Part 1 Normal ranges, terms, and temperature
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50 Terms
What main vital signs are covered in this guide?
Temperature, pulse, respirations, blood pressure, and oxygen saturation. Pain is also assessed.
What is the typical normal adult oral temperature range in this guide?
About 97–99°F (36.1–37.2°C).
What is the normal adult resting pulse?
60–100 beats per minute.
What is the normal adult respiratory rate?
12–20 breaths per minute.
What is normal adult blood pressure?
Systolic below 120 AND diastolic below 80 mmHg.
What is the usual oxygen saturation for a healthy adult?
95–100%.
How should pain be assessed?
Use a pain scale appropriate for the patient.
What does bpm mean?
Beats per minute.
What is tachycardia in an adult?
A heart rate above 100 beats per minute.
What is bradycardia in an adult?
A heart rate below 60 beats per minute.
What is tachypnea?
Abnormally fast breathing.
What is bradypnea?
Abnormally slow breathing.
What is apnea?
No breathing.
What is hypertension?
High blood pressure.
What is hypotension?
Low blood pressure.
What is pyrexia?
Fever.
What is hypothermia?
An abnormally low body temperature.
What is hypoxemia?
A low oxygen level in arterial blood.
What is an arrhythmia?
An abnormal heart rhythm.
What is dyspnea?
Difficult or uncomfortable breathing.
What is orthostatic hypotension?
A drop in blood pressure with a position change, especially standing up.
What does afebrile mean?
Without fever.
What are the five common temperature routes?
Oral, axillary, tympanic, temporal, and rectal.
What temperature commonly indicates a fever?
100.4°F (38°C) or higher.
What core temperature generally indicates hypothermia?
Below 95°F (35°C).
What is hyperthermia?
Overheating because the body cannot get rid of enough heat.
What high-temperature number does your guide highlight?
Above 104°F (40°C); this is not the definition of all hyperthermia.
What five factors can affect body temperature?
Measurement site, time of day, activity, age, and the patient's condition.
What should you document when measuring temperature?
The temperature reading and the route used.
What policy should you follow when using a thermometer?
Facility policy for thermometer use and infection prevention.
Where is an oral temperature measured?
In the mouth, under the tongue.
Where should the oral thermometer probe be placed?
In the appropriate pocket under the tongue.
What must a patient be able to do for an oral temperature?
Stay alert, cooperate, and close their mouth.
What recent activities can affect an oral temperature?
Hot or cold drinks, eating, smoking, and chewing gum.
How long should you wait after food, drinks, smoking, or gum before an oral temperature?
Follow facility policy for the waiting time.
When should the oral temperature route be avoided?
When the patient cannot safely cooperate or has certain oral injuries or procedures.
Where is an axillary temperature measured?
In the armpit.
How should you position the probe for an axillary temperature?
Place it against dry skin in the center of the armpit.
How should the patient's arm be positioned during an axillary temperature?
Hold it firmly against the body.
What is a limitation of axillary temperatures?
They are generally less accurate for estimating core temperature.
Where is a tympanic temperature measured?
In the ear.
How should a tympanic thermometer be positioned?
Follow device instructions and obtain a proper seal.
What can affect a tympanic temperature reading?
Earwax, ear-canal anatomy, incorrect positioning, and lying on the ear beforehand.
What should you check before using a tympanic thermometer in someone with ear problems or recent ear surgery?
The device guidance and any applicable clinical restrictions.
Where is a temporal artery temperature measured?
Across the forehead over the temporal artery.
How should a temporal artery thermometer be used?
Scan the correct area according to the device instructions.
What can affect a temporal artery temperature reading?
Sweat, head coverings, environmental temperature, and incorrect scanning.
Where is a rectal temperature measured?
In the rectum.
What is an advantage of the rectal temperature route?
It can approximate core body temperature.
When may a rectal temperature be taken?
When indicated, allowed by facility policy, and within the nurse's scope and training.