Chapter 20

What does 'vital' mean in vital signs?

Necessary to life.

What are the four vital signs?

Temperature, pulse, respirations, blood pressure.

Why are vital signs important?

They provide essential information about health.

What can a major or lasting vital-sign change indicate?

Illness or injury.

What is considered the fifth vital sign?

Pain.

When should vital signs be rechecked after activity?

After the person rests a few minutes.

What should you do if a vital sign is abnormal?

Recheck it, then report immediately.

Why must vital signs be measured accurately?

They guide important care decisions.

When should you ask for help taking vital signs?

When you have difficulty or are unsure.

What can be normal for one person but abnormal for another?

Vital-sign measurements.

What is body temperature?

The difference between heat produced and lost.

What process produces body heat from food?

Metabolism.

Where is body-temperature regulation controlled?

The brain.

What can physical or emotional stress do to temperature?

Increase it.

When is body temperature typically lowest?

In the morning.

What two age groups are more temperature-sensitive?

Infants and older adults.

What five sites can measure body temperature?

Oral, rectal, axillary, tympanic, temporal.

What should you document about temperature measurement?

The measurement method.

What does 'febrile' mean?

Having a fever.

What can an elevated temperature indicate?

Infection.

Why are glass thermometers rarely used?

Risk of breakage and mercury exposure.

What temperature range is marked on a Fahrenheit glass thermometer?

94°–108°F.

Below what Fahrenheit temperature must glass thermometers be shaken?

Below 94°F.

What should never be used to clean a glass thermometer?

Hot water.

What should you do if a glass thermometer breaks?

Avoid touching the liquid and broken glass.

What color electronic probe is used orally or axillary?

Blue.

What color electronic probe is used rectally?

Red.

What does a tympanic thermometer measure?

Ear temperature.

Why are tympanic thermometers often used with children?

Safe, quick, and relatively painless.

What is the least invasive thermometer?

Temporal artery thermometer.

Which temperature site is least reliable?

Axillary.

How long should you wait after eating before an oral temperature?

Usually 15–30 minutes.

What activities can affect an oral temperature reading?

Eating, drinking, smoking, chewing gum.

Name one situation when oral temperature should not be taken.

Unconsciousness.

How deep may a rectal thermometer be inserted in an adult?

No more than 1 inch.

Why must you stay with someone during rectal temperature measurement?

Vagus stimulation can be dangerous.

Name one condition preventing rectal temperature measurement.

Diarrhea.

How long should you wait after axillary washing/deodorant?

At least 15 minutes.

Which ear should be used with an earache?

The other ear.

What can cause a falsely low temporal temperature?

Sweating.

What does the pulse represent?

The heartbeat traveling through arteries.

What is pulse rate?

Number of pulsations per minute.

What is pulse rhythm?

Pattern of pulsations and pauses.

What is an irregular pulse rhythm called?

Dysrhythmia.

What is pulse amplitude?

Force or quality of the pulse.

What can a weak or thready pulse indicate?

Trouble circulating blood.

What factors can increase pulse rate?

Exercise, anxiety, illness, pain, fever, excitement.

Where is the radial pulse located?

Inside of the wrist.

Which fingers should take a radial pulse?

Middle two or three fingers.

Why shouldn't you use your thumb for a pulse?

It has its own strong pulse.

When may carotid or femoral pulses be used?

During emergencies or CPR.

What is an apical pulse?

Heartbeat heard with a stethoscope.

Where is the apical pulse heard?

Left chest, below the left nipple.

When is an apical pulse especially useful?

Weak or irregular radial pulse.

What is the diaphragm of a stethoscope used for?

Loud, harsh sounds.

What is the bell of a stethoscope used for?

Softer sounds.

What is a pulse deficit?

Difference between apical and radial rates.

Which is always equal or higher: apical or radial?

Apical pulse.

What is adult tachycardia?

More than 100 beats per minute.

What is adult bradycardia?

Less than 60 beats per minute.

What is the normal adult pulse range?

60–100 beats/minute.

How long is a child's pulse measured if under age 12?

A full minute.

What is respiration?

The process of breathing.

What happens during inhalation?

Chest rises as air enters.

What happens during exhalation?

Chest falls as air leaves.

What three things are assessed with respirations?

Rate, rhythm, and depth.

What is one complete respiration?

One inhalation and one exhalation.

What is the normal adult respiratory rate?

12–20 breaths/minute.

What is eupnea?

Normal breathing.

What is tachypnea?

More than 24 breaths/minute.

What is bradypnea?

Less than 10 breaths/minute.

What is dyspnea?

Difficult or labored breathing.

What is hyperventilation?

Increased rate and depth.

What is hypoventilation?

Decreased rate and depth.

How can you get a more accurate respiratory count?

Count while appearing to take the pulse.

What respiratory sounds should be reported?

Wheezing or congestion.

What is blood pressure?

Force of blood against arterial walls.

What is systolic pressure?

Pressure when the heart contracts.

What is diastolic pressure?

Pressure when the heart relaxes.

What is pulse pressure?

Difference between systolic and diastolic pressure.