Lesson 4 Flashcards
Temperature Abnormally low: Normal: Abnormal high: Abnormal high (severe):
Abnormal low: 35 C
Normal: 37 C
Abnormal high: 38.5 C
Abnormal high (severe): 40 C
BP Normal: Prehypertension: Stage 1 HTN: Stage 2 HTN:
Normal: SBP 90-119 DBP: 60-79
Prehypertension: SBP 120-139 DBP: 80-89
Stage 1 HTN: SBP 140-159 DBP: 90-99
Stage 2 HTN: SBP >160 DBP: >100
Where do you do oral temperature and what would you instruct the patient to do?
Place under the tongue (sublingual pocket) and instruct patient to keep their lips closed
Where do you do axillary temp?
Place snugly in the axilla (arm pit)
What is the most accurate temp route?
Rectal
Where do you do rectal? And describe technique.
Rectum; Wear gloves; insert ubricated thermometer (with cover) 2-3 cm in the adult rectum toward the umbilicus. Do not let go of the thermometer while testing
Where do you do tympanic membrane temp?
Patients ear canal and aim the infrared beam at the tympanic membrane; do not occlude the canal
Where do you do temporal artery temp? and How?
Forehead and behind the ear; slide the probe across the forehead and behind the ear
What artery do you palpate to measure HR?
Radial
If you are measuring HR and everything is normal, how long would you be counting for? And what would you do?
30 seconds; multiply by 2
If you are measuring HR and during the first 30 seconds notice something abnormal, how long would you be counting for?
60 seconds
HR: 3+: 2+: 1+: 0:
3+: Full, bounding (anxiety, exercise, some abnormal conditions)
2+: Normal
1+: Weak, thready (decreased stroke volume)
0: Absent
When do you count respirations? Why is it best to be sneaky about this?
Count respirations for 30 seconds after you count HR. If you suspect something normal, count the full minute. It is best to be sneaky about this because if you are not sneaky and tell the patient you are counting respirations, they will begin to breathe oddly
What procedure do you allow the patient to rest for 5 minutes before testing?
BP
What are the pros and cons for measuring temporal temp?
Pro: Accurate
Con: If you are sweating (common with fever), you may not get an accurate temp
What are the pros and cons of measuring tympanic temp?
Con: Not very accurate due to earwax
What are the pros and cons of measuring axillary temp?
Con: Measuring under the weak arm of a stroke patient will give a false reading
Con: Not as accurate because it is external
What are the pros and cons of measuring oral temp?
Con: Hard with noncompliant/unconscious patients
Con: Chewing gum and recently eating changes temperature
What are the pros and cons of measuring rectal temp?
Pro: Accurate
Con: Invasive
What color thermometer is used to measure rectal temp?
Red
What color thermometer is used to measure oral/axillary temp?
Blue
A 35 C temp means they may be _____.
Hypothermic
A 37 C temp means it is ____.
Normal
A 38.5 C temp means the patient has a _____.
Fever
