Chapter 28—Vital Signs Flashcards

1
Q

when to assess VS

A

On every admission, every office visit
Before & after procedures/interventions
Anytime there is a change in status
Before d/c

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2
Q

normal temp oral

A

98.6 to 99.5 F

36 to 37.5 C

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3
Q

VS

A
temp
HR
RR
BP
O2
pain
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4
Q

2 types of body temp

A

surface

core

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5
Q

________ regulates temp

A

hypothalamus

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6
Q

URGENT temp assessment

A

<95 F or 35 C

>103.1 F or 39.5 C

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7
Q

5 temp routes

A
oral
axillary
tympanic
temporal (TAT)
rectal
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8
Q

safest but least accurate temp reading

A

axillary

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9
Q

preferred temp route for newborns

A

axillary

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10
Q

rectal temp is taken if pt…

A

is comatose, confused, having seizures, or unable to close the mouth

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11
Q

insert rectal thermometer ____ into anus

A

1.5”

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12
Q

leave axillary thermometer in for ___ mins

A

10

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13
Q

rectal temp is ____ higher than oral temp

A
  1. 7 to 1 F

0. 5 C

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14
Q

axillary temp is _____ lower than oral temp

A

1 F

0.5 C

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15
Q

tympanic temp is _____ higher than oral temp

A
  1. 4 F

0. 8 C

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16
Q

TAT temp is a little bit ______ than oral

A

higher

17
Q

location of apical pulse

A

5th intercostal space (adult)

midclavicular

18
Q

normal HR for adults

A

60-100 bpm

19
Q

pulse locations

A

Apical, temporal, carotid, radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsalis pedis

20
Q

count for _____ time for apical pulse

A

1 full minute

21
Q

dehydration effect on pulse

A

HR increases, then decreases as we lose fluid volume

22
Q

5 things when assessing pulse

A
Rate
Rhythm
Strength
Elasticity
Symmetry
23
Q

Pulse deficit

A

difference between apical & peripheral pulse, or 2 peripheral pulses

24
Q

pulse alternans

A

irregular - strong & weak together

25
Q

pulse bisferiens

A

double heartbeats - aortic valve regurgitation

26
Q

normal RR

A

12-20 breaths/min

27
Q

breathing controlled by…

A

medulla oblongata, pons, carotid and aortic bodies

28
Q

4 things when assessing respiration

A

Rate (Inspiration and expiration)
Rhythm (Interval between breaths)
Depth (Body position and medications)
Quality (The effort to breathe of sound)

29
Q

SPO2

A

O2 saturation level

30
Q

normal O2 sat

A

97%-100%

31
Q

possible emergency O2 sat

A

<85%

32
Q

how to document doppled or palpated BP

A

120/doppled or palpated

33
Q

normal BP

A

110/70 mmHg

34
Q

hypotension

A

<100 SBP

35
Q

hypertension

A

> 120 SBP

36
Q

point of maximal impulse

A

best place to palpate apical pulse

37
Q

mean arterial pressure

A

the average arterial pressure throughout one cardiac cycle, systole, and diastole

38
Q

finding mean arterial pressure

A

[2(DBP) + SBP] / 3