Vital Signs

Question 1

Vital Signs

Answer 1

Objective measurement for the essential physiological functions of a living organism.

Question 2

Vital Signs - Primary Survey

Answer 2

Airway, breathing, circulation, disability, exposure, fluids, glucose

Question 3

Airway

Answer 3

Assess airway patency

Question 4

Breathing

Answer 4

Measure respiratory rate. Evaluate work of breathing. Measure oxygen saturation

Question 5

Circulation

Answer 5

Palpate pulse, rate, and rhythm. Measure manual blood pressure. Assess urine output.

Question 6

Disability

Answer 6

Assess the level of consciousness. Evaluate speech. Assess pain.

Question 7

Exposure

Answer 7

Measure body temperature. Inspect skin integrity. Observe any wound, dressings, drains, invasive lines. Observe ability to transfer and mobilise. Assess bowel movements

Question 8

Fluids

Answer 8

Assess input and output

Question 9

Glucose

Answer 9

BSL

Question 10

Vital signs and interpretation

Answer 10

Knowledge, Analysis, Critical thinking

Question 11

Vital signs and interpretation - Knowledge

Answer 11

Knowledge of normal physiology and acceptable ranges

Question 12

Vital signs and interpretation - Analysis

Answer 12

Analysis of trends over time for the patient

Question 13

Vital signs and interpretation - Critical Thinking

Answer 13

Critical thinking and knowledge of how illness or treatment may affect vital signs

Question 14

Guidelines for measuring vital signs

Answer 14

Knowledge, responsibility and delegation, frequency of measurement, equipment, approaching the patient, systematic approach, analysis and interpretation, and communicate findings

Question 15

Observations

Answer 15

respiratory rate, oxygen saturation, blood pressure, heart rate, temperature, level of consciousness, pain score as a minimum

Question 16

Respiratory rate adult

Answer 16

12-20

Question 17

Respiratory rate child

Answer 17

20-30

Question 18

Oxygen Saturation

Answer 18

95%-100%

Question 19

Common sites for palpation

Answer 19

Carotid, brachial, radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis.

Question 20

Carotid

Answer 20

neck

Question 21

Brachial

Answer 21

elbow

Question 22

Radial

Answer 22

wrist - thumb

Question 23

Ulnar

Answer 23

wrist - pinky

Question 24

Femoral

Answer 24

groin

Question 25

Popliteal

Answer 25

behind knee

Question 26

Posterior tibial

Answer 26

ankle

Question 27

Dorsalis pedis

Answer 27

foot

Question 28

Heart rate - adult

Answer 28

60-100

Question 29

Heart rate - child

Answer 29

75-100

Question 30

Systolic Pressure

Answer 30

The maximum pressure exerted on the arterial wall during left ventricular contraction or systole.

Question 31

Diastole Pressure

Answer 31

The resting pressure exerted by blood on the arterial wall between each contraction or diastole.

Question 32

Blood pressure - adult

Answer 32

120/80

Question 33

Blood pressure - child

Answer 33

105/65

Question 34

Temperature

Answer 34

36.2-37.5*C

Question 35

Temperature sites

Answer 35

Oral, axillary, skin, tympanic, rectum

Question 36

Core temperature

Answer 36

Tympanic membrane, Oesophagus, Urinary bladder, Pulmonary artery

Question 37

Surface temperature

Answer 37

Skin, Axillae, Oral

Question 38

Early signs of a clinically deteriorating patient

Answer 38

Partial airway obstruction (excluding snoring), SpO2 90–95%, Respiratory rate 5–9 bpm or 30–40 bpm, Pulse rate 40–50 or 120–140, Systolic BP 80–100 mmHg or 180–240 mmHg, Urine output < 200 mL over eight hours, Greater than expected drainage fluid loss, A drop in GCS of 2 points or GCS < 12 or any seizure, ABGs Pa02 50–60, PCO2 50–60, pH 7.2–7.3, BE –5 to –8 mmol/LBSL 1–3 mmol/L, Poor peripheral circulation, New or uncontrolled pain (including chest pain)

Question 39

Late signs of a clinically deteriorating patient

Answer 39

Airway obstruction or stridor, Sp02 < 90%, Respiratory rate < 5 bpm or > 40 bpm, Pulse rate < 40 or > 140, Systolic BP < 80 or > 240 mmHg, Urine output < 200 mL in 24 hours or anuria, Excess blood loss not controlled by ward staff, Unresponsive to verbal command or GCS < 8ABGs Pa02 < 50, PCO2 > 60, pH < 7.2, BE < –7BSL < 1 mmol

Question 40

Early signs of a clinically deteriorating patient

Answer 40

Partial airway obstruction (excluding snoring), SpO2 90–95%, Respiratory rate 5–9 bpm or 30–40 bpm, Pulse rate 40–50 or 120–140, Systolic BP 80–100 mmHg or 180–240 mmHg, Urine output < 200 mL over eight hours, Greater than expected drainage fluid loss, A drop in GCS of 2 points or GCS < 12 or any seizure, ABGs Pa02 50–60, PCO2 50–60, pH 7.2–7.3, BE –5 to –8 mmol/LBSL 1–3 mmol/L, Poor peripheral circulation, New or uncontrolled pain (including chest pain)