vital signs

Question 1

temperature range

Answer 1

36-38, normal is 37. higher for babies and lower for over 70

Question 2

what is pyrexia

Answer 2

inc in temp 38-40

Question 3

what is hyperpyrexia

Answer 3

very elevated 41-44

Question 4

hypothermia

Answer 4

low temp 36-34

Question 5

factors affecting temp

Answer 5

• age
• exercise
• hormone
• circadian rhythm
• stress
• environment

Question 6

what are the sites of assessment of temp

Answer 6

• tympanic membrane (ear)
• mouth
• rectum
• axilla

Question 7

what is the pulse

Answer 7

is a throbbing sensation that can be palpated over a peripheral artery or auscultated over the apex of the heart

Question 8

what factors indicated the effectiveness of the heart

Answer 8

rate, rhythm, quality and volume

Question 9

what are the pulse rates (BPM)

Answer 9

newborn = 120-160
6-12 = 75-110
adult = 60-100

Question 10

where the pulse locations

Answer 10

radial, brachial, carotid, pedal and apical

Question 11

what is inspiration

Answer 11

diaphragm contracts and moves down

intercostal muscles pull ribs = inc in size of thoracic cavity (expansion)

intraplueral pressure decreases

pressure = less than atmospheric- air moves into lungs

Question 12

what is expiration

Answer 12

• Diaphragm relaxes and moves up
• Intercostal muscles relax and ribs move inwards
• Decreases the size of thoracic cavity and lung size
• Increases gas pressure in the lungs to greater than atmospheric pressure and gas moves out of lungs.

Question 13

normal rates of rest

Answer 13

newborn = 30-60
child = 20-30
adult= 12-20

Question 14

assessment of respirations

Answer 14

count full inspiration and expiration for 1 minute
observe movement in chest wall
breathing pattern and observe chest or abdomen

Question 15

what is apnoea

Answer 15

periods of no breathing

Question 16

dyspnoea

Answer 16

difficulty breathing

Question 17

orthopnoea

Answer 17

being able to breath more easily upright than lying flat

Question 18

tachypnoea

Answer 18

fast resp rate

Question 19

bradypnoea

Answer 19

slow resp rate

Question 20

what is blood pressure

Answer 20

the force on the walls of an artery by the pulsing bp

Question 21

what is systolic bp

Answer 21

the pressure recorded when the left ventricle pushes blood into the aorta and out of the heart

Question 22

what is diastolic bp

Answer 22

when the ventricles relax and the blood remaining in the arteries exerts and min pressure

Question 23

what are the factors to maintain bp

Answer 23

• cardiac output
• Peripheral resistance
• Blood volume
• Viscosity
• Elasticity

Question 24

BP sounds

Answer 24

• Phase 1- 1st faint tapping sound which increase as cuff is deflated (systolic)
• Phase II- murmur or swishing during cuff deflation
• Phase III- sounds are crisper and inc in intensity
• Phase IV- distinct, abrupt, muffling of sound
• Phase V- last sound is heard (diastolic)

Question 25

BP technique

Answer 25

• Patient seated, arm supported, have rested for 5 minutes
• Use appropriate cuff size
• No smoking or coffee 30min prior
• Korotkoffs phase V

Question 26

average optimal BP

Answer 26

1y = 95/65
middle adult = 120/80
older = 140/90

acceptable values of <130/<85