vital signs, nursing process, nursing diagnosis – Flashcards
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vital signs
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temperature, pulse, respirations, and blood pressure
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fifth vital sign
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pain
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nurse guidelines for obtaining vital signs
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- measure vital signs correctly - understand and interpret the values - communicate findings appropriately - begin interventions as needed
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when vital signs are taken
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- when a patient is admitted to a facility - as prescribed by the physician - as policy dictates - more ill patient is more frequently you will take vital signs
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rise of temperature causes
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-increase pulse rate 1 degree = 4 beats per minute -increase respiratory and blood pressure
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graphic flow sheets
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most facilities record vital signs on
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rectal temperature
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R
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Ax
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axillary temperature
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how to write blood pressure
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systolic first and diastolic beneath (ex: 120/80)
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regular temperature
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body strives for 98.6 F; however usually between 97-99.6 F
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cause change in body temp
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-environment -time of day -patient's state of health -activity levels -stage of the patient's monthly menstrual cycle
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hypothalamus
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in charge of temperature; helps maintain a balance between heat lost and heat produced by the body
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categories of body temp
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core temperature and surface temperature
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core temperature
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temperature of the deep tissues of the body
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surface temperature
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the temperature of the skin
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temperature evaluations are
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usually the first sign of illness
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use a stethoscope to
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measure the apical rate of the heart
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stethoscope
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an instrument that is placed against the patient's chest or back to hear heart and lung sounds
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ausculate
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listen for sounds within the body
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pulse
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a rhythmic beating or vibrating movement, it signifies the regular, expansion and contraction of an artery
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tachycardia
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pulse faster than 100 beats per minute
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bradycardia
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pulse slower than 60 beats per minute
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dysrhythmia
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any disturbance or abnormality in a norma rhythmic pattern, specifically, irregularity in the normal rhythm of the heart
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noting pulse
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-note the rate, the rhythm, and volume or strength of the pulse -assess pulses on both sides of the peripheral vascular system
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major pulses
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-temporal -facial -carotid -brachial -radial -femoral -popliteal -posterior tibial -dorsalis pedis
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apical pulse
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represents the actual beating of the heart
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pulse deficit
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difference between the radial and apical rate
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inspiration
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inhaling air with oxygen into the lungs
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expiration
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exhaling air with carbon dioxide out of the lungs
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normal respiratory rate
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12-20 respirations per minute
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tachypnea
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rapid respiratory rate
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bradypnea
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slow respiratory rate, below 10 per minute
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respirations
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assess the depth, the quality and the rhythm
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dyspnea
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breathing with difficulty
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apnea
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lack of spontaneous respirations
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cheyne stokes respirations
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abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing
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hypoventilation
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occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs
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best time to assess respiration
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when counting a radial or apical pulse, patient will be unaware you are doing so
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blood pressure
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the pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart
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blood pressure unit
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millimeters of mercury (mm Hg)
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systolic pressure
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higher number that represents the ventricles contracting
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diastolic pressure
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lower number of blood pressure, the second pressure
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pulse pressure
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difference between the two readings (ex: 120/80. answer: 40)
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cardiac output
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amount of blood discharged from the left or right ventricle per minute
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120/80
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optimal blood pressure for middle-aged adult
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hypertension
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occurs when elevated pressure is sustained above 140/90 mm Hg
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hypotension
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below normal blood pressure
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orthostatic hypotension
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a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from lying to sitting or from sitting to standing position
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nursing process
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assessment, diagnosis, outcome identification, planning, implementation, and evaluation
