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245 Cards in this Set

  • Front
  • Back
What 4 things are assessed when taking vital signs? What is often assessed along with vital signs?
- temperature
- pulse
- respiration
- blood pressure

(pain is often assessed with vital signs)
What is the primary purpose of taking vital signs?
to monitor essential physiologic function of vital organs
In addition to monitoring vital organ function, what other purpose does taking vital signs serve?
evaluates health status and gives us baseline information regarding health
How long should you wait before assessing a person's vital signs who was active?
about 15 minutes
Guidelines are in place when assessing vital signs to offer a range for reference. However, when assessing an individual patient what must you also consider?
trends or patterns established by that particular patient
Observing trends in Vital Signs allows the nurse to do what 4 things?
- clinical problem solving
- make decisions about treatments/interventions
- evaluate effectiveness of medications and treatments
- evaluate the response to illness
What are 5 occasions when vital signs are taken?
- on admission
- per hospital routine or physician's order
- before and after surgery or diagnostic procedure, medications or nursing interventions affecting VS
- before, during, and after blood/blood product transfusion
- when there is a change in client's condition or a report of physical distress

A nurse must obtain a doctor's order to take vital signs.

A nurse can use his/her own judgment to take vital signs. REMEMBER- You have to take them minimally according to policy or orders, but can access more often using YOUR judgment!

the heat of the body determined by the balance of heat produced and heat lost
body temperature
Body temperature is stated in what two degrees?
Fahrenheit or Celsius
What are two examples of temperature methods used to detect core temperature?
Tympanic and rectal
What are two examples of temperature methods used to detect surface temperature?
Oral and axillary
What part of the brain is the thermoregulatory center?
The hypothalamus receives messages from ___________ ____________.
thermal receptors
What type of regulatory response would you see when the nerve cells in the hypothalamus become heated?
Compensatory mechanisms, such as sweating and vasodilation to promote heat loss
What type of reaction might you see in the body when the hypothalamus detects a low body temperature?
shivering and vasoconstriction
How does vasoconstriction apply to body temperature?
vasoconstriction conserves body heat
Temperature deep in the body is referred to as what?
core temperature
What is the primary source of heat production in the body?

heat production at rest

Shivering decreases body temperature.

Shivering is the body's mechanism of INCREASING body temperature.
What are the 4 methods of heat transfer?
- radiation
- conduction
- convection
- evaporation
Heat loss caused by sitting in a cold room is an example of what mechanism of heat transfer?

diffusion of heat by electromagnetic waves
Heat loss caused by taking a cool bath is an example of what mechanism of heat transfer?

transfer of heat through direct contact
Heat loss caused by using an electric fan to cool off is an example of what mechanism of heat loss?

transfer of heat via air currents
Heat loss caused by sweating and respiration is an example of what mechanism of heat transfer?

the conversion of liquid to vapor

raised body temperature; fever
Pyrexia is described as a fever over ______ F or _______ C.
100.4 F or 38 C

the condition of having a body temperature greatly above normal

the condition of having a subnormal temperature
To be classified as hypothermia, the body's temperature must be lower than _____ F or ______ C.
96.8 F or 36 C
What is the normal value for an oral temperature?
97.6 to 99.6 F or 36.5 to 37.5 C
How much higher is a rectal temperature vs. an oral temperature?
1 F or 0.5 C
How much lower is an axillary temperature vs. and oral temperature?
1 F or 0.5 C

A tympanic temperature is 0.5 F higher than an oral temperature.
What are the 4 types of thermometers?
- mixture of gallium, indium and tin enclosed in plastic
- electronic
- chemical
- temperature-sensitive tape
What type of thermometer requires you to shake it down and hold it at eye level to read?
What type of thermometer has a pencil like probe with a cover?
Chemical thermometers that are disposable plastic strips are used for what two methods of assessment?
oral and axillary
What type of thermometer would be applied to the skin and changes color according to the skin temperature?
temperature-sensitive tape
What is the most commonly used method of temperature assessment?
How long should you wait to take a temperature after a patient has eaten, drank or smoked?
30 minutes
How long does it take to take an oral temperature using a gallium thermometer?
3-5 minutes
What are some contraindications to taking an oral temperature?
- mouth breathing
- uncooperative
- seizures
- unconscious
- younger than 6 years old
- nasal/oral surgery or trauma
What is the most accurate method of assessing temperature?
What PPE should be donned when taking a rectal temperature?

