Vitals Study Cards

Question 1

Vitals

Answer 1

Temperature, Pulse, Blood Pressure, Respiratory Rate, Oxygen Saturation

Question 2

When to Measure Vital Signs

Answer 2

On admission (hospital,OR,PACU,ETC..brand new), Per physician order (routine every 4 hrs, Q4h), Any change in patient’s condition(make sure okay first), Before and after any major procedure , During blood transfusion, After medications or interventions that affect vital signs

Question 3

Normal Temp Ranges for an adult

Answer 3

96.8-100.4

Question 4

Oral/tympanic/ temporal Temp range

Answer 4

97.6-99.6

Question 5

Rectal Temp range

Answer 5

98.6- 100.4

Question 6

Axilla Temp range

Answer 6

96.6-98.6

Question 7

Pulse Range

Answer 7

60-100 BPM

Question 8

Respirations

Answer 8

12-20 breaths per minute

Question 9

Normal blood pressure for adult

Answer 9

Less than 120/80 mmHg

Question 10

Pre-hypertensive BP

Answer 10

Systolic: 120-139
Diastolic: 80-89

Question 11

Hypertensive BP

Answer 11

Systolic: Higher than 140
Diastolic: Higher than 90

Question 12

Hypotensive

Answer 12

Systolic: less than 90 and symptomatic

Question 13

Body Temp measures and sites

Answer 13

Heat produced, Heat lost. Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery, urinary bladder

Question 14

Neural and Vascular Temp Regulation site

Answer 14

Anterior/Posterior Hypothalamus

Question 15

Heat production

Answer 15

Shivering, BMR

Question 16

Heat loss

Answer 16

Radiation, Convection, Conduction, Evaporation, Diaphoresis

Question 17

Skin Temp Regulation

Answer 17

Insulation, Vasoconstriction (Shivering), Sensation (Moving away or putting down)

Question 18

Radiation

Answer 18

transfer of heat from surface of one object to surface of another without direct contact between the two

Question 19

Conduction

Answer 19

transfer of heat from one object to another with direct contact

Question 20

Convection

Answer 20

transfer of heat away by air movement

Question 21

Evaporation

Answer 21

transfer of heat energy when a liquid is changed to a gas

Question 22

Diaphoresis

Answer 22

visible perspiration

Question 23

Factors Affecting Body Temp

Answer 23

Age (Very Old/Young), Exercise(creates heat, increase metabolism), Hormonal level(ovulating, Menopause), Circadian Rhythm(Body Temp is low at 1-4), Temp alterations(fever)

Question 24

Fever

Answer 24

Pyrexia, Usually not harmful if below 102.2°F, Important defense mechanism, Temp should be taken several times throughout day, Results from an alteration in the hypothalamic set point.
Causes increase in metabolism and oxygen consumption
Increased heart rate and respiratory rate

Question 25

Temperature alteration-High

Answer 25

Hyperthermia- Inability to promote heat loss or reduce production. Heatstroke
Dangerous heat emergency/high mortality rate
Body temp 104°F or more
Signs and Symptoms
Most important: dry, hot skin
Confusion, excess thirst, muscle cramps
Vital signs: Increased HR, decreased B/P
No sweating

Question 26

Temperature Alteration-Low

Answer 26

Heat Exhaustion, Diaphoresis results in excess water and electrolyte loss. Need to replace.
Hypothermia-Prolonged exposure to cold decreases body’s ability to produce heat
Can be accidental or intentional
Temps <86-96.8

Question 27

Fahrenheit to Celsius

Answer 27

F=(9/5 x C) + 32

Question 28

Celsius to Fahrenheit

Answer 28

C=(F - 32) x 5/9

Question 29

Oral Temperature

Answer 29

Temperature easily influenced by hot or cold foods
One of the most frequently used methods of attaining temperature
Approximately one degree lower than core temp.
May be glass (mercury) or electronic

Question 30

Rectal Temperature

Answer 30

Placement of thermometer:
Adult- insert 1 ½ inches. To go past anal sphincter
Child- insert 1 inch. Bacteria making fluctuate
Infant-insert ½ inch
Placement of thermometer into feces may give inaccurate readings

Question 31

Axillary Temperature

Answer 31

Considered safest
Must be left in place 5-10 minutes
Moisture in axillary area may reduce the temp

Question 32

Tympanic Temp

Answer 32

One of the most rapid means of measurement
Unaffected by PO (Per oral cavity) intake
Must remember to remove
hearing aides before using

Question 33

Temporal Temperature

Answer 33

Most accurate compared to core temp
Fast read: 2-3 seconds
Ease of use
Fewer errors that tympanic

Question 34

What do you do for a fever?

Answer 34

Obtain blood cultures if ordered
Monitor VS, assess skin color, temperature, turgor and lab work
Reduce frequency of activities to ↓ 02 demand
Maximize heat loss
Extra fluids
Tepid water bath
Oral hygiene
Dry bed linens
Antipyretic meds as ordered

Question 35

Pulse

Answer 35

Palpable or audible bounding of blood flow noted at various points on the body. An indirect measure of circulatory status

Question 36

Radial Pulse

Answer 36

Most common for routine vital signs
Used for patient teaching
Assesses circulation status to the hand
Should be assessed together as well as once for pulse

Question 37

Apical pulse

Answer 37

If pulse is abnormal
If taking meds that affect HR
If radial inaccessible

Question 38

Carotid pulse

Answer 38

If patient condition suddenly worsens
Need pulse quickly
Do not measure bilateral at the same time

Question 39

Dorsalis Pedis pulse

Answer 39

Top of foot
Assesses status of circulation to foot
Via Doppler if unable to palpate
Assess bilaterally, at the same time