Modo de aprendizaje: Vital signs Exam 1

List the vital signs

Temperature

Pulse

Respiration

Blood Pressure

Pain Level

Oxygen Saturation

Vital Signs: What is a normal Temperature

35.8-37.5 C

96.4-99.5 F

Vital Signs: What is a normal Pulse

60-100 beats/min

Vital Signs: What is normal respiration

12-20 breaths/ min

Vital Signs: What is a normal blood pressure

120/80 mm hg

Vital Signs: What is a normal Pain level

Vital Signs: What is normal Oxygen Saturation (02 sat)

95-100%

List when to assess vital signs

-On admission

-Change in clients health

-Client reports symptoms such as chest pain, feeling hot, or faint

-Pre & post surgery/invasive procedure

-Pre & post medication administration that could affect CV/ reap. system

-Pre & post nursing intervention that could affect vital signs

-Based on agency institutional policy and procedures

Define Pyrexia

fever

Define Intermittent Pyrexia

feverish periods lasting a few hours alternate with periods in which the temperature is normal

Define remittent Pyrexia

elevated body temperature showing fluctuation each day, but never falling to normal.

Define relapsing Pyrexia

recurrent acute episodes of fever

Define constant Pyrexia

constant fever

Define Hyperpyrexia

Extremelly high body temperature. Above 105

Define Hypothermia

Extremelly low body temperature. Below 95

List and describe the sites for assessing Temperature

Oral: mouth

Axillary: armpit

Tympanic: Ear

Rectal

Look up the different Nursing cares for fever on slide

List some Nursing Care for Hypothermia

-Provide warm environment

-Provide dry clothing

-Apply warm blankets

-Keep limbs close to body

-Cover the client's scalp

-Supply warm oral or intravenous fluids

-Apply warming pads

Define palpation

Assessment technique that uses the sense of touch

List the sites for Assessing Pulse by palpation (8)

Temporal (temple)

Carotid (throat)

Brachial (inside elbow)

Radial (wrist)

Femoral (groin)

Popliteal (back side of knee)

Posterior tibial (inside ankle)

Dorsalis Pedis (top of foot)

Pulse by palpation sites: Describe Radial

Readily accessible

Pulse by palpation sites: Describe Temporal

When radial pulse is not accessible

Pulse by palpation sites: Describe Carotid

During cardia arrest/ shock in adults

Determine circulation to the brain

Pulse by palpation sites: Describe Apical (chest)

Infants and children up to 3 years of age

Discrepancies with radial pulse

Monitor some medications

Pulse by palpation sites: Describe Brachial

Blood pressure

Cardia arrest in infants

Pulse by palpation sites: Describe Femoral

Cardia arrest/ shock

Circulation to a leg

Pulse by palpation sites: Describe Popliteal

Circulation to lower leg

Pulse by palpation sites: Describe Posterior tibial

Circulation to the foot

Pulse by palpation sites: Describe Dorsalis pedis

Circulation to the foot

List and describe pulse amplitude

0: absent, unable to palpate

+1: Diminshed

+2: Brisk, expected (normal)

+3: Bounding

List characteristics of the pulse (5)

Rate

Rhythm

Volume

Arterial wall elasticity

Bilateral euality

Describe Apical- Radial Pulse

Two nurse method:

-Decide on start time, nurse counting radial says start

-Both count to 60 seconds

-Nurse counting radial says stop

-Radial can never be greater than apical

If circulation is compromised, ____ or ____ may be present

& define them

Pallor: paleness of skin, lack of oxygen

Cyanosis: bluish coloring of skin, lack of oxygen

Respirations: Deine Pulmonary ventilation

movement of air in and out of lungs

Define inhalation

breathing in

Define Exhalation

Breathing out

Define Tachypnea

abnormally rapid breathing, >24 breaths/min

From: Fever, anxiety, exercise, respiratory disorders

Define Bradypnea

abnormally slow breathing,

Define apnea

Absence of breathing

Define Hyperventilation

Increased rate and depth of breathing

From: extreme exercise, fear, overdose of aspirin

Define Hypoventilation

Decreased rate and depth of breathing

From: overdose of narcotics or anesthetics

List the Components of respiratory Assessment

Rate (12-20)

Depth

Rhythm

Quality

Effectiveness

Define Systolic pressure

highest point of pressure on arterial walls

Define diastolic pressure

Lowest pressure present on arterial walls during diastole

Define Hypertension

High blood pressure

Define Hypotension

Low blood pressure

Give Systolic and Diastolic ranges for Prehypertension

S: 120-139

D:80-89

Give Systolic and Diastolic ranges for Stage 1 hypertension

S:1400-159 or

D:90-99

Give Systolic and Diastolic ranges for stage 2 hypertension

S:Greater or equal to 160 or

D: 100 or higher

The series of sounds for which we listen to when assessing blood pressure are called

Korotkoff sounds

Describe measuring blood pressure

Listening for Korotkoff sounds with stethoscope

-First sound systolic pressure

-Change or cessation of sounds occurs-diastolic pressure

Look at slides again