Lubricant is not required for taking a rectal temperature.
false - you should always lubricate the tip of the thermometer
Rectal thermometers should be inserted towards the ___________.
How far should a rectal thermometer be inserted in adults? children? infants?
adults - 1.5 inches
children - 1 inch
infants - 1/2 inch
How long must you hold a rectal gallium thermometer in place?
2-4 minutes
What are some contraindications in assessing rectal temperature?
- rectal/prostate surgeries or disorders
- diarrhea or impacted stool
- serious heart disease
- newborns
Why would you not want to assess the temperature rectally in a patient with serious heart disease?
- vagal stimulation may sow the heart rate
Why would you not want to assess the temperature rectally in a newborn?
- you could perforate the rectal wall
What is the safest and least invasive method of assessing temperature?
How long must you hold a gallium thermometer in place to assess axillary temperature?
8-10 minutes
Would the tympanic method of assessing temperature provide you with an accurate surface or core temperature?
________, __________, or __________ processes may cause fever.
Infection, inflammatory, or immunologic processes

a substance, typically produced by a bacterium, that produces fever when introduced or released into the blood.
What happens to the body's setpoint temperature when endogenous pyrogens are introduced into the blood?
the hypothalamus raises the body's setpoint in response to the pyrogens being present
What are some beneficial consequences of fever?
- stimulate the body to produce WBCs
- decreases iron in blood plasma which suppresses bacterial growth
- increases production of interferon, a virus-fighting substance
What are some harmful consequences of fever?
- increases BMR, P and R rates
- excessive sweating may lead to dehydration
- prolonged fever may result in tissue catabolism, muscle wasting, aching, negative nitrogen balance, weight loss, apathy, delirium and withdrawl
- fever over 41 C may lead to seizures or neurological complications
Fever above _____ C may lead to seizures or neurological complications.
What are the 3 phases of the febrile episode?
- chill phase
- plateau phase
- fever break
During which phase of the febrile episode is heat conserved? During which phase is heat lost?
During the "chill phase" heat is conserved. During the "fever break" heat is lost.
During which phase of the febrile episode does the setpoint rise?
Chill phase
Why does the client experience chills and shivering during the "chill phase" of the Febrile Episode?
because the body is trying to conserve heat
What occurs during the plateau phase of the Febrile Episode?
Chills subside and the client experiences a warm and dry feeling because the new temperature setpoint is reached
During which phase of the Febrile Episode would a patient experience vasodialation?
Fever break
Why does a client experience sweating (diaphoresis) during the "fever break" phase of the Febrile episode?
because the setpoint decreases, and the body is attempting to lose heat or return to its normal setpoint
What is the proper way to clean a thermometer prior to use? What about after use?
Prior to use, clean from the bulb to your hand (clean to dirtiest). After use, clean from hand to bulb (clean to dirtiest)
Which temperature route best reflects the core body temperature?
rectal is said to be most accurate
When assessing a client with fever, you should always assess for causality as well. What are some examples of situations that may cause fever?
- dehydration
- infection
- environment (exposure to extreme heat/cold)
What other assessment measures should be done for a client experiencing fever?
- monitor all vitals (not only fever)
- assess for causality
- assess skin color and temperature
- determine phase of febrile episode
- assess comfort level
Which of the following symptoms of fever would adversely affect an already weakened patient?

