Patient Assessment: Vital Signs (U3)

Question 1

Vital signs definition?

Answer 1

Physical signs that indicate an individual is alive

Question 2

How are vital signs seen?

Answer 2

Observed, measured and monitored to assess an individual’s level of physical functioning, patient must have been sitting for approx. 5 minutes (relax)

Question 3

What should you do before assessing a patient?

Answer 3

Take a minute to look at the entire patient, all assessments made when seated (ex. patient hygiene level, are they relaxed….)

Question 4

What are some factors to consider when looking at normal vital signs?

Answer 4

Age/sex/weight/exercise tolerance/condition

Question 5

What are the four assessments, and why in that order?

Answer 5

1. Temperature
2. Pulse
3. Respiration
4. Blood pressure

Least to most invasive

Question 6

Temperature can vary due to what reasons?

Answer 6

Time of day, illness, stress, exposure to heat/cold

Question 7

Normal temperature?

Answer 7

36.5-37.7 degrees Celsius

Question 8

What are the four temperature sites?

Answer 8

Oral, axillary, tympanic, rectal

Question 9

What is the oral temperature site?

Answer 9

Within the mouth/under tongue

Question 10

What is the axillary temperature site?

Answer 10

In the armpit

Question 11

What is the tympanic temperature site?

Answer 11

In the ear canal

Question 12

What is the rectal temperature site?

Answer 12

Through the anus in the rectum

Question 13

What is a pulse?

Answer 13

Pressure of the blood felt against the wall of an artery as the heart contracts/relaxes

Question 14

What are the three things pulse measures?

Answer 14

Rate, rhythm, volume

Question 15

What is pulse rate?

Answer 15

Number of beats/minutes

Question 16

What is pulse rhythm?

Answer 16

Refers to regularity

Question 17

What is pulse volume?

Answer 17

Refers to strength

Question 18

What is the pulse taken on?

Answer 18

Radial/carotid artery, and on arteries

Question 19

What are the arteries that pulse is taken on?

Answer 19

Temporal, carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial

Question 20

What is the temporal site?

Answer 20

Sides of the head

Question 20

What is the carotid site?

Answer 20

Sides of the neck

Question 21

What is the brachial site?

Answer 21

Inner aspect of forearm at the antecubital space

Question 22

What is the radial site?

Answer 22

Inner aspect of the wrist, above thumb

Question 23

What is the femoral site?

Answer 23

Inner aspect of the upper thigh

Question 24

What is the popliteal site?

Answer 24

Behind the knee

Question 25

What is the dorsalis pedis site?

Answer 25

Top of the foot arch

Question 26

What is the posterior tibial site?

Answer 26

Medial aspect of the ankle

Question 27

What are the two most common sites for taking a pulse?

Answer 27

Radial, and apical

Question 28

What is an apical pulse?

Answer 28

Ausculated with a stethoscope on the chest wall, pulse is found on the apex of the heart (bottom)

Question 29

Characteristics of a pulse?

Answer 29

Pulse rate, rhythm, strength and intensity, bilateral presence

Question 30

How is a pulse rate found?

Answer 30

Assessed in BPM, counted for 15/20/30/60 seconds

Question 31

Tachycardia definition?

Answer 31

Pulses rate faster than normal

Question 32

Bradycardia definition?

Answer 32

Pulse rate slower than usual

Question 33

What does rhythm refer to?

Answer 33

Refers to the regularity of the pulse (spacing of the beats), the pattern of the heartbeat

Question 34

What types of pulse rhythm are there?

Answer 34

Regular and irregular

Question 35

What is an irregular pulse rhythm?

Answer 35

Arrhythmia, Usually caused by a defect in the electrical conduction pattern

Question 36

What do you do when documenting a client with an irregular heartbeat?

Answer 36

Must be measured a full minute to determine average rate, document pulse rhythm as irregular (regular for a normal patient)

Question 37

What are the two ways to describe a pulse's strength and intensity?

Answer 37

Strong/bounding and weak/thready

Question 38

Bilateral presence definition?

Answer 38

Pulses should have bilateral presence, found on both sides

Question 39

BP definition?

Answer 39

Pressure/tension exerted on the arterial walls of blood pulsates through them

Question 40

Systolic blood pressure definition? What is expected?

Answer 40

Pressure exerted on the arteries during the contraction phase of the heartbeat (100-149mm HG)

Question 41

Diastolic blood pressure definition? What is expected?

Answer 41

Resting pressure on the arteries as the heart relaxes between contractions (60-90mm HG)

Question 42

Hypotension definition?

Answer 42

When blood pressure drops below expected

Question 43

Hypertension definitino?

Answer 43

High blood pressure (medical condition with multiple readings)

Question 44

Equipment to measure BP?

Answer 44

Sphygmomanometer/BP cuff/cuff

Question 45

Respiration definition?

Answer 45

Process of taking in O2 and expelling CO2 from lungs and respiratory tract

Question 46

One is contained in one breath?

Answer 46

One inspiration and expiration

Question 47

Dyspnea definition?

Answer 47

Difficult/laboured breathing

Question 48

Apnea definition?

Answer 48

Absence of respiration?

Question 49

Orthopnea definition?

Answer 49

Severe dyspnea in which breathing is very difficult in any position other than sitting erect/standing

Question 50

What is a tachypnea resting respiratory rate?

Answer 50

RR>20 bpm

Question 51

What is a bradypnea respiratory rate?

Answer 51

RR<12 bpm

Question 52

Cheyne-Stokes respiration definition?

Answer 52

Periods of dyspnea followed by periods of apnea (dying patient)

Question 53

Signs of respiratory distress?

Answer 53

Cyanosis, central asphyxiation, hyper/hypoventilation, rhythm of respiration and quality of respirationC

Question 54

Cyanosis definition?

Answer 54

Dusky, bluish discolouration of the skin/lips/nail beds due to low O2 and high CO2 in the bloodstream

Question 55

What is central cyanosis a sign of?

Answer 55

Respiratory distress

Question 56

Central asphyxiation definition?

Answer 56

Lock of O2 getting into the body

Question 57

What does it mean when the peripheral heart is not pumping properly?

Answer 57

Respiratory distress

Question 58

Hyperventilation definition?

Answer 58

Increased respiratory rate (related to shallow breaths)

Question 59

Hypoventilation definition?

Answer 59

Decrease in respiratory rate and depth (related to shallow breaths, but with its depth

Question 60

Rhythm respiration should be...

Answer 60

Regular

Question 61

What are the two qualities of respiration?

Answer 61

Shallow/deep