Vital Signs

Question 1

Clinical measurement of temperature, pulse, respiration and blood pressure and give some indication of the state of health of an individual. Ir represents interrelated physiologic systems of the body

Answer 1

Vital Signs

Question 2

Purposes of Vital Signs

Answer 2

• universally communicate a patient’s condition and severity of disease
• helps in identifying nursing diagnosis, assess interventions and make decisions concerning the reponse of patients to treatment

Question 3

Normal Range of Temperature

Answer 3

36-37.5 degrees Celsius

Question 4

temperature of internal organs

Answer 4

core temperature

Question 5

temperature of skin, outside surface

Answer 5

surface temperature

Question 6

Purposes of taking temperature:

Answer 6

• establish data for subsequent evaluation
• check whether the core temperature is within normal range
• determine changes in response to specific therapies

Question 7

surface-surface without contact

Answer 7

Radiation

Question 8

molecule-molecule with contact

Answer 8

Conduction

Question 9

dispersion of heat through air currents

Answer 9

Convection

Question 10

continuous evaporation of moisture from the repiratory tract, oral mucoda and skin

Answer 10

Vaporation

Question 11

patients having fever

Answer 11

febrile

Question 12

Methods of taking Temperature:

Answer 12

• Oral
• Axillary
• Rectal
• Non-contact

Question 13

it is the difference between heat produced and heat lost by the body and is measured through the use of a thermometer

Answer 13

Temperature

Question 14

Contraindications for Oral Method

Answer 14

1. infants
2. unconscious and irrational patients
3. patients who breath through their mouths
4. those with disease of the oral cavity or surgery of the nose or mouth
5. patients who have had taken cold or hot foods or fluids

Question 15

Purposes of Rectal Method

Answer 15

1. to obtain first temperature of newborn to check rectal patency
2. to check core temperature of an adult

Question 16

contraindications for Rectal Method

Answer 16

1. patients with recent rectal surgery
2. patients having diarrhea
3. patients having disease of the rectum
4. patients having cardiovascular alternation because the thermometer may stimulate the vagus nerve causing bradycardia or rhythm disorder
5. Patients with leukemia which may traumatize the rectal mucosa causing bleeding

Question 17

it is a rhythmical throbbing that results from a wave of blood passing through an artery as the heart contracts

Answer 17

Pulse

Question 18

possible sites for taking pulse:

Answer 18

apical
radial artery
facial artery
temporal artery
dorsalis pedis
femoral artery
popliteal artery
carotid artery
bracial artery
posterior tibialis

Question 19

what to note when taking pulse:

Answer 19

rate
rhythm or regularity
tension or compressibility
volume

Question 20

normal pulse rate per minute (Average and Range): Newborn

Answer 20

130 (80-180)

Question 21

normal pulse rate per minute (Average and Range): 1 year

Answer 21

120 (80-140)

Question 22

normal pulse rate per minute (Average and Range): 5-8 years

Answer 22

100 (75-120)

Question 23

normal pulse rate per minute (Average and Range): 10 years

Answer 23

70 (50-90)

Question 24

normal pulse rate per minute (Average and Range): Teen

Answer 24

75 (50-90)

Question 25

normal pulse rate per minute (Average and Range): Adult

Answer 25

80 (60-100)

Question 26

normal pulse rate per minute (Average and Range): Older Adult

Answer 26

70 (60-100)

Question 27

purpose of taking pulse rate:

Answer 27

to obtain an estimate of the wuality of the heart's action per minute

Question 28

if patient is a newborn or an infant, pulse will be assessed through the

Answer 28

brachial, apical and femoral artery

Question 29

the apical pulse is found where? (adult and children)

Answer 29

5th left intercostal space, midclavicular line (adults) 4th left intercostal space, miclavicular line (children)

Question 30

cardiac rate is best assessed on the?

Answer 30

apex part of the heart

Question 31

the heartbeat is usuallyt loudest over where?

Answer 31

at the apex part of the heart

Question 32

the two heart sounds are produced by?

Answer 32

closure of the heart valves

Question 33

normal respiration rate per minute (Average and Range): Newborn

Answer 33

35 (30-60)

Question 34

it is the exchange of oxygen and carbon dioxide between the atmnosphere and body cells and is initiated by the act of bretahing

Answer 34

Respiration

Question 35

normal respiration rate per minute (Average and Range): 1 year

Answer 35

30 (20-40)

Question 36

normal respiration rate per minute (Average and Range): 5-8 years

Answer 36

20 (15-25)

Question 37

normal respiration rate per minute (Average and Range): 10 year

Answer 37

19 (15-25)

Question 38

normal respiration rate per minute (Average and Range): Teen

Answer 38

18 (15-20)

Question 39

normal respiration rate per minute (Average and Range): Adult

Answer 39

16 (12-20)

Question 40

normal respiration rate per minute (Average and Range): Older Adult

Answer 40

16 (15-20)

Question 41

Purpose of taking RR

Answer 41

to obtain the respiratory rate per minute and an estimate of the patient's respiratory status

Question 42

is the lateral force exerted by the blood on the arterial walls

Answer 42

Blood Pressure

Question 43

Purposes of taking Blood Pressure

Answer 43

1. to aid in diagnosis 2. to observe changes in a patient's condition

Question 44

Contraindications for Brachial Artery Blood Pressure Measurement

Answer 44

1. surgery including the breats, axilla, shoulder, arm or hands 2. Venous Access Device such as AV shunt and IVF 3. Injury or disease to the shoulder, arm or hands such as trauma, burn or application of cast or bandage

Question 45

Sites for BP taking:

Answer 45

1. either arm on the antecubital space 2. either leg on the popliteal space 3. dorsalis pedis

Question 46

Normal BP

Answer 46

<120/<80

Question 47

Prehypertension

Answer 47

120-139 over 80-89

Question 48

Hypertension, Stage 1

Answer 48

140-159 over 90-99

Question 49

Hypertension, Stage 2

Answer 49

>180 over >100