Chapter 5: Vital Signs

Question 1

What are the main vital signs?

Answer 1

Temp, BP, Pulse, Respirations, 02 Sat, Pain

Question 2

Best practices for counting respirations

Answer 2

Obtain 60 seconds when respirations are low or high; Obtain when patient is unaware; accurate prediction of cardiac arrest/patient deterioration

Question 3

Best practices for body temp

Answer 3

Normal range 96.8-100.4; communicate appropriate route, device, and frequency. Any positioning precautions.

Question 4

What are symptoms of ineffective tissue perfusion? Think when taking a pulse

Answer 4

Pallor/cool skin distal to weak pulse. Swelling in tissues may impede blood flow.

Question 5

What to do if pulse is too high (over 100) or too low (under 60)?

Answer 5

Assess for factors that would increase or decrease heart rate. Observe for signs and symptoms that are associated with abnormal cardiac function.

Question 6

What are unexpected respiration outcomes? How do you handle them?

Answer 6

Below 12 breaths/min (bradypnea) and over 20 (tachpnea). Bring patient to sitting position if allowed, provide 02 as ordered, assess environmental factors, notify health provider of changes

Question 7

What are Kussmaul respirations?

Answer 7

Rapid, deep breathing at a consistent pace. They are indicative of metabolic acidosis, or when the body accumulates too much acid. Kussmaul respirations are occasionally described as air hunger, emphasizing the strong need to breathe

Question 8

What are Cheyne-Stokes respirations?

Answer 8

Rare abnormal breathing pattern that can occur while awake but usually occurs during sleep. The pattern involves a period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all, called apneas.

Question 9

What are Biot respirations?

Answer 9

A term rarely used today that describes an abnormal respiration pattern. Biot’s breathing occurs when periods of apnoea alternate irregularly with series of breaths of equal depth that terminate abruptly, and is associated with meningitis

Question 10

What do you do if patient BP is high?

Answer 10

Repeat measurement in other extremities and compare findings; verify correct size and placement of cuff; have another nurse repeat the measurement in 1-2 min; report to provider, administer meds as ordered

Question 11

What do you do if patient BP is low?

Answer 11

Compare BP to baseline; position supine/restrict activity; assess for signs and symptoms associated with hypotension (blurry vision, confusion, dizziness, fainting, nausea/vomiting, weakness); report to provider; increase rate of IV infusion or administer meds as ordered

Question 12

What do you do if you can’t obtain BP reading?

Answer 12

Determine that no immediate crisis is present by obtaining plus and respiratory rate

Question 13

What are specific factors that falsely lower 02?

Answer 13

Motion artifact, hypotension, nail polish, dark skin, venous pulsations

Question 14

Sterile Field Principles

Answer 14

1. Sterile field remains sterile only if other objects that touch it are sterile
2. If your hands or sterile object drop below waist level, both are considered contaminated
3. Becomes contaminated if moisture permeates the field