Vital Signs

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Author:
lvn2011
ID:
32001
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Vital Signs
Updated:
2010-08-31 22:00:15
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NUR10 Vital Signs
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Description:
NUR10 Chapter 4: Vital Signs
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  1. Vital Signs include...
    temperature, pulse, respirations & blood pressure
  2. many facilities have began using a fifth vital sign which is...
    pain level or comfort level
  3. your assessment of vital signs enables you to...
    identify nursing diagnoses, to implement planned interventions, and to evaluate success when vital signs have returned to acceptable values
  4. whether and how frequently vital signs are measured depends on...
    your judgment of the need, the patient's condition and physician orders
  5. what are vital signs charted on?
    graphic flow sheets
  6. the body strives to maintain a temerature of...
    98.6 F (37 C)
  7. hypothalamus
    regulates body temperature/ located in the brain, forming the floor and part of the lateral wall of the third ventricle/ helps maintain a balance between heat lost and heat produced by body
  8. two categories of body temperature are...
    core temperature & surface temperature
  9. core temperature
    temperature of the deep tissues of the body
  10. surface temperature
    the temperature of the skin
  11. pyrexia
    above-normal body temperature
  12. febrile
    above-normal body temperature
  13. hyperthermia
    above-normal body temperature
  14. factors affecting body temperature
    age/ excercise/ hormonal influences/ diurnal (daily) variations/ stress/ environment/ ingestion of hot & cold liquids/ smoking
  15. signs & symptoms of elevated body temperature
    thirst/ anorexia/ flushed, warm skin/ irritability/ glassy eyes or photophobia (sensitivity to light)/ headache/ elevated pulse & respiratory rates/ restlessness or excessive sleepiness/ increased perspiration/ disorientation, progessing to convulsions in infants & children
  16. constant fever
    remains elevated consistently and fluctuate very little
  17. intermittent fever
    rise and fall; for example, temp. is normal or subnormal in the morning and spikes in the afternoon
  18. remittent fever
    similar to intermittent fevers except the temp. does not return to normal at all until the pt becomes well
  19. hypothermia
    abnormally low body temp.
  20. sites for temperature measurement
    oral/ rectal/ axilla/ tympanic/ temporal artery
  21. stethoscope
    an instrument that is placed against the pt's chest or back to hear heart and lung sounds
  22. auscultate
    to listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones
  23. pulse
    a rhythmic beating or vibrating movement; in the body it signifies the regular, recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts
  24. normal adult pulse rate
    between 60 and 100 beats per minute; approximate average being 80
  25. tachycardia
    abnormally fast pulse rate; faster than 100 beats per minute
  26. bradycardia
    pulse rate slower than 60 beats per minute
  27. potential causes of tachycardia
    shock, hemorrhage leading to hypovolemia (an abnormally low circulating blood volume), exercise, fever, medication or substance abuse, and acute pain
  28. factors influencing pulse rates
    age/ exercise/ fever, heat/ acute pain, anxiety/ unrelieved severe pain, chronic pain/ medications/ hemorrhage/ postural changes/ metabolism/ pulmonary conditions
  29. potential causes of bradycardia
    unrelieved severe pain/ some drugs (beta blockers)/ resting in a supine position/ cardiac condition called heart block
  30. dysrhythmia
    any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart
  31. apical
    refers to apex of the heart
  32. apical pulse
    represents the actual beating of the heart/ used when taking the pulse rate of an infant
  33. pulse deficit
    a difference between the radial and apical pulse rates
  34. respiration
    the taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing, i.e. inhaling & exhaling
  35. internal respiration
    refers to the exchange of gas at the tissue level caused by the process of cellular oxidation, as well as the gas exchange that occurs in the alveoli of the lungs
  36. external respiration
    breathing movements of the pt that you can observe
  37. cycle of external respirations
    1: inspiration-inhaling air with oxygen into the lungs; 2: expiration- exhaling air with carbon dioxide out of the lungs
  38. rate of respiration is controlled by the...
    medulla oblongata in the brain
  39. tachypnea
    rapid respiratory rate
  40. bradypnea
    a slow respiratory rate ( below 10 per minute)
  41. factors influencing respiration
    disease or illness/ stress/ fever/ age/ sex/ body position/ medications/ exercise/ acute pain/ smoking/ brainstem injury/ hemoglobin function
  42. dyspnea
    breathing with difficulty
  43. Cheyne-Stokes respirations
    abnormal pattern of respiation characterized by alternating periods of apnea and deep, rapid breathing
  44. apnea
    not breathing
  45. hyperventilation
    when the rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases, such as during emotional trauma/ volume and depth of respirations increase
  46. hypoventilation
    occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs/ respiratory rate is below normal and depth of ventilation is depressed/ ex: after open cholecystectomy is performed, when deep breathing results in discomfort
  47. best time to assess respirations
    when counting a radial or an apical pulse
  48. blood pressure
    the pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart
  49. blood pressure is measured in...
    millimeters of mercury (mm Hg)
  50. systolic
    systolic pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries/ indicated by the first sound heard on auscultation
  51. diastolic
    lower number of the bp reading, represents the pressure within the artery between beats, that when blood enters the relaxed chambers from the systemic circulation and the lungs
  52. pulse pressure
    difference between systolic and diastolic readings (a reading of 120/80 mm Hg reveals a pulse pressure of 40)
  53. factors influencing blood pressure
    age/ anxiety, fear, pain, & emotional stress/ medications/ hormones/ diurnal (happening daily) variations/ race/ sex
  54. hypertension
    occurs when the elevated pressure is sustained above 140/90 mm Hg
  55. prehypertensive
    values of 120-139/80-89 mm Hg
  56. risk factors for hypertension
    family history of hypertension/ obesity/ smoking/ heavy alcohol consumption/ elevated blood cholestrol level/ continued exposure to stress
  57. hypotension
    below normal blood pressure
  58. Orthstatic hypotension
    a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position/ occurs when a person rises too quickly, usually from a supine position & frequently feels lightheaded and unstable
  59. sphygmomanometer
    a device for measuring the arterial blood pressure
  60. Korotkoff sounds
    first sounds heard while taking BP using sphygmomanometer and stethoscope

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