Vital Signs Assessment

When analyzing vital signs, you are analyzing

Homeostasis

What are the aims of temperature assessment

to obtain a representative average of the core body tissue

The diffusion of heat by electromagnetic waves is an example of what mechanism of heat transfer?

Radiation

The dissemination of heat by motion between areas of unequal density is an example of what mechanism of heat transfer?

Convection

The conversion of a liquid to a vapor is an example of what mechanism of heat transfer?

evaporation

The transfer of heat to another object during direct contact is describing what mechanism of heat transfer?

Conduction

What are the different sites and methods if assessing body temp.

oral, tympanic, temporal, axillary, rectal

Out of the 5 different methods/sites, which is the BEST root to obtain core body temp.

Rectal

Out of the 5 different methods/sites, which is the most common root to obtain body temp.

Oral

When taking a Tympanic Temperature, it is important to pull what up and back to obtain an accurate reading

the pinna

Where is the prob placed when taking an oral temperature and why

In sublingual pocket, many blood vessels are in that area

T/F: When taking an oral temp. it is important to use the red prob and place a disposable covering on it.

False! the red prob is used for rectal temp. the blue one is for oral temp.

Which method of temp. measurement requires a physician's order?

Rectal

T/F: When taking a rectal temp. insert the probe about 5-5.5inches into the rectum

False, it’s 1-1.5 inches.

When taking the temporal temp. you are measuring the body temp. by capturing

the heat emitted by the skin over the temporal artery

When taking the tympanic temp. you are measuring

The heat from the body given off by the tympanic membrane

Temporal temp. are more accurate than which method?

Axillary

What is the normal body temp. range in Celsius

35.9-38 (96.8F-100.4F)

The environment has a large impact on which age group's temperature reading?

Infants

What is the common method used to measure a neonatal's temp.

Axillary

Out of the 5 methods to take temp. which measure core temp.

rectal and oral

Out of the 5 methods to take temp. which measure surface temp.

Axilla, temporal, tympanic

If someone has a temperature >39C or 102.2 F, they are considered these three terms

Febrile, pyrexia, or they have a fever

If someone has an abnormally low body temp between 34C-35C they are referred to being

hypothermic

Pulse is

the measurement of heart rate and rhythm, wave like impulses that are felt in peripheral arterial vessels or apex of the heart

What is the average pulse rate

60-100 bpm

An individual who has a heart rate <60bpm is considered to have

bradycardia

An individual who has a heart rate >100bpm is considered to have

tachycardia

Pulses are either ________ or ________

regular, irregular

Which age group is expected to have a faster apical pulse?

infants

A RN is assessing an infants and goes to obtain their bpm. Which peripheral artery should the RN use

brachial

What are the 8 peripheral arteries that are palpable

Carotid, temporal, brachial, radial, femoral, popliteal, posterior tibial, pedial

What is the grading system for pulse amplitude

0=absent, unable to palpate

+1= diminished, weaker than expected

+2= brisk, expected (NORMAL)

+3= bounding

What are the expected apical sounds

S1 (lub) S2 (dub)

What is the expected range for bpm with an infant

120-160

What is the expected range of bpm for newborn

80-150

Respiratory rate is

the movement of air and gases out of the lungs

What is the normal range of respirations/min

12-20

What are some indicators of labored breathing

flaring nostrils. use of accessory chest muscles, distended veins in neck

bradypnea

slow breathing

Tachypnea

rapid breathing, >20 breaths/min

Shortness of breath is

dyspnea

orthopnea is

Shortness of breath when lying flat

Apnea is

periods of no breathing

Hyperventilation

very rapid breathing

hypoventilation

decreased breathing

Chyne-Stokes respiration

often associated w. end of life

alteration periods of deep or rapid breathing then periods of apnea

Biot's respirations

Similar to Chyne stokes but not as deep breathing

What is normal breathing

eupnea

Pulse oximetry is the

noninvasive indirect measurement of oxygen saturation of the blood

What is the normal range of pulse oximetry

95%-100%

Hypoxia is

pulse oximetry

Blood pressure is the measurement of

the force of the blood against the walls of the arteries during systole and diastole

T/F: it is ok to take BP on a limb that had surgical removal of axillary lymph nodes

False, cause lymphedema

An accurate BP cuff should be about ___% of arm circumference

40

When taking BP the bladder should be at least ___ the size of the arm

2/3

If a RN would take BP with a cuff too large you would expect the reading to be falsely ____

low

If a RN would take BP with a cuff too large you would expect the reading to be falsely _____

high

T/F: When taking BP, it is OK to reinflate the cuff if you missed a sound

False! Deflate cuff, wait 1-2 minutes, and start over, leads to false reading

When doing the two step method to obtain BP, you should add __ mm Hg to your estimate systolic number

30

BP that is

hypotension

BP that is >180/120 mm Hg is considered

Hypertensive crisis

BP that is >140/90 mm Hg is considered

Hypertension Stage II

BP that is between 130-139/80-89 mm Hg is considered

Hypertension Stage I

When taking BP what are the sounds called you are listening for

Korotkoff sounds (ko-rot-koff)

How many phases are associated with Korotkoff sounds

5 phases

This phase is characterized by the first appearance of faint but clear tapping sounds that gradually increase in intensity; the first tapping sound is systolic #

Phase I

This phase is characterized by distinct, loud sounds as the blood flows relatively freely through an increasingly open artery

Phase III

This phase is characterized by muffled or swishing sounds and sees the temporary disappearance of sounds

Phase II

This phase is characterized by a distinct, abrupt, muffling sound with a soft, blowing quality

Phase IV

This phase is the last sound heard before a period of continuous silence; this is your diastolic pressure

Phase V

What is orthostatic hypotension?

When a person's blood pressure falls when moving from a seated or lying position to a standing position.