Chapter 28—Vital Signs Flashcards
(38 cards)
when to assess VS
On every admission, every office visit
Before & after procedures/interventions
Anytime there is a change in status
Before d/c
normal temp oral
98.6 to 99.5 F
36 to 37.5 C
VS
temp HR RR BP O2 pain
2 types of body temp
surface
core
________ regulates temp
hypothalamus
URGENT temp assessment
<95 F or 35 C
>103.1 F or 39.5 C
5 temp routes
oral axillary tympanic temporal (TAT) rectal
safest but least accurate temp reading
axillary
preferred temp route for newborns
axillary
rectal temp is taken if pt…
is comatose, confused, having seizures, or unable to close the mouth
insert rectal thermometer ____ into anus
1.5”
leave axillary thermometer in for ___ mins
10
rectal temp is ____ higher than oral temp
- 7 to 1 F
0. 5 C
axillary temp is _____ lower than oral temp
1 F
0.5 C
tympanic temp is _____ higher than oral temp
- 4 F
0. 8 C
TAT temp is a little bit ______ than oral
higher
location of apical pulse
5th intercostal space (adult)
midclavicular
normal HR for adults
60-100 bpm
pulse locations
Apical, temporal, carotid, radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsalis pedis
count for _____ time for apical pulse
1 full minute
dehydration effect on pulse
HR increases, then decreases as we lose fluid volume
5 things when assessing pulse
Rate Rhythm Strength Elasticity Symmetry
Pulse deficit
difference between apical & peripheral pulse, or 2 peripheral pulses
pulse alternans
irregular - strong & weak together
