Week 2, Vital Signs

Question 1

Normal Blood pressure upper arm:

Answer 1

Normal: <120/<80

Question 2

What is considered to be hypertension?

Answer 2

> 140/90 (> in EITHER systolic or diastolic)

Question 3

Normal HR:

Answer 3

60-100bpm

Question 4

Normal RR:

Answer 4

12-20 breaths/minute

Question 5

Normal Temp:

Answer 5

97-99 degrees F (varies by site)

Question 6

Normal O2 sat:

Answer 6

90-100%

Question 7

Temp: Fever, VS

Answer 7

> 100.4F
increased HR, RR,
Thirst –> dehydration = low BP

Question 8

Fever, assessment and interventions

Answer 8

-Determine cause, monitor I+O, avoid things to cause shivering, blankets, FLUIDS, antipyretics, tepid bath, oral hygiene, keep linins and clothes dry

Question 9

Temp: Hypothermia, VS

Answer 9

<95 F, all vitals decrease

Question 10

Hypothermia, assessment and intervensions

Answer 10

Warm, dry, cover head, warm fluids (slowly)

Question 11

Rectal temp vs oral temp

Answer 11

Rectal is slightly higher

Question 12

Most accurate temp sites:

Answer 12

Rectal, oral, tympanic

Question 13

What can affect the temp reading?

Answer 13

Age, time of day, activity, hormones, stress, environment can all affect value

Question 14

What do we document for pulse?

Answer 14

Rate, rhythm, quality, bilateral (location) equality

Question 15

Pulse quality:

Answer 15

0= absent
2+ = normal
4+ = bounding

Question 16

tachycardia bpm:

Answer 16

> 100 bpm

Question 17

bradycardia bpm:

Answer 17

<60 bpm

Question 18

Check apical pulse if:

Answer 18

pulse irregular, cardiac hx or meds, infants and children

Question 19

Where is the apical pulse located?

Answer 19

5th intercostal space, mid clavicular line

Question 20

How long do you count for apical pusle?

Answer 20

60 seconds

Question 21

What do you document for Respiratory VS?

Answer 21

rate, rhythm & depth, quality

Question 22

What is the normal stimulus to breathe? (not in COPD)

Answer 22

Increase in CO2

Question 23

Tachypnea:

Answer 23

> 20 RR

Question 24

Bradypnea:

Answer 24

<12 RR

Question 25

Ventilation is:

Answer 25

movement of gases in/out of lungs

Question 26

Diffusion is:

Answer 26

CO2 and O2 b/w alveoli and RBC; perfusion, movement of RBC

Question 27

What factors determine Blood Pressure:

Answer 27

Cardiac Output, Pulmonary Vascular Resistance, blood volume, vessel elasticity

Question 28

What is systole?

Answer 28

Ventricle contraction

Question 29

What is diastole?

Answer 29

ventricle rest/filling

Question 30

HYPERtension?

Answer 30

systolic >120 –> decreased blood flow to organs (thickening of artery walls + loss of elasticity)

Question 31

HYPOtension?

Answer 31

> 100/60 or 20-30mmHg below patient baseline–> leads to increased HR (body compensating to perfuse)

Question 32

Preparation for BP reading:

Answer 32

no caffeine or nicotine 30 min before, sit resting for 5 min, correct cuff size, don’t cross legs, arm supported @ heart level, no talking

Question 33

Bladder of BP cuff:

Answer 33

80%-100% limb circumference, width 40% length of arm

Question 34

Orthostatic Hypotension

Answer 34

20mmHg drop in SYSTOLIC OR

10mmHg drop in DIASTOLIC + increase of 10Bpm HR

Question 35

Measuring Orthostatic Hypotension

Answer 35

-lay down 10 min, take HR + BP, move to sitting, wait 2 min, take HR + BP, move to standing, wait 2 min, take HR+ BP

Question 36

When do you collect vital signs?

Answer 36

Admission, change in status/condition/patient transferred, administering meds (especially apical pulse with BP meds), whenever you need to

Question 37

How often do you check vitals?

Answer 37

Find in orders (q4 is most common for most acute care)