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CNA > 13. Vital Signs > Flashcards

13. Vital Signs Flashcards

1
Q

Name the 5 vital signs

A

temperature, pulse, respirations, blood pressure, and pain

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2
Q

Normal pulse range

A

60-100 bpm

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3
Q

Normal respiratory rate

A

12-20 respirations per minute

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4
Q

Normal blood pressure

A

systolic: 119 or lower
diastolic: 79 or lower

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5
Q

What is considered low BP?

A

90/60

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6
Q

What is considered prehypertensive BP?

A

systolic: 120-139
diastolic: 80-89

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7
Q

What is considered high BP?

A

140/90 or above

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8
Q

What controls temperature in the human body?

A

hypothalamus

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9
Q

How might a person’s age affect body temp?

A

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

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10
Q

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

A

True

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11
Q

How might dehydration affect body temp?

A

temp may increase in response

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12
Q

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

A
  • sub-normal when measures below 97F

- severe sub-normal = hypothermia

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13
Q

Signs and sx of a fever

A

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

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14
Q

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

A

take their temperature and report it to the nurse immediately

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15
Q

What is normal body temp in F and C?

A

F: 98.6
C: 37

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16
Q

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

A
  • most accurate: rectal

- least accurate: axillary

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17
Q

What colors are oral and rectal thermometers usually?

A
  • oral: green or blue

- rectal: red

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18
Q

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

A

digital and electronic thermometers

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19
Q

Name the 6 types of thermometers

A
  • mercury free
  • digital
  • electronic
  • disposable
  • tympanic
  • temporal A.
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20
Q

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

A

disposable thermometers

21
Q

What may cause inaccurate readings with a tympanic thermometer?

A

earwax buildup

22
Q

Describe people who you should not use an oral thermometer on

A
  • 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
23
Q

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

A
  • 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
24
Q

When should rectal temperatures not be taken?

A

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

25
Q

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

A

True

26
Q

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

A

those who are confused, disoriented, uncooperative or have dementia

27
Q

What does one respiration consist of?

A

inspiration and expiration

28
Q

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

A
  • 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
29
Q

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

A

Cheyne-Stokes respiration

30
Q

most common site for counting pulse beats

A

radial A.

31
Q

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

A
  • pulse rate
  • pattern of pulse (regular or irregular)
  • strength of pulse (weak or strong)
32
Q

When should you count someone’s respiration rate?

A

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

33
Q

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

A
  • respiratory rate
  • overal pattern (regular or irregular)
  • quality or type of breathing (quiet/noisy, deep/shallow)
34
Q

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

A

apical pulse

35
Q

When might you check the apical pulse?

A

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

36
Q

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

A

True

37
Q

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

A

may indicate poor circulation to the extremity

38
Q

measurement of the difference between an apical pulse and another pulse

A

pulse deficit (apical - other pulse)

39
Q

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

A

systolic

40
Q

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

A

diastolic

41
Q

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

A

orthostatic hypotension/postural hypotension

42
Q

Name 5 things that can increase BP

A

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

43
Q

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

A

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

44
Q

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

A

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

45
Q

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

A
  • 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)
46
Q

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

A

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

47
Q

How is pain level different from all other vital signs?

A

it is a subjective experience while all others are objective

48
Q

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

A
  • 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]

CNA (17 decks)

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