INP 200 vital signs

Question 1

what is the range for Temperature and what does it measure

Answer 1

normal: 36-38
oral and tympanic: 37
rectal: 37.5
axillary: 36.5
measures the heat production and heat loss in the body’s core

Question 2

what is hypothermia?

Answer 2

body temp below normal 36

Question 3

what is hyperthermia?

Answer 3

hyperthermia is high temperature, above 38

Question 4

what are some factors affecting temperature?

Answer 4

• anything to eat or drink 30 mins before
• age (lower body fat = less insulation to keep them warm, thinner skin making it harder for the heat to stay in)
• exercise (any sort of exercise can increase temperature)
• hormones (estrogen and progesterone increase and decrease in the body making the body feel hot and cold at times)
• circadian rhythm (is the body’s 24hr clock that regulates temp from 4-6am early hours the body is cooler, during 4-7pm the body is warmer)
• neurological conditions affecting the hypothalamus (regulates body’s temp) ex, stroke, Alzheimer’s, dementia
• environment (colder room vs sunny summer day)

Question 5

S&S of hyperthermia

Answer 5

• heat stroke (confusion, no sweating, rapid breathing and pulses)
• heat exhaustion ( dehydration, heavy sweating, pale and moist skin)
• dehydration (dry mouth, lightheadedness, headache, cracked lips)

Question 6

S&S of hypothermia

Answer 6

• frostbite
• cyanosis
• slow pulse (bc as body becomes cooler pulse is harder to find)
• cool to the touch and appear pallor

Question 7

what does pyrexia mean

Answer 7

fever triggered by pathogens (infections) anything above 38 and bellow 39

Question 8

what are some advantages and disadvantages of getting a oral temperature?

Answer 8

advantage: oral is accessible and no position changes are needed, doesn’t cause pain or discomfort

disadvantage: ate or drank anything 30 mins prior, don’t use when patient is unconscious, if patient may bite, if their confused and wont follow instructions (close your mouth), or have facial reconstruction surgery.

Question 9

what are some advantages and disadvantages of getting a rectal temperature?

Answer 9

advantage: most reliable because it’s closest to the body’s core temperature

disadvantage: its invasive may cause discomfort, don’t use if patient has hemorrhoids, diarrhea, constipated (impacted stool), lubricant is required, risk for injury if done incorrectly

Question 10

what are some advantages and disadvantages of getting a axilla temperature?

Answer 10

advantage: is non-invasive

disadvantage: sweaty, lack of ROM, excessive clothing or layers

Question 11

what are some advantages and disadvantages of getting a tympanic temperature?

Answer 11

advantage: no need to move or disturb patient to get reading, can be used in a unconscious patient, can be used in a aggressive patient because your out of their sight

disadvantage: reading will be altered if cerumen or otitis media are present, hearing aid, external factors like fans or heaters, and use of improper technique (like pulling the pina up and back)

Question 12

what does pulse measure and what is the range

Answer 12

60-100 bpm
how much blood is flowing through the body and how well it’s being pumped (measures HR, blood volume)

Question 13

what are the different 10 pulse points

Answer 13

• temporal
• carotid (on the neck below the jawline)
• apical (between the 4th or 5th intercostal space nipple line)
• brachial (ringer finger up or inner arm side)
• radial (on wrist at thumb side)
• ulnar (on wrist on pinky side)
• femoral
• popliteal (behind the knee)
• dorsalis pedis (foot pulse)
• posterior tibial (foot pulse)

Question 14

factors influencing pulses

Answer 14

• any caffeine consumptions
• exercise increases HR
• emotions like fear or anxiety raise HR
• medications (beta blockers and lower HR, other meds include opioids (makes person low and slow), antidysrhythmic, calcium channel blockers)
• heart conditions arrhythmias, HF, MI

Question 15

for pulses what do we note down for when we document?

Answer 15

rate: numerical value
rhythm: regular/irregular
strength, depth: weak, thready, strong, bounding, easy, shallow, labored
equality: bilaterally

Question 16

what does respirations measure and what is the range

Answer 16

12-20 breaths per min (bpm)
were measuring the inhalation and expiration (ventilation)

Question 17

what does hypoxemia mean

Answer 17

not enough oxygen in the blood
hyp= low
ox= oxygen
emia= in the blood

Question 18

what does hypoxia mean

Answer 18

not enough oxygen in the tissues

Question 19

what does bradypnea mean

Answer 19

means abnormally slow breathing under 12 bpm

Question 20

what does tachycardia mean

Answer 20

fast heat rate above 100bpm

Question 21

what does tachypnea mean

Answer 21

fast breathing above 20 bpm

Question 22

what does bradycardia mean

Answer 22

slow heartrate below 60 bpm

Question 23

factors affecting respirations…

Answer 23

-exercise; breathing increases to meet the bodys needs
- emotions; like pain, fear, and stress can increase bodys breathing
- body position; being flat gives you better results than being slumped
- medications like bronchodilators and opioids can affect the respiration rate
- smoking causes damage to the lungs and increases breathing rate

Question 24

what is the rate of SpO2 and what does it messure

Answer 24

95-100%
measures the arterial blood (oxygenated blood) and measures the oxygen that’s already in the blood attached to the hemoglobin

Question 25

when measuring pulse oximeter when should you avoid checking the fingers?

Answer 25

- cyanotic - cold - fidgety - nail polish or artificial nails (block or interfere light sensors)

Question 26

with someone who has COPD what is appropriate rate of SpO2

Answer 26

85-89% less than 85% is abnormal when pt is on air dont go above 92% because you'll over oxygenate them giving too much CO2 in their body

Question 27

what normal rages for blood pressure and what does it measure?

Answer 27

hypotension 90/60 hypertension 140/90 measure the pressure of the blood against the arterial walls

Question 28

what is cardiac output

Answer 28

amount of blood your heart pumps in one minute

Question 29

factors affecting blood pressure

Answer 29

- smoking; makes blood vessels constrict (narrow) giving a higher blood pressure - emotions like fear, anxiety, stress, pain stimulate the fight or flight increasing HR, breathing, and BP - daily variations (bodys 24hr clock) circadian rhythm in mornings and evening bp usually low bc your just starting off your day, midday bp could be higher bc of the activity - medications; pt on antihypertensive drugs could give us a lower bp ready, adrenergic medications stimulate fight or flight and increase BP.

Question 30

What are medications you could provide for someone who has high vital signs

Answer 30

beta 1 drugs; help the heart (lowers blood pressure and HR) beta 2 drugs; helps with vasodilation of the lungs (lowers respirations for tachypnea ie. bronchodilators) classifications - antihypertensive - antidysrhythmic - antipyretic

Question 31

What are medications you could provide for someone who has low vital signs

Answer 31

agonists medications epinephrine, norepinephrine, dopamine (these will stimulate the fight or flight to increase low BP, HR, and respirations)