse found on top of foot dorsalis pedis
factors affecting pulse rate gender, level of fitness; emotional state, pregnancy, fever, medications, increase activity
rapid heart rate over 100bpm tachycardia
slow heart rate under 60bpm bradycardia
refers to amount of blood being discharged from the heart strength or volume
refers to the interval timing between measured beats rhythm
a regular pulse is counted for how long and then multiplied times 2? 30 seconds
and irregular pulse should be counted for 1 minute
if you cannot palpate a radial pulse you should do a apical pulse
the apical pulse can be heard at the 5th intercostal space, mid-clavicular line over the apex of the heart
process of inspiration and expiration respiration
respiration is controlled by the medulla oblongata
factors that affect respiration physical activity, emotional state, medications, age, infectious states
difficult or labored breathing dyspnea
rapid shallow breathing tachypnea
rapid deep breathing hyperpnea
hyperpnea is also known as hyperventilation
measurement of the amount of force exerted on arterial walls as the hearts ventricles contract and relax blood pressure
phase where ventricles contract creating the greatest force against arterial walls systole
phase where ventricles relax and have the least amount of pressure against arterial walls diastole
always recorded as the top number of blood pressure systolic
always recorded as the bottom number of blood pressure diastolic
the difference between the systolic and diastolic pressure pulse pressure
sounds heard during blood pressure measurement Korotkoff sounds
Korotkoff sounds include tapping, swishing, knocking, muffling, silence
normal BP for adults <120/80
elevated or controlled HTN 130/90
stage 1 hypertension 130-139/ 80-89
stage 2 hypertension >140/90
measurement of amount of arterial oxygen saturation in the blood pulse oximetery
oxygen saturation that requires intervention less than 95%(94% and below)
normal resp rate for newborns 30-60/min
normal resp rate for adults 12-16/min
normal pulse for athletes less than 60bpm
normal pulse for adults(>10yrs) 60-100bpm
period of silence between phase one and phase two of korotkoff sounds ausculatory gap
numeric difference between the apical pulse and radial pulse pulse deficit; may indicate an arrhythmia
easier breathing while sitting or standing orthopnea
blood pressure that drops with a change in position, usually from lying to standing orthostatic hypotension
elevated blood pressure hypertension
low blood pressure hypotension
normal HR for newborns 140-160bpm
normal BP for newborns 60-70/30-40
normal HR for children 3-10yrs 60-120bpm
normal RR for children age 3-10yrs 18-30/min
normal BP for children 3-10yrs 80-120/40-80
deep breathing followed by periods of apnea; usually preceeds death Cheyne-Stokes breathing
irregural and unpredictable breathing pattern indicating brain damage Ataxic breathing
wet sounding breath sounds usually heard with CHF or pneumonia rales
course or snore like breath sounds usually heard with bronchitis or an URI rhonchi
high pitched whistle like breath sound usually heard with asthma and COPD wheezing
barky seal like sound associated with croup stridor
creaking crackle sounds usually indicating inflammation of the pleural mambreanes pleural rub
piece of equipment that actually measures the BP sphygmomanometer
T 100.4-101 low grade fever
T101-103 moderate fever
T 103-105 high grade fever
T >105 hyperpyrexia
antipyretics ibuprofen and acetaminophen
hypertensive crisis >180/120
Created by: clarevoyant1019