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Health Assessment Theory Exam 1 > Ch. 10-Vital Signs Assessment > Flashcards

Ch. 10-Vital Signs Assessment Flashcards

1
Q

What do vital signs include?

A
  • Temperature
  • Pulse
  • Respirations
  • Blood Pressure
  • Oxygen Saturation
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2
Q

What is the normal range of a temperature in a resting person?

A

96.4* F- 99.1* F

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3
Q

Rectal temp is how much higher than an oral temp?

A

0.7* F -1* F

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4
Q

Tympanic temp is how much higher than an oral temp?

A

0.5* F- 1* F

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5
Q

An axillary temp is how much lower than an oral temp?

A

1* F

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6
Q

What is the Oral Temperature Assessment Procedure?

A
  • Place thermometer under pt tongue, off to side, in sublingual pocket
  • Instruct person to keep his/her lips closed
  • Nurse holds thermometer in place
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7
Q

How long should you wait to take a temp after someone has just taken hot or iced liquids?

A

15 minutes

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8
Q

How long should you wait to take a temp if person has just smoked?

A

2 minutes

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9
Q

Electronic temps have fast results that read in how Manny seconds typically?

A

20-30 (disposable probe)

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10
Q

What are important things to consider when taking a axillary temp?

A
  • Place probe under axilla
  • Hold arm close to axilla
  • Less accurate and reliable
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11
Q

What are things to consider when using a temporal thermometer?

A
  • Place probe directly on skin, midway between one eyebrow and hairline
  • Depress probe on forehead, push start button and move slowly from forehead across temporal artery
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12
Q

What should you do when taking a rectal temp?

A
  • wear glove
  • lubricate probe cover
  • insert only 2 to 3 cm (1 in) for adults
  • designated red base
  • always hold thermometer in place
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13
Q

What things should you know about a tympanic membrane thermometer?

A
  • noninvasive, non traumatic, efficient
  • reduced risk of injury or infection
  • probe tip has shape of otoscope
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14
Q

What is the Tympanic Temperature Assessment Procedure?

A

-Gently place covered probe tip in the person’s ear canal
-temp can be read in 2-3 seconds
-straighten external ear canal
(adults= pull pinna up and back/ children <1 year=pull pinna straight back)

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15
Q

What should not be done when taking a tympanic temp?

A
  • Do not force or push hard
  • tip should not touch ear drum
  • Turn thermometer on and await beep
  • discard used probe cover
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16
Q

Pulse is the same as what?

A

HR

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17
Q

What is a normal HR for a adult?

A

60-100 bpm (95% range in 50-95)

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18
Q

Infants/children HR’s are what compared to adults?

A

Higher

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19
Q

Who typically has a lower HR?

A

conditioned athletes or a person taking certain medications

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20
Q

bradycardia is considered what?

A

<60 bpm

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21
Q

tachycardia is considered what?

A

> 100 bpm

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22
Q

What should you do if a pulse is irregular?

A

count for one full min

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23
Q

When should you start your count when taking a pulse?

A
  • start your count with “zero” for first pulse felt

- second pulse felt is “one”

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24
Q

What 3 things should you assess a pulse for?

A
  • rate (bpm)
  • rhythm
  • strength
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25
Q

Pulse force is recorded using what?

A

three-point scale

26
Q

pulse of 3+ =?

A

full, bounding (common after activity)

27
Q

pulse of 2+ =?

A

Normal (at rest)

28
Q

pulse of 1+ =?

A

Weak, thready (more common in lower extremities)

29
Q

pulse of 0 = ?

A

absent

30
Q

Normally a person’s breathing is what?

A

relaxed, regular, automatic, silent

31
Q

Because most people are unaware of their breathing don’t do what?

A

Tell them when you are assessing their respirations

32
Q

Avoid 15 seconds intervals when checking respirations, instead do what?

A

count for 30 seconds or a full minute if you suspect as abnormality

33
Q

What is the normal range of respirations for adults?

A

16-24 bpm

34
Q

What is a pulse oximeter?

A

a noninvasive method to assess arterial oxygen saturation (SpO2)

35
Q

How does a pulse oximeter work?

A

Compares ratio of light emitted to light absorbed with oxyhemoglobin and converts this ratio to percentage of oxygen saturation

36
Q

A healthy person with no lung disease and no anemia normally has an SpO2 of what?

A

97%-98%

37
Q

Earlobe probe is used for what?

A

Lower saturations

38
Q

What is a finger probe?

A

Spring loaded and feels like a clothespin attached to finger but does not hurt

39
Q

What is BP?

A

Force of blood pushing against vessel walls

40
Q

What is a average young healthy adult bp?

A

120/80 mmHg

41
Q

What is systolic pressure?

A

maximum pressure felt on artery during left ventricular contraction, or systole

42
Q

The point at which an audible sound is first heard during a bp is what?

A

Systolic BP (1st Korotkoff sound)

43
Q

What is diastolic pressure?

A

elastic recoil, or resting pressure that blood exerts constantly between each contraction, represents diastole

44
Q

Disappearance of audible bp sounds is what?

A

diastole BP (5th Korotkoff sound)

45
Q

What is a blood pressure measured with?

A

Stethoscope and shygmomanometer

46
Q

What is a bp cuff?

A

an inflatable bladder inside a cloth cover

47
Q

The width of a rubber bladder (bp cuff) should equal what?

A

80% of this circumference

48
Q

Top to bottom of bp cuff should equal what?

A

60-75% of olecranon to acromion

49
Q

An oversized bp cuff can lead to what?

A

falsely low reading

50
Q

An undersized bp cuff can lead to what?

A

falsely high reading

51
Q

how do you close and release the bulb valve when taking a bp?

A

close- turn right

open- turn left

52
Q

A manual bp should only be recorded in what?

A

even numbers

53
Q

What things are important to remember when taking a manual arm BP?

A
  • Pt. positioned correctly
  • cuff 1 inch above brachial artery
  • inflate cuff while feeling brachial artery until not felt and then add 30
  • wait 15-30 seconds after feeling brachial artery before taking bp
  • deflate cuff about 2 mmHg at a time
54
Q

What situations should you avoid taking a bp in?

A
  • Previous mastectomy/axillary surgery
  • fistula or dialysis in place or planning to be placed
  • injury/cast
  • IV in place (if possible)
55
Q

What is an alternative site to an arm bp?

A

thigh (systolic value usually 10-40mmHg higher and diastolic same)

56
Q

what position should you take a thigh bp in?

A

prone

57
Q

Thigh cuff should be centered over what?

A

popliteal artery on back of knee

58
Q

What situations should you take orthostatic/postural vital signs?

A
  • You suspect volume depletion
  • Person reports fainting or syncope
  • Person reports feeling lightheaded when going from lying or sitting to standing
  • may or may not be on bp meds
59
Q

How do you perform Orthostatic bps?

A
  • supine for five min
  • then take bp and pulse
  • pt stands 2-3 min and then take bp and pulse while standing
  • depend on policy may do bp while sitting also
  • if pt can’t stand have them sit EOB
60
Q

What are positive orthostatic bp findings?

A
  • SBP drops > or equal 20 mmHg
  • DBP drops > or equal 10 mmHg
  • and/or HR increases > or equal 20 bpm

Health Assessment Theory Exam 1 (8 decks)

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