NSG 1610 - Vitals

Question 1

What is the purpose of taking vital signs?

Answer 1

provides a baseline of client’s thermoregulatory, respiratory, and cardiovascular status

Question 2

what is the normal stable core temperature?

Answer 2

37.2 degrees

Question 3

what is one risk associated with taking a rectal temperature?

Answer 3

it may stimulate the vagus nerve which may result in bradycardia (slowed HR) and syncope (temporary LOC)

Question 4

what may increase temperature?

Answer 4

increased metabolism, during/post-exercise, after eating, and external envrionments

Question 5

what may contribute to heat loss?

Answer 5

heat radiation, sweat evaporation, convection (air currents), reduction (cold cloth)

Question 6

at what point of the day is body temperature the lowest?

Answer 6

during sleep

Question 7

how does age effect body temperature?

Answer 7

older and younger individuals may have reduced temperatures

older adults have a reduced capacity to conserve heat and detect cold due to degeneration of nerves

Question 8

what range does temperature have to be above in order to be classified as hyperthermic? where must this temperature be taken?

Answer 8

greater than 40.0 degrees - must be taken through a rectal temperature

Question 9

what range does temperature have to be above in order to be classified as hypothermic? where must this temperature be taken?

Answer 9

equal to or lower than 35.0 degrees - must be taken through a rectal temperature

Question 10

describe febrile and afebrile, what their ranges are, and where these temperatures are taken

Answer 10

• febrile is a pt with a fever ranging above 38 degrees
• afebrile is a pt without a fever and temp within a normal range (35.8-38.0)
• taken through tympanic temperatures

Question 11

what are the normal/average ranges of tympanic temperature?

Answer 11

could range from 35.8 to 38.0 degrees but averages at 36.5

Question 12

what are the normal/average ranges of temporal temperature?

Answer 12

could range from 36.5 to 37.5 but average is 37.0 degrees

Question 13

What are the five sites for temperature?

Answer 13

1. tympanic
2. temporal
3. rectal
4. oral
5. axillary

Question 14

what is the pathophysiology of a pulse?

Answer 14

we are feeling a pressure wave from the left ventricle of the heart

Question 15

what 10 factors may influence pulse/HR?

Answer 15

1. age
2. disease
3. stress
4. exercise
5. ethnicity
6. temperature (fever will increase HR)
7. acute vs chronic pain
8. positional changes
9. lung changes
10. medical emergencies (hemorrhaging)

Question 16

how does acute vs. chronic pain influence HR/pulse?

Answer 16

• acute pain will increase pulse rate
• chronic pain does not create changes in pulse

Question 17

what is the normal range for pulse rate?

Answer 17

50-95 beats per minute

Question 18

describe the pulse scale and what each number correlates to

Answer 18

0 – absent pulse (cannot feel it or not palpable)
1+ - weak or thready pulse (can barely feel it), diminished, weak, and barely palpable – easy to obliterate
2+ - normal pulse (Obliterate with slight pressure)
3+ - full and bounding pulse (obliterate with firm pressure or unable to obliterate)

Question 19

list the 8 sites for pulse palpation

Answer 19

1. carotid
2. brachial
3. radial
4. popliteal
5. dorsalis pedis
6. apical
7. femoral
8. posterior tibial

Question 20

what parts of the brain determine resp. rate?

Answer 20

medulla oblongata and pons

Question 21

what is a normal range for resp. rate?

Answer 21

12-20

Question 22

if resp. rate is coming out as abnormal, how long should you record for?

Answer 22

1 full minute

Question 23

what is tachypnea?

Answer 23

fast resp. rate above 20

Question 24

what is bradypnea?

Answer 24

slow resp. rate - below 12

Question 25

what is dyspnea?

Answer 25

difficulty breathing

Question 26

what is hyperpnea?

Answer 26

fast and elevated depth - could be caused by exercise

Question 27

what is the difference between hyperventilation and hyperpnea?

Answer 27

Hyperpnea is breathing more deeply but not necessarily faster. It happens when you exercise or when you're doing something strenuous. Hyperventilation is breathing very fast and deeply, and exhaling more air than you take in.

Question 28

what is apnea?

Answer 28

no breathing for several seconds

Question 29

what is hypoventilation?

Answer 29

low rate and shallow

Question 30

what is the normal range for BP?

Answer 30

135/80

Question 31

what is orthostatic hypotension?

Answer 31

If systolic drops 20 or more mmHg and HR goes up by 20 beats or more when position is changing

Question 32

What are the three portions of a general survey?

Answer 32

1. Physical appearance 2. Mobility 3. Behaviour

Question 33

What 6 components are part of the physical appearance portion of a general survey?

Answer 33

1. Age (appears vs. actual) 2. sex 3. LOC X3 or X4 (place, person, time) & (know the situation) 4. skin colour and lesions 5. facial features (symmetry) 6. body structure

Question 34

what component is part of mobility in the general survey?

Answer 34

Gait - coordinated or uncoordinated, ROM

Question 35

what 5 parts are part of the behaviour component of general survey?

Answer 35

1. facial expressions 2. mode & affect 3. speech 4. dress 5. personal hygiene

Question 36

what is the gate control theory?

Answer 36

closing the ‘gate’ of sensations from entering the brain to provide a perception of pain Includes the notion that the perception of pain may be altered by stimulating other sensory pathways that interefere with the transmission of pain messages to the brain

Question 37

what are the 4 sources of pain?

Answer 37

1. somatic - damage to the tissue that creates pain 2. visceral - anything relating to the internal organs 3. neuropathic - relating to the nerves 4. referred - pain that originates from another area and shows in a separate area (i.e., appendicitis, myocardial infarction)

Question 38

What does OPQRSTUV stand for? explain each one

Answer 38

o Onset – when did it start? o Provocative and palliative – what makes it better, what makes it worse? o Quality – what kind of pain? Can you describe it for me? o Region/radiation – show me where the pain is o Severity – pain scale 0-10 o Treatment and timing – what have you done to help it? Does it happen at a certain time of day? o Understanding – do you think this could be caused by anything? o Values – how is this pain impacting your life and ADLs? Any limitations due to pain?

Question 39

What is considered as the fifth vital sign?

Answer 39

Pain

Question 40

How would you assess pain in an unconscious individual?

Answer 40

Individuals will exhibit grimacing, wincing, rigidity, or shaking