NUR 116 CL - TPR (Vitals)

Question 1

What are the 5 vital signs?

Answer 1

• Temperature
• Pulse
• Respirations
• Blood Pressure
• Pain

Question 2

What is the purpose of Vital Signs?

Answer 2

-Reflect essential body functions
-Get a baseline of patient’s health
-Reflect changes in patient’s health (improvement of deterioration)

Question 3

When do we take Vital signs?

Answer 3

• On admission
• Prior to administration of any medication that affects: heart rate, BP or respiration rate
• Anytime the client’s condition changes or they have a complaint
• At the beginning of your shift
• Whenever the client is leaving unit or returning to unit for testing (PT, OT, etc)
• According to agency policy

Question 4

What are we measuring when we take a client’s temp?

Answer 4

The difference between the heat the body produced through metabolism and the heat lost to the environment

Question 6

Areas to acquire temperature, and their effectiveness

Answer 6

Oral: common
Axillary: least accurate; 0.5 degrees lower than oral
Rectal: most accurate; sims position; 0.9 degrees higher than oral
Temporal
Tympanic: child, pull ear down and back; adult, pull ear up and back (inspect ear for cerumen/ear wax); 0.5 degrees lower than oral

Question 7

Which temps sites give different readings compared to oral temp?

Answer 7

Rectal: 0.9 degrees higher than oral
Axillary & Tympanic: 0.5 degrees lower

Question 8

What is the expected body temperature?

Answer 8

96.8 - 100.4 Fahrenheit
Average is 98.6
Older adults = lower end of normal

Question 10

How far should the nurse insert the Rectal Thermometer for: adult, child, infant

Answer 10

Adult: 1-1.5 inches
Children: 0.5-1 inch
Babies: About 0.5 inches

Question 11

When would you not take an oral temperature?

Answer 11

• Inaccurate if client ate/drank/smoked in past 30 minutes
• Safety concern for newborns, infants and young children

Question 12

When would you not take a rectal temperature?

Answer 12

• Immune compromised
• Cardiac history (thermometer hits vagus nerve)
• Diarrhea, hemorrhoids
• Rectal surgery, coagulation disorders or
• If the patient has a sewn anus

Question 13

Factors that affect temperature

Answer 13

Age, exercise, hydration levels, medications, daily fluctuations, health status

Question 14

What is a normal pulse?
What are the names for low and high pulse rate?

Answer 14

Normal: 60-100 bpm
Bradycardia - Less than 60 bpm
Tachycardia - Greater than 100 bpm

Question 15

Factors that affect pulse

Answer 15

Age, exercise, hydration levels, medication, temperature, position changes

Question 16

What is the pulse deficit?

Answer 16

Difference between apical and radial pulse by more than 2 beats, when assessed by 2 nurses

Question 17

What adjectives would you describe a pulse with?

Answer 17

Bounding +4
Strong +3
Weak +2
Thready +1
No pulse 0

Question 18

List the landmark pulse sites

Answer 18

Temporal - temples; side of forehead
Carotid - Neck, under jaw
Apical - 5th intercostal space/mid clavicular line; PMI (point of maximum impact, apex of heart)
Brachial - “palm” side of elbow joint
Ulna - Pinky side wrist
Radial - Thumb side wrist
Femoral - Groin; upper thigh, where femur joints pelvis
Popliteal - Behind the knee
Posterior tibial - Lateral side of foot, behind ankle?
Dorsal pedal - Top of foot

Question 19

What is the normal respiration rate for an adult?
What is the term for low and high respiration?

Answer 19

12-20 breaths (inhalation and exhalation)

Tachypnea - Greater than 20 resp
Bradypnea - Lower than 12 resp

Question 20

What is eupnea vs apnea?

Answer 20

Eupnea - Normal respiration (Think eu = true)
Apnea - No respiration

Question 21

What are dyspnea and orthopnea?

Answer 21

Dyspnea - Difficulty breathing
Orthopnea - Difficulty breathing when supine

Question 22

Adjectives to describe respiration?

Answer 22

Pattern: regular or irregular
Shallow or deep

Question 23

What is Systolic and Diastolic BP?

Answer 23

Systolic BP: The maximum amount of pressure exerted when the heart contracts and forces blood into the aorta
Diastolic BP: The minimum amount of pressure exerted when the heart is relaxed

Question 24

What is hypertension?
Define Stage I and II Hypertension

Answer 24

Hypertension - blood pressure above the expected reference range

Stage I hypertension - systolic pressure is 130 to 139 mm Hg, or the
diastolic pressure is 80 to 89 mm Hg

Stage II hypertension - Systolic pressure is greater than 140 mm Hg or the diastolic pressure is greater than 90 mm Hg

Question 25

What is a hypertensive crisis?

Answer 25

Hypertensive crisis - when the systolic pressure is greater than 180 mm Hg
and/or the diastolic pressure is greater than 120 mm Hg

Question 26

How to estimate systolic pressure?

Answer 26

Palpate the brachial artery while inflating the cuff by increments of 10
- When pulse is lost add 20-30 mmHG then release feeling for return of brachial, which is estimate systolic

Question 27

How to measure cuff?

Answer 27

40% arm circumference = cuff bladder width
80% arm circumference = cuff bladder length
- Too large will give false lower reading
- Too tight will give false higher reading

Question 28

How to get systolic-diastolic

Answer 28

Pump up cuff to 20-30 mmHG above estimated systolic, release 2mmHG/sec
Initial sound is systolic
Last sound is diastolic

Question 29

What is oxygenation saturation?

Answer 29

The estimated amount of oxygen bound to the hemoglobin
- It’s a direct reflection of client’s respiratory status
-Expected range is 95%-100%