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