Vital Signs

Question 1

4 Major vital signs routinely monitored

Answer 1

Temperature

Blood Pressure

Pulse

Respiration

Question 2

Normal oral body temperature range

Answer 2

35.8 - 37.3 ℃

Question 3

Temperature variation causes

Answer 3

Diurnal cycle
1-1.5 ℃ fluctuation throughout the day, reaching peak late afternoon/early evening

Menstrual cycle
0.5-1 ℃ at ovulation until menses (progesterone secretion)

Exercise

Age
Infants and young children have less effective temperature control
Older adults average 36.2 ℃

Question 4

How to take oral temperature

Answer 4

Clean thermometer thoroughly with alcohol swabs before and after

Place in POSTERIOR sublingual pocket

Lips closed

Wait 2 minutes or until beep

Wait 15 minutes after hot or iced liquids

Wait 2 minutes after smoking

Question 5

Hyperthermia

Answer 5

Increased body temperature, typically above 38℃

Possible causes:
Infection
Tissue breakdown
Neurological condition
Environmental heat

Question 6

Hypothermia

Answer 6

Drop in core body temperature, typically below 36℃

Possible causes:
Overexposure to cold
Endocrine disorders
Metabolic disorders
Alcohol or drug use
Advanced age

Question 7

Normal Pulse Ranges

Answer 7

Adults 60-100 bpm

Newborns 70-190 bpm

Question 8

How to take Pulse

Answer 8

Place 3 finger pads along groove between radius and palmaris longus tendon

Count beats for 30sec if regular, or 60sec if irregular

Report rate in beats per minute (bpm), force and rhythm

Question 9

Pulse Rhythm

Answer 9

Normal pulse = sinus rhythm = regular, even tempo

Deviation = arrhythmia = auscultation of heart sounds required

Question 10

Tachycardia

Answer 10

rapid heart rate over 100bpm

Possible causes:
fever, anxiety, stress, exercise, increased metabolic demands, anaemia, overactive thyroid

Question 11

Bradycardia

Answer 11

pulse rate lower than 60bpm

Possible causes:
Physiological bradycardia (athletes), parasympathetic stimulations, sleep, sedatives, painkillers, calcium-channel blockers, heart block, inflammatory disease, underactive thyroid

Question 12

Pulse Force Scale

Answer 12

3 point scale

3 - full, bounding pulse; difficult to obliterate - increased stroke volume, during exercise or some conditions

2 - normal, detected easily; obliterate by applying strong pressure

1 - weak, thready, difficult to feel - dehydration, abnormal heart conditions

0 - absent, no pulse felt at all

Question 13

Normal Range for Respiration rate

Answer 13

Adults 10-20 brpm

Newborns and Children 30-40
brpm

Question 14

How to assess Respiration Rate

Answer 14

Unobtrusively while maintaining radial pulse examination position

Observe rise and fall of chest, count for 30sec and record in breaths per minute (brpm)

Note rate, rhythm and effort

Question 15

Tachypnoea

Answer 15

Increased respiratory rate of 24+ brpm (in adults)

Possible causes:
fever, fear, anxiety, sympathetic stimulation, exercise, respiratory conditions

Question 16

Bradypnoea

Answer 16

Slow breathing, less than 10 brpm

Possible causes:
Certain drugs, parasympathetic activities, increased intracranial pressure, diabetic coma

Question 17

Normal range for Blood Pressure

Answer 17

Optimal
>120 / >80

Average
120-129 / 80-84

High Normal
130-139 / 85-89

Question 18

Ranges for Hypertension

Answer 18

Grade 1/Mild
140-159 / 90-99

Grade 2/Moderate
160-179 / 100-109

Grade 3/Severe
>180 / >110

Isolated Systolic Hypertension
>140 / <90

Question 19

Range for Hypotension

Answer 19

> 95 / >60

Question 20

Orthostatic Hypotension

Answer 20

Sudden drop accompanying quick change in body position

More than
-20 / -10

Question 21

Questions before BP assessment

Answer 21

Communication
- previous BP measurements
- preferred arm
- food/drink consumption past 15-20min
- current medications
- smoking past 15-20min
Physical activity past 15-20min

Question 22

How to assess BP

Answer 22

Client seated, feet flat, arm rested or supported at heart level
Client calm, relaxed, rested

Locate brachial artery pulse point

Correct cuff size, tied approx. 2-3 fingers above antecubital fossa; cover approx. 80% of arm circumference

Palpate radial pulse, inflate cuff until pulse obliterated = rough systolic reading

Wait 10-15sec, re-inflate cuff to approx 20-30mmHg higher than rough systolic reading

Deflate cuff carefully 2mmHg at a time
Listen for Karotkoff sounds
- first = systolic
- silence = diastolic

Question 23

Common errors in taking BP

Answer 23

Inappropriate timing - after stimulants, exercise, heightened emotions etc

Incorrect positioning of client

Incorrect cuff size or position

Incorrect inflation or deflation of cuff

Incorrect use of stethoscope