Chapter 13 Vital Signs And Monitoring Devices

Question 1

Whats the Most important part of patient assessment

Answer 1

Chief Complaint

Question 2

Vital signs

Answer 2

outward signs of what is going on inside the body, including:

• respiration
• pulse
• skin color
• temperature
• and condition (Capillary refill in infants and children),
• pupils
• and Blood Pressure
• SpO2

Question 3

Tachycardia

Answer 3

Fast/rapid Heart rate any pulse rate above 100 beats per minute

Question 4

Bradycardia

Answer 4

Slow/below normal Heart rate any pulse rate below 60 beats per minute

Question 5

pulse rate

Answer 5

the number of pulse beats per minute

Question 6

pulse

Answer 6

the rhythmic beats felt as the heart pumps through the arteries

Question 7

what is a high pulse rate and at what trending HR would you consider something to be seriously wrong?

Answer 7

if HR is 150 or trending at 120 or below 50 something may be seriously wrong
-high priority-

Question 8

Pulse Quality

Answer 8

The Rhythm (regular or irregular) and Force (Strong or weak-thready) of the pulse

Question 9

Ventricular assist device

Answer 9

An implanted device in the chest that helps the heart move blood through the circulatory system

• propels blood continuously and not in waves
• Patient will have NO PULSE

Question 10

Serious Respiratory Rates are?

Answer 10

Above 24 breaths/min

or Below 10 breaths/min

Question 11

Respiratory Quality

Answer 11

Normal or Abnormal character of breathing

1. Normal
2. Shallow
   - observed by slight movement in chest or abdomen
3. Labored
   - increase in work of breathing (in and out), use of accessory muscles (nasal flaring, retractions,
4. Noisy
   - obstructed breathing (stridor, gurgling, weeping, crowing, snoring)

Question 12

Respiratory Rhythm

Answer 12

The regular or irregular spacing of breaths

Question 13

Cyanotic (blue-grey) Color signify’s

Answer 13

Lack of O2 from inadequate breathing or heart function

Question 14

Pale Color signify’s

Answer 14

Constricted blood vessels resulting in:

• blood loss
• shock
• hypotension
• emotional distress

Question 15

Jaundiced (yellow) Color signify’s

Answer 15

abnormalities of the liver

Question 16

Mottled (blotchy) Color signify’s

Answer 16

Occasionally in patients with shock

Question 17

Flushed (red) Color signify’s

Answer 17

exposure to heat, emotional excitement

Question 18

Pupil abnormalities suggest

Answer 18

• drug use
• head injury
• eye injury

Question 19

Systolic Blood Pressure

Answer 19

pressure created when the heart contracts and forces blood into the arteries

Question 20

Diastolic Blood Pressure

Answer 20

pressure remaining in the arteries when the left ventricle of the heart is relaxed and filling

Question 21

mmHg

Answer 21

Millimeters of Mercury

Question 22

sphygmomanometer

Answer 22

The cuff and gauge used to measure blood pressure

Question 23

Hypertension

Answer 23

High blood pressure
When an Adult has a:
- SBP of 140 or greater
- DBP of 90 or greater

Question 24

Hypotension

Answer 24

Low blood pressure

SBP of 90 or less

Question 25

Palpation

Answer 25

Listening

Question 26

Auscultation

Answer 26

Feeling

Question 27

A Healthy temperature is?

Answer 27

equal or greater than 96F or less than 100F

Question 28

Pulse Oximeter

Answer 28

an electronic device for determining the amount of oxygen carried in the blood, know as the oxygen saturation (SpO2)

Question 29

Oxygen Saturation (SpO2)

Answer 29

the ratio of the amount of oxygen present in the blood to the amount that could be carried, expressed as a percentage.

Question 30

SpO2 Readings

Answer 30

- 96-100 is normal - 91-95 indicates mild hypoxia - 86-90 indicate moderate hypoxia - 85 or less indicates severe hypoxia

Question 31

types of situations a pulse oximeter may be inaccurate

Answer 31

- patient exposed to carbon monoxide (CO) - patient in shock or hypothermic - excessive moving - anemia, hypovolemia, and certain kinds of poisoning

Question 32

Normal Glucose Readings

Answer 32

- at least 60-80 mg/dL | - no more then 120-140 mg/dL