-increase WBCs
-increase BMR
-suppress bacterial growth
-decrease level of iron in the blood
Increase BMR - this results in an increase in caloric intake, weight loss, and increases need for oxygen
What are 2 nursing interventions that will decrease heat production in a client with fever?
- limit physical activity
- promote rest
What are 2 nursing interventions that will increase heat loss in a client with fever?
- remove external covers
- keep linens and clothing dry
What can be done to meet the increased BMR needs of a febrile patient? (2)
- Administer O2 as ordered
- Provide adequate nutrition and fluids
How can you promote client comfort in a febrile patient? (4)
- frequent oral care
- control environmental temperature
- bed bath
- change linens
During the systolic phase of the cardiac cycle, the left ventricle ejects approximately how many mL of blood into the aorta?
60-70 mL
How is Pulse or Heart Rate measured?
by counting the number of palpable pulse beats per minute
What is the adult normal range for pulse?
60-100 bpm
What does palpate mean?
What body system regulates the pulse rate?
Autonomic Nervous System
Would the parasympathetic Vagus nerve increase or slow the pulse rate?
slows the pulse rate
What is increased via the sympathetic nervous system to increase pulse?
epinephrine and norepinephrine
How long should "you" count the pulse?
30 seconds

(multiply results by 2)
What are some factors affecting P or HR?
- age
- sex
- activity
- fever
- medications
- hemorrhage
- stress
- position changes
- vagal stimulation
- pain
Which would you expect to have a higher pulse, a 6 month old female or a 22 year old male?
6 month old female
Do men or women have a higher pulse rate?
How long should you wait to take a pulse after activity?
30 minutes
Would an athlete have a higher or lower than average heart rate?
A patient is in recovery after surgery. You observe an increase in heart rate followed by a sudden, drastic decrease. What would this be indicative of?
Would medications increase or decrease heart rate?
It depends on the medication
What effect does stress have on heart rate?
it increases it
Does the body's position affect heart rate?
Yes, for example standing after lying will result in a decrease in blood pressure
Will pain increase or decrease heart rate?
Where is the vagus nerve located in the body?
In the GI tract, extending from the mouth to the anus
How does straining to have a bowel movement, gagging or vomiting affect heart rate?
It decrease heart rate due to vagal nerve stimulation
Where are the vagal receptors located in the body?
- Carotid artery sinus in the upper third of the neck
The carotid artery sinus houses vegal receptors. How does this affect our procedure for taking a carotid pulse?
We palpate the carotid artery in the lower half of the neck
What are 2 methods for assessing pulse?
- palpation
- auscultation
What fingers should be used to assess the pulse? Which should be avoided?
Middle 3 to palpate (pads of fingertips more sensitive); avoid using the thumb
What are 2 tools used to ausculate pulse?
- stethoscope
- doppler ultrasound
What are the 6 major Peripheral pulses?
- Carotid
- Radial
- Brachial
- Femoral
- Popliteal
- Pedal pulses
What is the most accurate peripheral pulse?
carotid pulse

You should never check both carotid pulses at the same time.
True - palpation of both at the same time could hinder blood flow to the brain
What type of pulse assessment is used in CPR?
Where should you place your fingers when assessing a carotid pulse?
between the trachea and the sternocleidomastoid muscle on the LOWER half of the neck
What is the most common type of pulse assessment?
What pulse assessment is used in infant CPR?
brachial pulse

Assessing both dorsalis pedis pulses at the same time is necessary to check for equal rates.
False- both pulses would be checked to assess equal volume or synchronized beats
What site for pulse assessment is used when taking blood pressure?
What pulse locations would be assessed when checking for circulation?
- femoral
- popliteal
- pedal pulses (dorsalis pedis, posterior tibial)
Which location would yield a higher blood pressure rating, the brachial or popliteal pulse?
popliteal yields higher results
How long should you auscultate a central pulse?
a full minute
What is the next assessment step if you detect an abnormal peripheral pulse?
ausculate the apical pulse
A nurse is caring for a patient with CV disease. What type of pulse assessment would be standard on this patient?
apical pulse
What is the standard location of the apical pulse?
the apex of the heart (usually heard loudest at the 5th intercostal space, midclavicular line)
Where should you begin your count when assessing a pulse?
always start at 0
What two sounds correlate with cardiac cycle?
systole and diastole (S1 and S2)
What anatomical landmarks should you follow to locate the apical pulse?
- locate the suprasternal notch, angle of Louis, which is level with the 2nd ICS

