Ch 29 Vital Signs

Question 1

Nursing guidelines for taking vital signs boils down to what five things?

Answer 1

• Responsibility: Ultimately, they’re your responsibility to take, document, analyze and report.
• Equipment : Is it clean, working, appropriate?
• Method: Have a organized and systematic process, control your environment and the patient’s situation to get accurate results.
• Analyze: What is normal for them given the client’s history and meds? How will their current vitals affect their next med dose? How often do you need to check?
• Collaborate: If vitals are off, have another someone repeat using different equipment (if poss), then notify the health care provider, charge, and document.

Question 2

Temperature range for peds is lower/higher than adults, and older folks are lower/higher?

Answer 2

higher
lower

Question 3

Put the location of the where the temperature was taken in order from lowest average temp to highest, and give the average value for adults in °F and°C:

oral
rectal
axillary

What is the range of normal values?

Answer 3

Axillary 36.5°C / 97.7°F
Oral 37°C / 98.6°F
Rectal/Ear 37.5°C / 99.5°F

Range of Normal - 36°C - 38°C / 96.8°F - 100.4°F

Question 4

What are the five +1 vital signs?

Answer 4

Temperature (T), pulse (P), blood pressure (BP), respiratory rate (R), oxygen saturation (O2 sat or PulseOx)​

Pain-often called 5th vital sign, subjective (so use scale when possible)​

Question 5

What is the range of normal for pulse?

Answer 5

60-100, strong and regular

Question 6

What is the range of normal for pulse oximetry pulse SpO2?

Answer 6

≥95%

Question 7

What is the normal range for respirations?

Answer 7

12-20, deep and regular

Question 8

What is the normal range for blood pressure?

Answer 8

Systolic <120 mm Hg

Diastolic <80 mm Hg

Pulse pressure: 30 to 50 mm Hg

Question 9

What is a pulse pressure, why do we care, and how do you calculate it?

Answer 9

*A pulse pressure is an indirect measure of how stiff blood vessels in general are. If they’re squishy, they stretch to accommodate the force of the blood moving through, and as a result, the systolic and diastolic numbers will be closer together. A bigger pulse pressure means the vessels are stiffer because all the energy of the heartbeat goes to moving the blood, not to expanding the blood vessels.
*Pulse pressure is a better predictor than SBP, independent of DBP levels, for risk of heart stuff.
* Just subtract diastolic from systolic to figure it out.

Question 10

What are normal values for Capnography EtCO2?

Answer 10

34-45 mmHg

Question 11

What is are the purposes of taking vitals?
Why do we care why we take vitals?

Answer 11

Baseline data​

Identify problems​

Evaluate response to intervention

Knowing why means you know when. When do you need baseline data? Admission, before surgery, before meds, etc. When do you need to identify problems? When someone is sick and in the hospital, so they’ll need monitoring based on their condition.
When do you need to evaluate response to intervention? After it, so , after surgery, after meds, etc.

Question 12

Body temperature = _________ - __________
Why do we care?

Answer 12

*Heat produced – heat lost = body temperature

*If someone’s body temperature is off, we can use our knowledge of how it’s produced and lost to manage it.

Question 13

The ___________________ controls our temperature.
The anterior/posterior controls heat loss and goes to work when our temperature is above/below the set point.
The anterior/posterior controls heat production and goes to work when our temperature is above/below the set point.

Answer 13

• Hypothalamus
• anterior, above
• posterior, below

Question 14

Why do we care about shivering?

Answer 14

It increases the patient’s energy use by 4-5 times, Important if your patient is fragile to begin with.

Question 15

The ability of a person to adjust their environment in response to body temperature depends on what four things?

Answer 15

(1) the degree of temperature extreme,
(2) the person’s ability to sense feeling comfortable or uncomfortable,
(3) thought processes or emotions, and
(4) the person’s mobility or ability to remove or add clothes.

Question 16

What is a FUO?

Answer 16

Fever of unknown origin

Question 17

What is the difference between a hyperthermia and pyrexia?

Answer 17

Pyrexia is a fever, and is created by the body.
Hyperthermia happens at higher temperatures, and is the result of our environment being warmer than our bodies can compensate for.

Question 18

What metabolic pressures are created by pyrexia?

Answer 18

The increase in respiratory rate, pulse, and metabolic needs place a large demand on water, oxygen, and caloric stores. If these are already compromised, as is the case for people with malnutrition, cardiac or pulmonary issues, cellular hypoxia can result.

Question 19

What are the four patterns of fever?

Answer 19

Question 20

How do you convert from °F to °C ?

Answer 20

minus 32, divide by 1.8

Question 21

Why do we measure pulse?

Answer 21

It is the primary indicator of circulatory status. A pulse tells you that the heart is beating and that the flow is reaching where ever you’re measuring it. Speed, regularity and strength give you information about what the heart is doing.

Question 22

How do you rate pulse strength?

Answer 22

Strength:
Bounding 4+
Strong 3+
Normal 2+
Weak 1+
None 0​

Question 23

What is a pulse deficit?

Answer 23

The difference between the apical and radial pulse taken at the same time

Question 24

Where can you take a pulse?

Answer 24

bc updraft
temporal,
carotid,
apical (use stethoscope),
brachial,
radial,
ulnar,
femoral,
popliteal,
posterior tibial
dorsalis pedis

Question 25

How old do you have to be to use an ear thermometer?

Answer 25

6 months +

Question 26

What is cardiac output defined as?

Answer 26

How much blood the heart pumps in 1 minute

Question 27

What are the four aspects of pulse character?

Answer 27

Rate, rhythm, strength, Equality

Question 28

Movement of oxygen and carbon dioxide between the alveoli and the red blood cells is _______________

Mechanical movement of gases into and out of the lungs ________________

Distribution of red blood cells to and from the pulmonary capillaries is ________________

Answer 28

Diffusion
Ventilation
Perfusion

Question 29

What do we use the Korotkoff phases for?

Answer 29

Onset of phase 1 corresponds to the systolic pressure.

Phase 4 is the diastolic pressure in infants and children.

In adolescents and adults the fifth phase corresponds with the diastolic pressure.

In some patients the sounds are clear and distinct. In others only the beginning and ending sounds are clear.

Question 30

What do the Korotkoff phases sound like?

Answer 30

Question 31

What are the acceptable ranges of heart beats in various ages groups?

Answer 31

Question 32

What are the acceptable ranges of respiratory rates?

Answer 32

Question 33

What are factors that increase and decrease heart rate?

Answer 33

Question 34

List the names for changes in the pattern of respirations:

Answer 34

Question 35

What are factors that affect the SpO2 reading from a pulse oximeter?

Answer 35

Question 36

What patient conditions are not appropriate for electronic BP measurement?

Answer 36

Question 37

What are unexpected outcomes for temperature readings, and common interventions?

Answer 37