Slides- Ch. 12

Question 1

Vital signs will be assessed as often as ordered by the health care provider, with the judgment of need by the nurse, and by the patient’s condition.

Question 2

The body’s regulation of temperature-regulated by the hypothalamus.

Question 3

Core temperature- stays relatively constant

Question 4

A fever that rises and falls but does not return to normal until the patient is well is classified as remittent

Question 5

Tympanic thermometer-taking a tympanic temp on a child pull the pinna down and back

Question 6

When using a stethoscope for apical pulse, point the earpieces toward the face toward the face for optimal hearing

Question 7

Pulse deficit—difference between the radial and apical rates

Question 8

Factors affecting pulse rate: Age, Sex, Emotion, Temperature

Question 9

Bounding- full and spring-like even under moderate pressure

Thready-difficult to feel and not palpable when light pressure is applied.

Weak- stronger than a thready pulse but not palpable when light pressure is applied

Normal-felt but not when moderate pressure is applied

Question 10

When listening for lung sounds with a stethoscope, use the diaphragm portion

Question 11

Hypertension—blood pressure elevated

Hypotension—blood pressure below normal

Question 12

B/P log- take the same time of day and apply the cuff snugly to fit but not too tight

Apply the cuff approx 2 inches above the antecubital fossa ( bend in the elbow)

Using a blood pressure cuff that is too small will give false high BP readings.

Question 13

Normal Limits:

Temperature: 97o to 98.8o F (36.1o to 37.5o C ) ( Infant temps run 35.5-37.5 C)
Pulse rate (adult): 60 to 100 beats per minute
Respiratory rate (adult): 12 to 20 respirations per minute
Blood pressure (adult): less than 120/80 mm Hg

Question 14

Fahrenheit to Celsius- subtract 32 from the F reading and multiply by 5/9.
(98.6-32 x 5/9= 37

Celsius to Fahrenheit- multiply Celsius reading by 9/5 and add 32 to reading ( 37 x 9/5 + 32=98.6)

Question 15

Temperature, pulse, respirations, and blood pressure are usually assessed at the same time at set intervals

Question 16

A set of vital signs is taken when the patient is admitted to the facility, and then as prescribed by the health care provider or the patient’s condition dictates. Nursing judgement comes into play also

Example: every 4 hours, once a shift, weekly

The more ill the patient, the more frequently vital signs are taken