Vital Signs

oral temp *C

35.9 - 37.5

Oral temp *F

96.6 - 99.5

tympanic temp C

36.8 - 38.3

tympanic temp F

98.2 - 100.9

temporal temp C

36.3 - 38.1

temporal temp F

98.7 - 100.5

axillary temp C

35.4 - 36.9

axillary temp F

95.6 - 98.5

rectal temp C

36.3 - 38.1

rectal temp F

97.4 - 100.5

How old should a patient be before taking an oral temp?

4

How long should you wait after the pt eats/drinks something hot or cold or smokes/chews gum to take an oral temp?

15-30 mins

T/F: It is not appropriate to take a rectal temperature on patients with CV disease or recent cardiac surgery. (Explain why)

T, can stimulate vagus nerve and slow HR

T/F: It is appropriate to take a rectal temp in pts with neutropenia. (Explain)

F, increases risk of infection

T/F: It is appropriate to assess a rectal temperature in a pt with thrombocytopenia (Explain).

F, increased chance of rectal bleeding.

How long should you wait after washing a pts axilla to take a temp there?

15 mins

Which temperature method is safest for patients under 3 months?

axillary

If axillary is above 99, recheck with a _______ measurement

rectal

What temp methods are best for children aged 3 months to 4 years

rectal and tympanic

after what age can a tympanic temp be taken?

6 months

Normal pulse rate

60-100

preferred pulse location for infants and kids under 2

apical

Generally preferred pulse location

radial

T/F: Pulses may not ever be delegated to unlicensed assistive personnel (Explain).

F, radial and brachial are allowed

T/F: RNs can delegate peripheral pulses to LPNs/LVNs

T

How long should you count a regular, strong pulse?

30s, then multiply by 2

If a pulse is weak and/or irregular, how long should you count for?

1 min

For pulses that are difficult to palpate or auscultate, what can be used?

Doppler ultrasound

Pulse rating for non existent pulse

0

Pulse rating for weak, irregular pulse

1+

Pulse rating for regular pulse

2+

Pulse rating for bounding pulse

3+

Where to place stethoscope for apical pulse?

5th intercostal space at left mid-clavicular line

What should you always do before placing stethoscope on pt?

clean diaphragm

point of assessing apical-radial pulse deficit?

assess how well blood is moving from heart into periphery

how many nurses needed to asses apical-radial pulse?

2

how long to measure apical radial pulse?

1 min

Normal rr

12-20 breaths/min, regular

RR range for Tachypnea

>24 breaths/min, shallow

Bradypnea

<10 breaths/min, regular

Characteristics of hyperventilation

Increased rate and depth

characteristics of hypoventilation

decreased rate and depth, irregular

Cheyne-Stokes respirations

Alternating periods of deep, rapid breathing followed by periods of apnea; regular

Biot's respirations

Varying depth and rate of breathing, followed by periods of apnea; irregular

If pt is breathing too shallowly to visibly or physically count RR, what should you do?

auscultate lung sounds for 30s, then multiply by 2

Where can you look to more easily see respirations?

Sternal notch

Where can you place your hand to feel for respirations if it is difficult to see them?

upper chest, abdomen, or shoulder

How long to count RR for infants and children?

1 min

What should you look for to count RR in infants?

abdominal movement

What should you look for to count RR for infants and children over 1 year?

thoracic movements

T/F: It is a good idea to assess RR in an infant or child that is crying, feeding, or moving around (Explain).

F, those actions may raise RR

Normal BP

<120/<80 mmHg

Elevated BP

120-129/<80 mmHg

Stage 1 HTN

130-139/80-89 mmHg

Stage 2 HTN

Systolic>=140 or diastolic >=90 mmHg

Hypertensive crisis

systolic >180 and/or diastolic >120 mmHg

2 most common sites for BP

brachial, popliteal

pulse pressure

systolic-diastolic

T/F: A rise or fall of 20-30 mmHg in a pts BP is ok as long as it stays within normal range

F

can pt talk or move during BP measurement

No

What 3 things can pt not do w/in 30 mins of measuring BP? (Ask pt before measuring)

consume caffeine, exercise, smoke

Where should pt’s arm be during seated BP measurement

heart level

T/F: pt’s feet and back should be supported during BP measurement

T

Pt is seated, leaning back, with arm on table at heart level and legs crossed. Are they ready for a BP?

No

how fast should you deflate the cuff while getting a BP?

2-3 mmHg/s

What is orthostatic hypotension

low BP caused by change in posture

1st step in assessing orthostatic hypotension

lower HOB and bed, lay pt supine for 3-10 mins, then take BP and pulse

2nd step in assessing orthostatic hypotension

Assist pt to seated position on side of bed w/legs dangling. Wait 1-3 mins. Assess BP and pulse.

3rd step in assessing orthostatic hypotension

Assist the pt to stand, if able or allowed. Wait 2-3 mins, then take BP and pulse

T/F: brachial artery BP may be delegated to UAP or LPN/LVNs

T

What conditions would prevent nurse from taking a BP in a particular side?

Mastectomy, axilla surgery, AV shunt, IV, disease or injury of limb

BP should be measured in 1/both arms the first time

both

If there is a consistent difference in BP between the 2 arms, which should you use?

arm with higher BP

BP while supine is slightly higher/lower than when seated

higher

What change in BP would indicate orthostatic hypotension

decrease by >=20 systolic or >= 10 diastolic

If you are unsure about the BP for any reason, how long should you wait before getting a second reading?

1 min

What population tends to have an auscultatory gap during phase 2 korotkoff sounds?

people with HTN

Why is it very dangerous to miss an auscultatory gap?

you may underestimate systolic BP

Systolic BP is about __-__ mmHg higher/lower at the popliteal site than at the brachial site. The diastolic is about the same.

10, 14