- count rib spaces down to the 5th ICS, midclavicular line
What is the purpose of detecting an apical-radial pulse?
to assess if there is a pulse deficit
When assessing apical-radial pulse, what might you deduct if the radial pulse produced is diminished or absent?
that the left ventricle contraction is weak
A ________ __________ occurs when the apical pulse is greater than the peripheral pulse.
pulse deficit
What does a pulse deficit indicate?
poor peripheral circulation/perfusion
What are the 5 things that you should assess the pulse for?
- rhythm
- amplitude (volume)
- rate
- elasticity
- equality

the pattern or spacing between pulse beats; may be regular or irregular
An irregular rhythm in pulse is known as what?
The strength or force of a pulse is known as what?
amplitude (volume)
The amplitude of a pulse is measured on a scale from 0 to +3. Describe each individual measurement.
0 = absent
+1 = difficult to feel (weak); easy to obliterate
+2 = normal; easy to feel; obliterates with stronger force
+3 = strong, bounding; difficult to obliterate

the number of heart beats per minute
How long should you count a regular rhythm pulse?
30 seconds (multiply by 2)
How long should you count an irregular rhythm pulse?
60 seconds
A pulse lower than 60 is called what?
A pulse greater than 100 is called what?
Describe normal and abnormal elasticity of arteries.
normal = soft, pliable
abnormal = hard, twisted, tortuous
How do you determine the equality of a pulse?
assess the left and right pulse at the same time
What type of changes should be reported immediately?
- absent, weak, thready pulse
- pulse deficit
- significant change in resting pulse
- change in volume or rhythm
- cool, pale skin
A nurse assesses a patient's radial pulse at 88. She/he finds it easy to feel and puts moderate force to obliterate the pulse. Upon further examination, she/he finds that the artery feels soft and pliable and that the rhythm is regular. How is this information documented?
radial 88/m regular, +2 smooth

When performing an apical-radial pulse, it is imperative that both nurses starts their individual watches at the exact same time to ensure an accurate count.

An apical-radial pulse requires that both nurses use the SAME watch!
What are some pulse/blood pressure changes you may expect to see in the elderly?
- loss of compliance (elasticity)
- Blood pressure may be higher to compensate for the loss of arterial compliance
- after activity, it takes longer for the pulse to return to "resting" state

The elderly usually have a higher heart rate.
False -

While blood pressure may be higher to compensate for compliance issues, heart rate is usually the same.

the act of breathing (exchange of gases) for 1 minute;
What is the average length of inspiration? Expiration?
Inspiration = 1-1 1/2 seconds
Expiration = 2-3 seconds
What 3 muscles 'may' be used in respiration?
- diaphragm
- intercostals
- accessory
What is the major muscle of respiration?
What muscle(s) would you expect to be used when a patient is having difficulty breathing?
- diaphragm
- intercostals
- accessory (ex. neck muscles)
What are the 3 processes of respiration?
- ventilation
- diffusion
- perfusion

