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72 Cards in this Set
- Front
- Back
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Sign vs symptom |
Sign is objective data, symptom is subjective data. Example: measels, sign is the rash, symptom is that it is itchy. |
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Define vital |
Necessary for life. |
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Four vital signs: |
Temperature, pulse, respiratory rate, blood pressure. |
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What is the "fifth vital sign"? |
Pain another vital sign is oxygen saturation |
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Why monitor vital signs? |
First part of assessing patient condition, to identify problems, evaluate response to interventions.( getting baseline to compare) |
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How do you communicate vital sign findings? |
By charting and documenting first! |
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How do we get our body temperature? |
Body heat produced minus body heat lost to environment equals our body temperature. |
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At what temperature do you want to start interventions? |
At 102 degrees |
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Normal range for temperature is: |
96.8-100.4 degrees F or 36-38 degrees C |
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How does hormone levels affect temp? |
Estrogen during ovulation cause temp to spike. If you don't have enough thyroid hormone your temp tends to be lower. |
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What is the purpose of a fever (pyrexia)? |
The purpose is to create a hostile environment for the pathogens so that they die. |
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What does FUO stand for? |
Fever of unknown origin. |
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What is hyperthermia? |
Body is unable to promote heat loss or reduce heat production. |
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What is malignant hyperthermia? |
Is deadly, and cause an extremely high fever, is genetic, and could be a bad reaction to an anesthesia. |
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what is heatstroke? |
When you have hot, dry skin, temp greater than 104, nausea, muscle cramps, giddiness, confusion, unconscious. Temp goes up because we are unable to get RIF of body heat. |
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What is heat exhaustion? |
Profuse diaphoresis(dripping sweat), cause by environmental heat exposure. |
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What is hypothermia? |
Heat loss due to prolonged exposure to cold. Temp less than 93.2 degrees F. |
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What kind of thermometer do you need to use for hypothermia? |
Bladder or esophogeal thermometer. |
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How can we produce heat? |
By products of metabolism, activity increases metabolic rate, basal metabolic rate, voluntary muscle movement, shivering (involuntary muscle movement), nonshivering thermogenesis. |
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What types of muscle movement is non shivering thermogenisis? |
It is a sympathetic nervous system response and is usually seen in infants since they have not yet learned to shiver. |
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What are the four ways we lose heat? |
Radiation, conduction, convection, evaporation. |
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Radiation: |
Transferring own heat from our body to the environment. |
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Conduction: |
Phsycially transferring heat from one thing to another. Example cold packs, hot blankets. |
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Convection: |
Air movement is necessary. Example fan or air conditioner. |
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Evaporation: |
Requires moisture/perspiring. Example is a sponge bath if they are unable to perspire. |
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The pulse is the... |
Indirect measurement of the heart rate, they should match up but sometimes that is not the case. |
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Where do you always measure infants pulse? |
Apical site. |
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If there is no pulse what should you do? |
Palpate until you find one or use a Doppler machine to listen to the pulse. |
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Where do you find the apical pulse? |
At the 5th intercoastal space midclavicular line. On children it is the 4th intercoastal space. |
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How does fever affect the pulse? |
Increases pulse rate to circulate blood to the peripheral capillaries and radiate heat. |
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How does cardiac medications affect bp and pulse? |
Beta blockers decrease pressure and pulse. |
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Define pulse deficit: |
Peripheral and apical pulse differ. |
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Define bradycardia |
Slow heart rate |
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Define tachycardia |
Fast heart rate |
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Define dysrhythmia |
Irregular heart rate. |
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What is a normal heart rate for an adult and child? |
Adult is 60-100bpm child 1-5 is 80-120 newborn is 120-160 |
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How do you assess ventolation? |
Measuring respirations, rate, depth, and rhythm. Air in and out. |
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How do you assess diffusion and perfusion? |
By measuring oxygen saturation. Ex oximetry . |
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What happens during inspiration? |
Diaphragm contracts, ribs retract or expand, normally inhale 500ml of air. |
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What controls or regulates rhythm and depth of respirations? |
Brain stem based in oxygen, carbon dioxide, and acid levels in blood. |
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What do you need to include when assessing respirations? |
Rate, depth, and rhythm . |
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How does a neurological injury affect respirations? |
Decreases them |
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How does hemoglobin function affect respirations? |
It increases then to try and get blood flowing. |
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If you are sitting upright you respirations will be higher or lower? |
Higher rate. |
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Define hyperpnea |
Increase in depth. |
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Define apnea |
No breathing |
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Define hyperventilation |
Increase of rate without increase of depth. |
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Define hypoventilation |
Result of bradypnea, decrease in rate. |
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What are cheyne-strokes respirations |
Periods if no breathing then shallow breathing. Deeper deeper deeper, shallow shallow shallow apnea, repeat. |
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What are kussmals respirations? |
Alternating breathing deep and shallow rapid breathing, attempt to get rid of acid from body. |
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What are biots respirations? |
Irregular and unpredictable. Signals neurological damage. |
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What is a normal respiration rate for newborn, child and adult? |
Adult is 12-30 breaths 6 months is 25-40 and newborn is 30-40 |
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What us the blood pressure? |
Force exerted on the walls of an artery by pulsing blood under pressure from the heart. |
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What is pulse pressure? |
Difference between systolic and diastolic pressure. |
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What is a normal range for pulse pressure? |
40-50 |
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What is an okay difference of blood pressure between extremities? |
5-10 mmHg |
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If hearing korotkoff sounds what is your diastolic number? |
It is at what point the sound changes |
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Age affect on blood pressure |
Older has higher blood pressure, but does not mean that is normal for elderly although it happens. |
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Gender affect on bp |
Men have higher bp than women. |
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When does prehypertension occur? |
120-139/80-89 two or more readings In a row becomes prehypertension. |
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When does hypertension occur? |
Greater than 140/90 two or more readings |
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During hypertension what happens to blood flow to the heart, brain, and kidneys? |
Blood flow decreases. |
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What is hypotension? |
Systolic pressure less than 90. |
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What cause hypotension? |
Dilation if arteries, loss of blood volume, failure of heart muscle to pump adequetly. |
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Symptomatic of hypotension? |
Light headed, dizzy |
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Orthostatic hypotension? |
Normal when lying flat buy when sit up or stand blood pressure goes down and get light headed possibly pass out. Could be due to bed rest, dehydration, anemia, blood loss, meds. |
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How long should you wait to take bp and pulse after repositioning? |
1-3 minutes. |
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What cause a false high bp? |
Too small cuff, wrapped cuff too tight, arm below heart level, deflating cuff too slow, arm not supported |
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What cause false low bp? |
Cuff too wide, arm above heart level, stethoscope applied too firmly. |
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If a systolic bp is less than 90 should you use electronic measuring device? |
No! |
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How do you document vital signs? |
Graphics or flow sheets to see trends. |
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What kind of data is pain? |
It is subjective data and is defined by the patient. Record pain with the vital signs on a flow chart. |
