Vital Signs

Question 1

Acceptable Ranges for Adults
(Temperature, Pulse, Blood Pressure, Respiration, O2 Saturation)

Answer 1

Temp: 36C - 38C (96.8F - 100.4F)
Pulse: 60 - 100 Beats/min
BP - Systolic: less than 120
- Diastolic: less than 80 mmhg
Pulse Pressure: 30-50 mmhg
Respiration: 12-20 breaths/min
O2 Sat: SPO2 95-100

Question 2

When to Measure Vital Signs (BASSH)

Answer 2

Before during after
- blood products transfusion
- medication administration
- nursing intervention
Admission
Status Changes
Symptoms that are non-specific
Hospital Routine Schedule

Question 3

General Preparation WIPE

Answer 3

• Wash hands before and after procedure
• Identify Information patient abt procedure
• Provide privacy and position patient accordingly
• Explain procedure and evaluate

Question 4

detects signals from receptors and sends signals to effectors to regulate body temperature.

Answer 4

Hypothalamus

Question 5

Low body Temperature preserves heat by limiting blood flow to surface

Answer 5

Vasoconstriction

Question 6

High body temperature increase blood flow to surface to promote

Answer 6

Heat loss

Question 7

4 types of heat loss

Answer 7

• Radiation - transfer of heat from an object to another without direct contact
• Conduction – transfer of heat from one object to another with direct contact.
• Convection – heat loss through air movement.
• Evaporation – transfer of heat via evaporation

Question 8

Factors Affecting Body Temperature

Answer 8

• Age
• Exercise
• Hormone level
• Circadian rhythm
• Stress
• Environment

Question 9

Fever vs Hyperthermia

Answer 9

Fever: pyrexia; infection
Hyperthermia: Nausea and vomiting
- Fainting
- Moderately increased temperature

Question 10

When the temperature drops the usual range of body temperature

Answer 10

Hypothermia

Question 11

How to measure body temperature

Answer 11

• Oral 37C or 98.6F
• Axillary 36.5 or 97.7F (armpit)
• Tympanic 37C or 98.6F (ear)
• Rectal 37.5C or 99.5 F(Butt but recommended for babies)
  1.5 inches for adults
  0.5 inches for babies

Question 12

Celsius to fahrenheit

Answer 12

(C x 1.8) + 32

Question 13

Fahrenheit to celsius

Answer 13

(F - 32) x 5/9

Question 14

Nursing Intervention for Hyperthermia AILMENT

Answer 14

Antipyretics
Limit physical activites
Increase rest
Monitor skin color and temp
Monitor blood count
Excess blankets when patient feels warm
Nutrition and fluids
Tepid sponge bath

Question 15

Nursing intervention for hypothermia CCAKES

Answer 15

Cover patient scalp with cap
Clothes are dry
Apply warming pads
Keep limbs close to body
Environment warm
Supply warm oral and IV fluids

Question 16

Amount of blood ejected per heartbeat

Answer 16

Stroke Volume

Question 17

Amount of blood ejected within 1 minute

Answer 17

Cardiac output

Question 18

Sites of Pulses

Answer 18

Radial - circulation of hand (near thumb)
Apical - 5th ICS at left clavicular line (for infants)
Brachial - for blood pressure

Question 19

Irregular rhythm of pulse

Answer 19

Dysrhythmias

Question 20

Phases of Fever (Pyrexia)

Answer 20

1. Cold/Chill Phase
2. Plateau Phase (warm skin)
3. Fever Abatement/Flush Phase (Sweating)

Question 21

Types of Fever SIRR

Answer 21

1. Sustained - elevated temp above 38C
2. Intermittent - temp spiked and returned to acceptable range after 24 hrs
3. Remittent - temp spiked and fluctuated but with no return to normal temp
4. Relapsing - returns to normal but recus

Question 22

Chracteristics of pulse

Answer 22

Infant - 120-160 bpm
Toddler - 90-140
Preschooler - 80-110 bpm
School aged - 74-100 bpm
Adolescent 60-90 bpm
Adult - 60-100

Question 23

Less than 60 beats/min

Answer 23

Bradycardia

Question 24

Greater than 100 beats/min

Answer 24

Tachycardia

Question 25

Tachypnea

Answer 25

RR over 20

Question 26

Bradypnea

Answer 26

RR below 12

Question 27

Absence of Breathing

Answer 27

Apnea

Question 28

Overexpansion of lungs

Answer 28

Hyperventilation

Question 29

Underexpansion of lungs

Answer 29

Hypoventilation

Question 30

alternating periods of apnea and hyperventilation; cardiac failure, increased ICP, or brain damage.

Answer 30

Cheyne-Stokes breathing

Question 31

shallow respiration of the same depth followed by a period of apnea.

Answer 31

Biot’s

Question 32

abnormally deep, regular, increased rate; hyperventilation commonly seen in patients with KDA.

Answer 32

Kussmaul’s

Question 33

Blood Pressure

Answer 33

Systole - Peak of maximum heart ejection Diastole - Ventricular relaxation Millimeters of mercury - mmhg

Question 34

Difference between systole and diastole

Answer 34

Pulse pressure

Question 35

Cardiac output

Answer 35

Stroke volume x heart rate

Question 36

Loses elasticity; cannot compensate for the increased vascular resistance.

Answer 36

Arteriosclerosis

Question 37

Ranges of BP

Answer 37

Normal - lower than 120 systolic and lower than 80 diastolic Prehypertension - systolic: 120-139 ; diastolic: 80-89 Stage 1 Hypertension - systolic: higher than 140 ; diastolic: higher than 90 Stage 2 Hypertension - systolic: higher than 160 ; diastolic: higher than 90

Question 38

Hypotension

Answer 38

Lower than 90mmhg or below

Question 39

- Also known as postural hypotension, occurs when a normotensive person develops symptoms. - Drop in blood pressure at least 20 mmHg for either systolic or diastolic pressure due to sudden movement or change in position.

Answer 39

Orthostatic Hypotension

Question 40

Korotkoff’s sound Phases

Answer 40

Phase 1: First sound: Onset of Systolic Pressure. (Tapping) Phase 2: Blowing or swishing sound occurs. Phase 3: Blood flows freely through open artery, more intense. (Crisp) Phase 4: Sounds become muffled and low pitched. Phase 5: The last sound is heard: Diastolic pressure.

Question 41

an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage, or both (IASP).

Answer 41

Pain

Question 42

Types of Pain

Answer 42

1. Referred pain - arising in different areas or other parts of body 2. Visceral Pain - arisings from organs 3. Acute Pain - lasts through recovery period 4. Chronic Pain - prolonged over 6 months

Question 43

Concepts associated with pain

Answer 43

- Hyperalgesia/Hyperpathia – increased sensation of pain in response to a normally painful stimulus. - Allodynia – sensation of pain from a stimulus that normally does not produce pain (e.g., light touch). - Dysesthesia – unpleasant abnormal sensation that can either be spontaneous or evoked.

Question 44

Pain Assessment PQRST COLDSPA

Answer 44

Provocation (what) Quality (how does it feel) Radiation (where pain) Severity (pain scale) Time (when) Character Onset Location Duration Severity Pattern Associated factors