mechanical movement of respiration; the act of breathing

the movement of O2 and CO2 between alveoli and RBCs

the distribution of RBCs from pulmonary capillaries to the rest of the body
Neural regulation of respiration involves what 2 parts of the brain?
- medulla oblongata
- cerebral cortex
You observe a client's respiration without their knowledge. What part of the brain is likely controlling the breathing that you document?
medulla oblongata - responsible for involuntary, automatic control of breathing
What part of the brain would likely be controlling breathing if the patient was aware that you were counting their respiration rate?
cerebral cortex - voluntary control of respirations
What structures detect the presence of CO2 and O2 in the blood?
chemoreceptors located in the aorta and carotid arteries
What 4 things should you assess when observing respirations?
- rhythm
- rate
- effort/ease
- depth
Rhythm of respirations should be recorded as either ________ or _______.
regular or irregular
If you cannot see the chest rise/fall when assessing respirations, how should you position the client?
place the client's arm over their abdomen
In the "Assessment of Vital Signs", at what point should you assess respirations?
immediately after taking their pulse
How long should you count respirations?
30 seconds
What is the normal range for respirations?
12-20 breaths per second

regular respirations between 12-20; no effort required to breath

respirations below 12 breaths per minute

respirations above 20 per minute

absence of breathing

difficulty breathing; shortness of breath

breathing done with great effort and difficulty

shortness of breath (dyspnea) which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair
What 3 descriptions are used to describe varying depths of respirations?
- full
- hypoventilation
- hyperventilation
What description would you use to describe breathing that was very shallow and undetectable by chest or abdomen movements?
If a client is experiencing hypoventilation, how might you have to observe respiration depth?
observe shoulders or use stethoscope

very deep movement of the chest/abdomen when breathing
What do you do if a client sighs or yawns while counting respirations?
You count that as a breath, both are part of the normal breathing cycle
Rapid, deep breathing as seen with diabetes ketoacidosis is known as what?
Respirations that go from shallow -> deeper -> shallow -> apnea, as seen in head injuries are known as what?
Totally erratic respirations displaying no pattern (often seen when death is imminent) are known as what?
How does exercise influence respirations?
increases the rate
How does acute pain influence respirations?
increases the rate and rhythm
How does anxiety influence respirations?
increases the rate and depth
How does smoking influence respirations?
increases the rate at rest
What body position offers full expansion of the chest cavity, easing breathing?
What change in respirations would you expect to see in a client who receives narcotics?
slower rate
How might a neurological injury affect respirations?
- decreases rate; changes rhythm
What occurs to respirations when a client has low hemoglobin function?
the rate increases
What effect does the decrease in the arterial elasticity of elderly clients have on their respiration rate?
respirations are shallower and slightly faster
A nurse assesses the respiration rate of an 83 year old black female at 23 per minute. Why is this not an immediate cause of concern?
Respiration rate in elderly clients is often higher due to the decrease in elasticity of arteries/veins
Arterial blood pressure measure what?
arterial wall pressure created as blood flows through the arteries throughout the cardiac cycle
BP is written as a fraction consisting of what 2 parts?
systolic BP
diastolic BP
What is the systolic and diastolic blood pressures of a BP 120/80?
systolic = 120
diastolic = 80
Which BP, systolic or diastolic, is the pressure created as the left ventricle ejects blood?
Which BP, systolic or diastolic, is when the heart relaxes?

the difference in systolic and diastolic BP
pulse pressure
What is the normal range of pulse pressure?
30-50 mm Hg
What might be the cause of an abnormal pulse pressure?
neurological or cardiac dysfunction
What is the range of normotensive BP? Pre-hypertensive? Hypertensive Stage 1 and 2?
normontensive 90/60 - 139/89
pre-hypertensive 120/80 - 139/89
hypertensive stage 1 - 140/90 - 159/99
hypertensive stage 2 - 160/100 and above
A blood pressure below 90/60 in an adult who's BP is normally higher than that is termed what?
For a blood pressure below 90/60 to be considered hypotensive, what must be present?
symptoms or a significant change

volume of blood (stroke volume) pumped by the heart in one minute
Cardiac Output (CO)

resistance to blood flow determined by the tone of vascular musculature and the diameter of blood vessels
Peripheral resistance

