Vital Signs and I/O

Question 1

Temperature

Answer 1

T, temp

Question 2

Pulse

Answer 2

P, HR

Question 3

Respirations

Answer 3

Resp, R

Question 4

Blood Pressure

Answer 4

BP, B/P

Question 5

Oxygen saturation

Answer 5

O2 Sat, Pulse Ox

Question 6

Body temp controlled by _____ of brain?

Answer 6

hypothalamus

Question 7

Body temp sites of measurement:

Answer 7

oral, rectal, axillary, tympanic

Question 8

Temperature can range depending on where you measure. This can also affect the temperature.

Answer 8

AGE

Question 9

Body temps for axillary, oral, and rectal

Answer 9

97.6 - axillary
98.6 - oral
99.6 - rectal

can fluctuate one degree higher or lower and still be ok

Question 10

A body temp below 95 degrees is considered

Answer 10

hypothermia

Question 11

the clinical term for a fever is

Answer 11

pyrexia

Question 12

rule of thumb for a fever, these are the body temps…

Answer 12

98 degrees axillary
99 degrees oral
100 degrees rectal

*if higher than that, may be fever

Question 13

If respirations, or R>22 than the patients has

Answer 13

tachypnea

Question 14

If respirations, or R<10 , the patient has

Answer 14

bradypnea

Question 15

Blood oxygen saturation must be greater than ____ or patient will exhibit signs and symptoms (S&S) of hypoxemia.

Answer 15

90

Question 16

How does a pulse ox device work?

Answer 16

uses infrared sensors that measure the saturation of oxygen in the hemoglobin molecules pulsating through underlying tissues… poor circulation can interfere with the reading

Question 17

Blood pressure is dependent upon a few things:

Answer 17

blood volume, strength of the heart, conditions of the arteries

Question 18

blood pressure, top number is _____ and bottom number is _____.

Answer 18

systolic (short term)
diastolic (long term)

Question 19

guidelines for blood pressure: what is normal, prehypertension, hypertension stage 1, hypertension stage 2

Answer 19

normal
<120 and <80

prehypertension
120-139 or 80-89

hypertension stage 1
140-159 or 90-99

hypertension stage 2
160+ or 100+

Question 20

Korotkoffs sounds

Answer 20

phase 1
faint tapping sounds
phase 2
murmur swishing sounds during cuff deflation
phase 3
sounds are crisper increase in intensity
phase 4
distinct muffling sound
phase 5
pressure level when last sound is heard

Question 21

to avoid inaccurate bp readings… do these things

Answer 21

patient should be seated and rest 5 mins
arms must be supported at heart level
wait 1-2 mins before repeating on same arm
choose appropriate cuff size

Question 22

to determine diet for patient who works together?

Answer 22

physician and dietician

Question 23

considerations of patient in regards to I/o

Answer 23

likes/dislikes, patient religion/culture, patient diagnosis (diabetes mellitus, heart disease, dysphagia)

Question 24

dysphagia is what

Answer 24

difficult swallowing

Question 25

symptoms of dysphagia

Answer 25

taking a long time to begin to swallow, multiple swallows with each bite of food
lack of gag reflex, weak cough
difficulty controlling secretions and fluids in the outhitting
wet, gurgling voice
pocketing food, refusing to eat, spitting
feel as if food is sticking in esophagus

Question 26

barium swallow would be a good therapeutic approach for a patient with

Answer 26

dysphagia

Question 27

for someone with dysphagia, liquids should be

Answer 27

thickened

Question 28

types of diets

Answer 28

house/regular diet
mechanical soft diet
pureed diet
diabetic diet
renal diet
sodium restricted cardiac diet

Question 29

post op diet progression

Answer 29

clear liquids, full liquids, low residue, D.A.T. (or diet as tolerated - normal diet)

Question 30

what are full liquids

Answer 30

INCLUDES all clear liquids ANNND

soups, ice cream, milk, all juices

Question 31

intake and output, what are some output measurements

Answer 31

urinary, emesis (vomit), diarrhea, drainage from wounds

Question 32

NPO

Answer 32

nothing by mouth

Question 33

what’s total parenteral nutrition or TPN

Answer 33

intravenous infusion
npo patients, patients on bowel rest

alternative way for patients to receive nutrition like a nasogastric tube feeding, or gastronomy tube feeding

Question 34

patients receiving tube feeds are at high risk for what

Answer 34

aspiration, keep them at semi-fowlers position or fowlers

Question 35

fecal impaction aka

Answer 35

constipation

Question 36

is catheterization a sterile procedure?

Answer 36

yes…

high risk of nosocomial infections
requires a doctors order

Question 37

alternative methods to a catheter

Answer 37

bladder scan, condom catheter