13. Vital Signs

Question 1

Name the 5 vital signs

Answer 1

temperature, pulse, respirations, blood pressure, and pain

Question 2

Normal pulse range

Answer 2

60-100 bpm

Question 3

Normal respiratory rate

Answer 3

12-20 respirations per minute

Question 4

Normal blood pressure

Answer 4

systolic: 119 or lower
diastolic: 79 or lower

Question 5

What is considered low BP?

Answer 5

90/60

Question 6

What is considered prehypertensive BP?

Answer 6

systolic: 120-139
diastolic: 80-89

Question 7

What is considered high BP?

Answer 7

140/90 or above

Question 8

What controls temperature in the human body?

Answer 8

hypothalamus

Question 9

How might a person’s age affect body temp?

Answer 9

as a person ages, fatty tissue is lost -> less able to prevent heat loss and may feel colder

Question 10

T/F - people may have lower avg temp in the morning and higher temp in the late afternoon and evening

Answer 10

True

Question 11

How might dehydration affect body temp?

Answer 11

temp may increase in response

Question 12

When is a body temp classified as sub-normal? What is it called when body temp is severely sub-normal?

Answer 12

• sub-normal when measures below 97F

- severe sub-normal = hypothermia

Question 13

Signs and sx of a fever

Answer 13

headache, fatigue, muscle aches, chills, and skin may feel warm and look flushed

Question 14

What should you do if you suspect someone has a fever?

Answer 14

take their temperature and report it to the nurse immediately

Question 15

What is normal body temp in F and C?

Answer 15

F: 98.6
C: 37

Question 16

Which type of thermometer is considered the most accurate and the least accurate?

Answer 16

• most accurate: rectal

- least accurate: axillary

Question 17

What colors are oral and rectal thermometers usually?

Answer 17

• oral: green or blue

- rectal: red

Question 18

What 2 types of thermometers require the use of a disposable plastic sheath to prevent infection?

Answer 18

digital and electronic thermometers

Question 19

Name the 6 types of thermometers

Answer 19

• mercury free
• digital
• electronic
• disposable
• tympanic
• temporal A.

Question 20

What type of thermometer is often used on residents who are in isolation?

Answer 20

disposable thermometers

Question 21

What may cause inaccurate readings with a tympanic thermometer?

Answer 21

earwax buildup

Question 22

Describe people who you should not use an oral thermometer on

Answer 22

• unconscious
• using oxygen
• confused or disoriented
• paralyzed from stroke
• facial trauma present or injury to face or neck
• likely to have seizure
• has NG tube
• younger than 5 y/o
• sores, redness, swelling, or pain in the mouth

Question 23

Describe when it may be necessary to get a rectal temperature on a resident

Answer 23

• may be necessary for residents who are unconscious, have poorly-fitting dentures or missing teeth, difficulty breathing through the nose, have a seizure disorder, or have been vomiting

Question 24

When should rectal temperatures not be taken?

Answer 24

when the resident has recently had rectal surgery or has a colostomy

Question 25

T/F - it is important to hold onto the thermometer at all times while the thermometer is in the rectum

Answer 25

True

Question 26

While axillary temperature is not very accurate, it is safer for which residents?

Answer 26

those who are confused, disoriented, uncooperative or have dementia

Question 27

What does one respiration consist of?

Answer 27

inspiration and expiration

Question 28

Define each of the following: apnea, dyspnea, eupnea, orthopnea, and tachypnea

Answer 28

- apnea: absence of breathing; may be temporary - dyspnea: difficulty breathing - eupnea: normal respirations - orthopnea: SOB when lying down; relieve when sitting up - tachypnea: rapid respirations

Question 29

agonal respiration: alternative periods of slow, irregular respirations and rapid, shallow respirations, possibly along with periods of apnea

Answer 29

Cheyne-Stokes respiration

Question 30

most common site for counting pulse beats

Answer 30

radial A.

Question 31

What 3 things should you observe for when checking someone's pulse?

Answer 31

- pulse rate - pattern of pulse (regular or irregular) - strength of pulse (weak or strong)

Question 32

When should you count someone's respiration rate?

Answer 32

directly after taking someone's pulse so they don't know you are watching them breathe

Question 33

What 3 things should you observe for when checking someone's respirations

Answer 33

- respiratory rate - overal pattern (regular or irregular) - quality or type of breathing (quiet/noisy, deep/shallow)

Question 34

pulse heard by listening directly over the heart with a stethoscope; located on the left side of the chest just below the nipple

Answer 34

apical pulse

Question 35

When might you check the apical pulse?

Answer 35

when someone has a week radial pulse or irregular pulse; may also be taken on infants or people with heart disease

Question 36

T/F - the apical pulse will always be the same or higher than any other pulse in the body

Answer 36

True

Question 37

What does it mean when the radial pulse is less than the apical pulse?

Answer 37

may indicate poor circulation to the extremity

Question 38

measurement of the difference between an apical pulse and another pulse

Answer 38

pulse deficit (apical - other pulse)

Question 39

phase of BP when the heart is at work, contracting and pushing blood out of LV

Answer 39

systolic

Question 40

phase of BP when the heart is relaxed and not contracting; in between beats

Answer 40

diastolic

Question 41

sudden drop in BP that occurs when a person stands or sits up

Answer 41

orthostatic hypotension/postural hypotension

Question 42

Name 5 things that can increase BP

Answer 42

stress, obesity, alcohol, tobacco, and race (african american)

Question 43

T/F - BP may be higher in the morning and lower in the evening

Answer 43

False - BP may be lower in the morning and higher in the evening

Question 44

What pulse is used to obtain a BP reading? Where is it located?

Answer 44

brachial A - inside of the elbow, about 1.5 inches above the elbow

Question 45

Name several situations in which you shouldn't take someone's BP on a certain an arm or side of the body

Answer 45

- IV is present or arm has a cast - cuff doesn't fit arm properly - burns or injuries present - arm or side has had recent trauma - arm or side is paralyzed due to stroke - amputation has been performed - the side has had a mastectomy (or any other surgery or incision)

Question 46

How many positions and times must BP be measured in someone with orthostatic hypotension?

Answer 46

3 times: lying down for 5 minutes, sitting, and standing for 1 to 5 minutes

Question 47

How is pain level different from all other vital signs?

Answer 47

it is a subjective experience while all others are objective

Question 48

Name 8 pieces of information you should collect when a resident is complaining of pain (6 according to the textbook)

Answer 48

- onset (when did it start, what were you doing, have you had it before) [STAR] - location [STAR] - duration [STAR] - characterization - aggravating factors [STAR] - alleviating factors [STAR] - radiation - severity [STAR]