amount of blood circulating within the vascular system
blood volume

thickness of blood

ability of arteries to stretch
What measures the ratio of blood cells to plasma?
A patient's hematocrit test indicates a high number of RBCs in ratio to blood plasma. How would you expect this to affect the blood's viscosity?
the blood would be thicker than normal
How does age affect BP?
Higher age = lower elasticity, build-up of plaque in arteries
How does stress affect BP?
stress stimulates flight or fight response (sympathetic system) and increases vasoconstriction
What are the differences in BP between males and females?
Males have higher blood pressure than females until menopause when it tends to equal out
What race tends to have higher BP?
African Americans
Would you expect to see a higher BP in the morning or evening? Why?
Higher BP in evening when metabolic rate peaks

Medications may increase or decrease BP.
How long should you wait to take the BP of a person who was exercising. Why?
30 minutes because exercise does increase BP (although the change is NOT as dramatic as pulse changes)
A client is diagnosed with diabetes mellitus. What type of BP reading would you expect to see in this client?
BP will be high, probable hypertension
Would you expect a higher or lower BP in an obese patient?

Smoking and/or high alcohol consumption results in higher BP
What are 3 known complications of hypertension?
- Kidney Failure
- Eyesight problems
Although hypertension is commonly asymptomatic, what symptoms are associated with this disorder?
- headaches
- nosebleeds
- flushing
- fatigue
What are some symptoms of hypotension?
- dizziness
- confusion
- fainting
- decreased urine output
- chest pain
- clamminess
- skin mottling
- pallor
- increased heart rate
To be diagnosed with hypertension, the client's BP must be measures ____ or more times and averaged out.
Orthostatic hypertension is a side effect of many ___________ medications.

a drop in BP of 20 or more systolic or 10 or more diastolic when you change from a sitting/lying position to a standing position
orthostatic hypertension
What type of method would be used to directly assess BP?
an arterial line
What are 3 methods of assessing BP?
palpatory (systolic only)
ausculatory (systolic and diastolic)
electronic (systolic and diastolic)
How would you document a palpatory BP?
The width of a BP cuff should be ___-___ % of the circumference of the midpoint of the limb on which the cuff is used.
If a BP cuff is too narrow, what will happen to the reading? What if it is too wide?
too narrow = false high
too wide = false low
What are 2 types of sphygmomanometers?
aneroid (dial) or mercury
The sounds heard when listening to the blood pressure are called what?
Korotkoff's sounds
What sound indicates the systolic BP when ausculating?
What sound indicates the diastolic BP when ausculating?
K5 (adults) K4 (children)
What are examples of situations where you would not take the BP from the arm?
- mastectomy
- recent blood drawn
- stroke deficit
- IV
- A line
- Shunt for dialysis
- surgery or any deviation to the hand, arm, shoulder, or axilla
If you take a BP using the leg, what deviation do you expect to see in the reading?
expect the systolic to be 20-30 higher
Why should you always palpate systolic pressure prior to taking BP?
to avoid misreading due to an auscultory gap
What are the follow up recommendations for the following:

Normal BP, Prehypertension, Hypertension Stage I, Hypertension Stage II
Normal - recheck in 2 years
Prehypertension - Recheck in 1 year
Stage I Hypertension - Confirm in 2 months
Stage II Hypertension - Confirm in 1 month
What is the protocal for a BP of 180/100 or greater?
Treat immediately to 1 week depending on clinical situation
When checking BP, the cuff should be inflated to _____ mercury above the palpated systolic pressure.
Where should you position the stethoscope when assessing BP in the arm?
over the brachial artery
How far above the brachial artery should the cuff be positioned?
1 inch
When taking BP, what point indicates Systolic pressure?
when the 1st sound is heard
When taking BP, what point indicates Diastolic pressure?
when the sound disappears
What is the very 1st step in the blood pressure procedure?
Wash hands
When releasing the valve of the BP cuff, what is the desired rate that the mercury will fall every second?
2-3 mm