Vital Signs (Quiz 1) Flashcards
What are the 4 vital signs
1) Temperature
2) Pulse rate & rhythm
3) Respiration rate
4) Blood pressure
What is normal core temperature?
In degrees Fahrenheit
97.0 - 99.5
How do oral and tympanic temperatures differ from core temperature?
Approximately 1 degree Fahrenheit lower
How do temporal artery and rectal temperatures differ from core temperature?
The are approximately the same.
Which temperature measurement is slowest to respond?
Rectal
Temperature fluctuates throughout the day. When is it highest? When is it lowest?
Highest: 4pm
Lowest: 4am
Name some conditions in which core temperature is elevated
Infection, cancers (eg leukemia, lymphoma), immunological conditions (eg SLE, sarcoid), and hyperthyroidism
Name some conditions in which core temperature is depressed
Exposure, hypothyroidism, Addison disease, diabetes mellitus, liver failure, kidney failure
Oral temperature measurement: describe the requirements of the patient and the procedure.
Patient should be rested and not have consumed hot or cold beverages for 30 minutes.
Place thermometer under tongue. Patient should breathe through nose and avoid talking.
Temporal artery (TA) temperature measurement: describe the technique
Remove the protective cap of the device. Clean contact area with alcohol swab. If needed, clean lens with cotton tip applicator with alcohol and the unit facing down (to avoid EtOH from entering the device).
Push button and slide probe straight across the forehead along the hairline. If perspiration present, also take reading of soft tissue behind the ear. Release button, remove from contact.
Normal pulse rate for adult
60-100 bpm
T/F: Bradycardia means elevated heart rate
Fale, bradycardia is depressed heart rate. Tachycardia is elevated heart rate
What artery is most commonly assessed in taking pulse rate?
Radial (on wrist, on the side of the thumb)
How long should you count heart beats for?
30 seconds
Name some conditions under which heart rate can be elevated
Infection, anxiety, fever, and heart or respiratory failure
T/F: You should measure pulse rate bilaterally on your patient. That is to say you assess both radial arteries
True: you do this to assess symmetry of pulse
What does it mean to assess contour of the pulse
Contour is how smooth the increase and decrease in pressure is during a pulse. It should smoothly build from low to high, and back down, as opposed to going from no pressure to high very quickly.
Explain the grading system for amplitude of pulse
4+: bounding, as after exercise 3+: increased, as with anxiety 2+: normal, as expected 1+: diminished, barely palpable 0: absent
Normal adult respiratory rate
12-18 CPM
Normal child respiratory rate
normal up to 20 CPM
Normal newborn respiratory rate
normal up to 44 CPM
What respiratory rate is considered bradypnea?
What respiratory rate is considered tachypnea?
> 20 CPM (for an adult)
What is hypercapnea, and what effect does it have on respiratory rate?
CO2 retention, or elevated blood CO2 levels. It results in deep, rapid breathing
How is breathing rate assessed
Patient should be unaware that you’re assessing. Perform during the second 30-second block of the 1 minute you’re “assessing pulse”
What factors are important when fitting a blood pressure cuff?
1) Cuff must fit properly: too small gives an artificially high reading
2) Artery marker must be placed over the artery
3) Cuff must not be placed over clothing
4) Working stethoscope
5) Quiet room
What patient factors are important in taking blood pressure?
1) Rested patient
2) No caffeine intake prior to reading
3) Arm relaxed, supported
Describe the blood pressure measurement technique, after set-up
Inflate cuff while palpating radial pulse. Disappearance indicated systolic BP. Inflate cuff another 20-30mmHg. Place stethoscope over brachial artery. Deflate the cuff at a rate of 2-3mmHg/second.
Appearance of first beat is systolic BP. Be sure to confirm that the sound was a heart beat by listening for the second.
Disappearance of beats indicates diastolic BP
If performing multiple readings, wait at least 1 minute
What effects of BP does venous congestion have?
Low systolic, high diastolic
Is the bell or diaphragm of the stethoscope preferred for BP evaluation?
Bell
What should be recorded after blood pressure evaluation?
1) Systolic over Diastolic in mmHg
2) Time of reading
3) Arm used
4) Patient position (sitting, supine)
5) Evaluation using age-appropriate charts
