Ch. 10-Vital Signs Assessment Flashcards
What do vital signs include?
- Temperature
- Pulse
- Respirations
- Blood Pressure
- Oxygen Saturation
What is the normal range of a temperature in a resting person?
96.4* F- 99.1* F
Rectal temp is how much higher than an oral temp?
0.7* F -1* F
Tympanic temp is how much higher than an oral temp?
0.5* F- 1* F
An axillary temp is how much lower than an oral temp?
1* F
What is the Oral Temperature Assessment Procedure?
- Place thermometer under pt tongue, off to side, in sublingual pocket
- Instruct person to keep his/her lips closed
- Nurse holds thermometer in place
How long should you wait to take a temp after someone has just taken hot or iced liquids?
15 minutes
How long should you wait to take a temp if person has just smoked?
2 minutes
Electronic temps have fast results that read in how Manny seconds typically?
20-30 (disposable probe)
What are important things to consider when taking a axillary temp?
- Place probe under axilla
- Hold arm close to axilla
- Less accurate and reliable
What are things to consider when using a temporal thermometer?
- 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
What should you do when taking a rectal temp?
- wear glove
- lubricate probe cover
- insert only 2 to 3 cm (1 in) for adults
- designated red base
- always hold thermometer in place
What things should you know about a tympanic membrane thermometer?
- noninvasive, non traumatic, efficient
- reduced risk of injury or infection
- probe tip has shape of otoscope
What is the Tympanic Temperature Assessment Procedure?
-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)
What should not be done when taking a tympanic temp?
- Do not force or push hard
- tip should not touch ear drum
- Turn thermometer on and await beep
- discard used probe cover
Pulse is the same as what?
HR
What is a normal HR for a adult?
60-100 bpm (95% range in 50-95)
Infants/children HR’s are what compared to adults?
Higher
Who typically has a lower HR?
conditioned athletes or a person taking certain medications
bradycardia is considered what?
<60 bpm
tachycardia is considered what?
> 100 bpm
What should you do if a pulse is irregular?
count for one full min
When should you start your count when taking a pulse?
- start your count with “zero” for first pulse felt
- second pulse felt is “one”
What 3 things should you assess a pulse for?
- rate (bpm)
- rhythm
- strength
Pulse force is recorded using what?
three-point scale
pulse of 3+ =?
full, bounding (common after activity)
pulse of 2+ =?
Normal (at rest)
pulse of 1+ =?
Weak, thready (more common in lower extremities)
pulse of 0 = ?
absent
Normally a person’s breathing is what?
relaxed, regular, automatic, silent
Because most people are unaware of their breathing don’t do what?
Tell them when you are assessing their respirations
Avoid 15 seconds intervals when checking respirations, instead do what?
count for 30 seconds or a full minute if you suspect as abnormality
What is the normal range of respirations for adults?
16-24 bpm
What is a pulse oximeter?
a noninvasive method to assess arterial oxygen saturation (SpO2)
How does a pulse oximeter work?
Compares ratio of light emitted to light absorbed with oxyhemoglobin and converts this ratio to percentage of oxygen saturation
A healthy person with no lung disease and no anemia normally has an SpO2 of what?
97%-98%
Earlobe probe is used for what?
Lower saturations
What is a finger probe?
Spring loaded and feels like a clothespin attached to finger but does not hurt
What is BP?
Force of blood pushing against vessel walls
What is a average young healthy adult bp?
120/80 mmHg
What is systolic pressure?
maximum pressure felt on artery during left ventricular contraction, or systole
The point at which an audible sound is first heard during a bp is what?
Systolic BP (1st Korotkoff sound)
What is diastolic pressure?
elastic recoil, or resting pressure that blood exerts constantly between each contraction, represents diastole
Disappearance of audible bp sounds is what?
diastole BP (5th Korotkoff sound)
What is a blood pressure measured with?
Stethoscope and shygmomanometer
What is a bp cuff?
an inflatable bladder inside a cloth cover
The width of a rubber bladder (bp cuff) should equal what?
80% of this circumference
Top to bottom of bp cuff should equal what?
60-75% of olecranon to acromion
An oversized bp cuff can lead to what?
falsely low reading
An undersized bp cuff can lead to what?
falsely high reading
how do you close and release the bulb valve when taking a bp?
close- turn right
open- turn left
A manual bp should only be recorded in what?
even numbers
What things are important to remember when taking a manual arm BP?
- 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
What situations should you avoid taking a bp in?
- Previous mastectomy/axillary surgery
- fistula or dialysis in place or planning to be placed
- injury/cast
- IV in place (if possible)
What is an alternative site to an arm bp?
thigh (systolic value usually 10-40mmHg higher and diastolic same)
what position should you take a thigh bp in?
prone
Thigh cuff should be centered over what?
popliteal artery on back of knee
What situations should you take orthostatic/postural vital signs?
- 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
How do you perform Orthostatic bps?
- 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
What are positive orthostatic bp findings?
- SBP drops > or equal 20 mmHg
- DBP drops > or equal 10 mmHg
- and/or HR increases > or equal 20 bpm
