Untitled Deck Flashcards
What are the vital signs that are commonly measured?
Body temperature, pulse, blood pressure, respiratory rate, and oxygen saturation.
What factors can influence vital signs?
Pain, environmental temperature, physical state, activities, or illness.
What is referred to as the ‘fifth vital sign’?
Pain.
Who is responsible for interpreting and acting on vital sign measurements?
The nurse is responsible, although unregulated care providers (UCPs) can take vital signs.
What is thermoregulation?
The process of regulating body temperature, primarily controlled by the hypothalamus.
What is the normal temperature range for adults?
36°C to 38°C.
What are the common sites for measuring body temperature?
Rectal, skin, oral, axillary, tympanic, and temporal.
What are some alterations in body temperature?
Fever (pyrexia), hyperpyrexia, hyperthermia, heatstroke, heat exhaustion, hypothermia.
What is the normal adult pulse rate?
60-100 beats per minute.
What factors influence pulse rate?
Exercise, temperature, emotions, pain, medications, hemorrhage, and postural changes.
What is the normal respiratory rate for adults?
12-20 breaths per minute.
What are the components of respiratory assessment?
Respiratory rate, pattern, depth, SpO2, ventilation, diffusion, perfusion.
What is the average normal blood pressure range?
120/80 mm Hg.
What are some nursing diagnoses related to blood pressure?
Anxiety, decreased cardiac output, deficient/excess fluid volume, risk for injury.
What is the significance of monitoring vital signs?
It provides baseline data for future assessments and helps in identifying health issues.
What are the common nursing diagnoses for temperature alterations?
Risk for imbalanced body temperature, hyperthermia, hypothermia, ineffective thermoregulation.
What should a nurse do if a patient has an irregular pulse?
Assess the apical pulse rate for one full minute.
What is the role of the diaphragm in respiration?
It aids in inspiration, which is an active process.
What is the purpose of the pulse pressure measurement?
To evaluate the difference between systolic and diastolic blood pressure.
What are the signs and symptoms of right-sided heart failure?
Shortness of breath, fatigue, and peripheral edema.
What is the average oral temperature?
37°C.
What is the average rectal temperature?
37.5°C.
What is the average axillary temperature?
36.5°C.
What should be done before taking oral temperature after eating?
Wait 30 minutes before taking the oral temperature.
