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Fundamentals of Nursing, 9th Ed., Potter, Perry, Stockert & Hall, 2017
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30 - Vital Signs

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Fundamentals of Nursing, 9th Ed., Potter, Perry, Stockert & Hall, 2017 | Registered Nurse (RN) School Study Aid

30 - Vital Signs
16 Picmonics to Learn | 30 mins
Vital Signs - Adult
Temperature (96.8-100.4 Degrees F) (36-38 Degrees C)
Rectal
Tympanic
Oral
Axillary
Temporal
Respiration (12-20)
Oxygen Saturation (95%-100%)
Pulse (60-100)
Blood Pressure (<120/80)
Pain
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2 mins
Blood Pressure Classification (JNC 7)
Classifications
Normal
Systolic (<120)
Diastolic (< 80)
Prehypertension
Systolic +20 (120-139)
Diastolic +10 (80-89)
Stage 1 Hypertension
Systolic +20 (140-159)
Diastolic +10 (90-99)
Stage 2 Hypertension
Systolic + > 20 (160)
Diastolic + > 10 (100)
Hypertensive Crisis
Systolic > 180
Diastolic > 110
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4 mins
Fever
Flushed skin, warm to touch
Chills
Sweating
Change in LOC
Provide adequate fluids
Monitor Electrolytes and Fluid
Monitor vital signs, esp temperature
Remove excess clothing and blankets
Sponge bath with tepid water
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2 mins
Hypothermia Interventions
Remove From Environment
Remove Wet Clothing
Passive Rewarming
Warm Clothing
Active Rewarming
Heated Blankets
Warm IV Solutions
Heated Oxygen
Warm Gastric Lavage
Considerations
Warm Trunk BEFORE Extremities
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2 mins
Traumatic Brain Injury Assessment
Assessment
Change in LOC
Personality Changes
Amnesia
Increased Intracranial Pressure
Diplopia
Posturing
Location of Injury
Basilar Skull Fracture
Halo or Ring Sign
Considerations
Intracranial Bleeding
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2 mins
ECG: Sinus Bradycardia
Rate
< 60 bpm
Rhythm
Regular
P Wave
Present, Upright, Every QRS
PR Interval
< 0.20 seconds
QRS Interval
< 0.12 seconds
Treatment
Atropine
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1 min
ECG: Sinus Tachycardia
Rate
> 100 bpm
Rhythm
Regular
P Wave
Present, Upright, Every QRS
PR Interval
< 0.20 seconds
QRS Interval
< 0.12 seconds
Treatment
Treat Underlying Cause
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2 mins
Respiratory Anatomy
Characteristics
Nasal Cavity
Hair Filters
Mucus Filters and Moistens
Capillaries Warm
Pharynx (Throat)
Larynx (Voice Box)
Cilia Expel Mucus and Dust
Trachea
Bronchi
Alveoli
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2 mins
Cardiac Cycle - Systole
Characteristics
AV Node
AV Node Conducts Signal to Bundle of His
Bundle of His Signals Purkinje Fibers to Contract Ventricles
Tricuspid Valve Closes
Pulmonary Valve Opens
Mitral Valve Closes
Aortic Valve Opens
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2 mins
Cardiac Cycle - Diastole
Characteristics
Aortic Valve Closes
Pulmonary Valve Closes
Ventricles Relax
Mitral Valve Opens
Tricuspid Valve Opens
Ventricles Fill
Sinoatrial (SA) Node Fires
Atrial Contraction
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3 mins
High Blood Pressure Response
Characteristics
Atria Release Atrial Natriuretic Peptide
Vasodilation
Antagonizes Aldosterone
Na+ and Water Excreted
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1 min
Calcium Channel Blockers (Verapamil and Diltiazem)
Mechanism of Action
Slows AV Conduction
Indications
Angina Pectoris
Arrhythmias
Essential Hypertension
Side Effects
Bradycardia
Hypotension
Constipation
Peripheral Edema
Gingival Hyperplasia
Nursing Consideration
Medication Education
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2 mins
Supine Hypotension (Vena Cava Syndrome)
Mechanism
Compression of the Vena Cava and Descending Aorta
Signs and Symptoms
Hypotension
Dizziness
Tachycardia
Decreased Renal Perfusion
Decreased Uteroplacental Perfusion
Intervention
Side-lying Position
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2 mins
Hypertension Medications
Diuretics
ACE Inhibitors
Angiotensin Receptor Blockers (ARBs)
Beta Blockers
Dihydropyridine Calcium Channel Blockers
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2 mins
Primary Hypertension Risk Factors
Excessive Alcohol Consumption
High Sodium Diet
Dyslipidemia
Obesity
People of African Descent
Advanced Age
Vitamin D Deficiency
Reduced Nephron Number
Diabetes
Lack of Physical Activity
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2 mins
Low Blood Pressure Response
Characteristics
Posterior Pituitary Releases Vasopressin
Vasoconstriction
Adrenal Cortex Releases Aldosterone
Increased Na+ and H2O Reabsorption
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1 min

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