Vital Signs and the Assessment of Pain

Question 1

Vital Signs

Answer 1

Temperature, Pulse, BP, Respiratory Rate, Height (m^2)/weight(kg) = BMI, Pain objective)

Question 2

Temperature

Answer 2

Balance of heat production an heat loss, controlled by hypothalamus
97.3-99.5 F (oral, adult)

Question 3

Factors Affecting Body Temp

Answer 3

metabolic (sleep, digestion, exercise)
Infectious process (fever)
Environment (hypo- hyperthermia)
Exogenous substances (cold/hot beverage, drugs)

Question 4

5 methods of temperature measurement

Answer 4

Oral - 98.6
Rectal - 99.6 (most accurate)
Axillary - 97.6
Tympanic - 99.6

Question 5

What constitutes a fever?

Answer 5

Adults: oral > 98.9 @6 am or >99.9 @ 4pm

Child: rectal > 100.4

Question 6

Respiratory Rate

Answer 6

one breathing cycling, inspiration and exhalation. measured by viewing chest rise. normal is 12-20 in adults

Question 7

Primary Muscles of Respiration

Answer 7

Diaphragm (contracts down) and intercostals

Question 8

4 parameters to asses in respiration

Answer 8

rate, pattern, depth, signs of distress

Question 9

6 patterns of respiration

Answer 9

apnea, tachypnea, bradypnea, dspnea, hypopnea, hyperpnea

Question 10

Cheyne Stokes respirations

Answer 10

periodic breathing, increased and decreased rate and depth, periods of apnea

Question 11

Kussmaul respirations

Answer 11

deep and labored. type of hyperpnea. metabolic acidosis (ex DKA)

Question 12

Signs of Resp. Distress

Answer 12

tachypnea, bradypnea, accessory muscle use, nasal flaring, cyanosis, difficulty speaking, audible breathing, coughing, diaphoresis

Question 13

Signs of REsp. Distress in Infants

Answer 13

flared nostrils, anxious face, cyanosis, intercostal retractions

Question 14

Pulse

Answer 14

Movement of blood in arteries.

Typical adult 50-90 bpm

Question 15

Characteristics of Pulse

Answer 15

Rate (bpm)
Rhythm (regular or irregular)
Regularity (regular or irregular)
Amplitude (strong, bounding, weak,0-4+)

Question 16

Factors Affecting Pulse

Answer 16

Heart health, exercise level, neurologic status, emotions, drugs

Question 17

Documenting Heart Rate

Answer 17

0-4+
Tachy is > 100 bpm
Brady is

Question 18

Normal BP

Answer 18

Adult SBP

Question 19

3 Factors that Affect BP

Answer 19

Stroke volume - amount of blood pumped by LV in 1 conraction
HR - bpm
Peripheral Vascular Resistance

Question 20

Cardiac Output

Answer 20

stroke volume x heart rate

Question 21

Korotkoff Sounds

Answer 21

low pitched sounds produced by turbulence of blood flow in the artery

Question 22

Auscultatory Gap

Answer 22

gap of 10-15 mmHg where korotkoff sounds can be heard, disappear, and reappear

Question 23

Pulse Pressure

Answer 23

systolic bp - diastolic bp. normal range is 30-50 mmHg

Question 24

Ideal conditions for measuring BP

Answer 24

no nicotine or caffeine
Rest
warm
no constricting clothing

Question 25

BP measurement step by step

Answer 25

1) place bell @ AC fossa, arm at heart level 2) center bladder over bracheal artery 3) inflate cuff 30mmHg above palpable radial pulse 4) deflate cuff 5) wait 30 sec, repeat steps 2-3 6) deflate slowly

Question 26

Factors affecting BP

Answer 26

``` hyper or hypo tension white coat syndrome vascular resistance from atherosclerosis pain fever weight sedentary lifestyle use of caffeine alcohol or drugs ```

Question 27

Medical Conditions that Affect BP readings

Answer 27

cardiac dysrhythmias aortic regurgitation venous congestion valve replacement

Question 28

Orthostatic BP

Answer 28

``` change in BP and pulse when pt. moves from supine to upright early detection of volume depletion 1) supine for 5 min, determine BP and HR 2) stand up 3) wait 1 minute, then take BP and HR ``` * drop in SBP > 10 mmHg or increase in HR > 20 bpm suggests volume depletion

Question 29

Height and Weight

Answer 29

under reported, self reporting is not adequate. | body habitus is closely linked to many chronic diseases

Question 30

BMI

Answer 30

weight (kg) / ht (m^2)

Question 31

Acute Pain

Answer 31

short duration, sudden onset, injury, surgery, acute illness

Question 32

Persistent / Chronic Pain

Answer 32

several months or longer. sustained by pathophysiologic process

Question 33

Neuropathic Pain

Answer 33

long term associated with damage or dysfunction of CNS or PNS

Question 34

How to document pain

Answer 34

value from 0-10 specify location quality, character, severity, frequency, duration, OPQRST