Vital Signs

Question 1

What type of patient is it important to establish a baseline

Answer 1

1. Elderly
2. Younger than 2 yrs
3. Debilitated patients
4. Limited activity
5. History of cardio problems
6. Recovering from recent trauma or surgery
7. With HTN

Question 2

What does temperature tell us

Answer 2

If there is an infection

Inflammatory Response

Question 3

Normal Range for Temp

Answer 3

96.4 - 99.1

Question 4

Which is most accurate way to measure temp

Answer 4

Rectal

• oral is most common
• Axillary will run lower than oral
• Temporal
• Tympanic

Question 5

Factors that can effect patient temp

Answer 5

1. Time of day (4-6pm = highest)
2. Age (Age will dec temp)
3. Environmental temp
4. Infection (inc)
5. Physical acitivty (inc)
6. Emotional stress (inc)
7. Ovulation (inc)

Question 6

What is pulse measuring

Answer 6

Measure of HR - beats per minute - blood flow from contraction of LV

Question 7

Norms for pulse

Answer 7

Adult = 60-100 
Child = 80-100
Newborn = 100-120

Question 8

Tachycardia

Bradycardia

Answer 8

Above 100

Below 60

Question 9

Pulse Force

Answer 9

4+ = bounding 
3+ = increased force
2+ = normal
1+ = weak
0 = unpalpable

Question 10

Factors that affect pulse

Answer 10

1. Age
2. Gender (males lower)
3. Environmental temp
4. Infection (inc)
5. Physical activity (inc)
6. Emotional stress (inc)
7. Medications

Question 11

Where might you palpate pulse

Answer 11

Temporal artery
Carotid Artery
Brachial artery
Radial artery
Femoral artery
Popliteal artery
Dorsal Pedal artery
Posterior tibial artery
Apex

Question 12

Pulse abnormal responses to exercise

Answer 12

Pulse rate slowly increase
Pulse rate does not increase
Pulse rate continues to increase or decrease as intensity stops
Pulse rate declines before intensity does
Rhythm becomes irregular

Question 13

What does BP tell us

Answer 13

Pressure on the arterial walls

Question 14

What does SBP tell us

Answer 14

Pressure when heart is contracting

Question 15

What does DBP tell us

Answer 15

Pressure when heart is relaxing

Question 16

Korokoff Sounds

Answer 16

Phase 1 = Tapping - systolic
Phase 2 = Swooshing
Phase 3 = Knocking
Phase 4 = Muffled 
Phase 5 = None - Diastolic

Question 17

What is auscultatoy Gap

Answer 17

You hear phase 1 and then goes away for 30 mmHg and then comes back at phase 2
Noncompliant vessels

Question 18

Infant birth - 3 months BP norm

Answer 18

85-90/35-65

Question 19

Infant 3 months - 1 year BP

Answer 19

90-100/60-67

Question 20

Children 1-4 years BP norm

Answer 20

100-108/60

Question 21

Children 4-12 BP norm

Answer 21

add 2 mmHg per year to 100/ 60-70

Question 22

Adolescents BP

Answer 22

100-120/65-75

Question 23

Adults BP

Answer 23

below 120/80

Question 24

Elderly BP

Answer 24

120-140/80-90

Question 25

Prehypertension

Answer 25

120-139/80-89

Question 26

Stage 1

Answer 26

140-159/90-99

Question 27

Stage 2

Answer 27

160-179/100-109

Question 28

Stage 3

Answer 28

180-209/110-119

Question 29

Stage 4

Answer 29

Greater than 210/120

Question 30

What contributes to hypertension

Answer 30

``` Obesity Physical activity Nicotine use Alcohol Salt Arteriosclerosis Diabetes Mellitus Oral contraceptives Advanced age Kidney disease Race Diet ```

Question 31

What factors affect BP

Answer 31

``` Age Physical activity Emotional status Medications Size of arteries Arm position Muscle contraction Blood volume Dehydration Cardiac output Site of measurement ```

Question 32

Technique for BP

Answer 32

Stethoscope Sphygmomanometer Cuff Bladder (40% of width of arm and 80% circumference)

Question 33

Errors in BP measurement

Answer 33

``` White coat reaction Pain Talking Cuff size Deflating Arm unsupported Paretic arm Environmental noise Cuff over clothing Parallax view Nicotine/Caffeine ```

Question 34

Abnormal BP responses with exercise

Answer 34

Sys inc rapidly Sys does not increase Sys continues to inc when activity stops Dias inc more than 15 mmHg

Question 35

What is orthostatic hypotension

Answer 35

A drop in systolic BP more than 20 mmHg or a drop in diastolic BP more than 10 mmHg

Question 36

How do we define respirations

Answer 36

Breaths/minute | Taking in O2 and giving off Co2

Question 37

Ratio of inspiration to expiration

Answer 37

Ratio of expiration should be longer Inhale 1-2 sec Exhale twice as long

Question 38

Methods to measure RR

Answer 38

Visual Auditory Palpation

Question 39

How to describe RR

Answer 39

Rate Rhythm Depth Character

Question 40

Norms for RR - Neonate

Answer 40

25-50/minute

Question 41

Norms RR Child

Answer 41

15-30/minute

Question 42

Norms RR Adult

Answer 42

12-20/minute

Question 43

What factors will affect RR

Answer 43

``` Age Physical activity Emotional stress Air quality Altitude Disease ```

Question 44

Technique RR

Answer 44

Need a stop watch | Differing intervals - 60 sec is best

Question 45

Abnormal responses RR

Answer 45

Slow or no inc with activity RR inc as activity stops Irregular rhythm Excessive rate of inc

Question 46

Pain measure

Answer 46

scale 1-10 Fifth vital sign Self report is most reliable indication Pan management team consult

Question 47

What needs to be included in documentation of pain

Answer 47

``` Onset Pattern Location Position Radiating Patients description Relieving factors Aggravating factors Rating ```

Question 48

What does oxygen saturation tell us

Answer 48

How much oxygen is bound to hemoglobin

Question 49

How is oxygen saturation measured

Answer 49

blood draw or pulse oximeter

Question 50

Norms for pulse Ox

Answer 50

90-100 = PaO2 (blood) 95-100% = SaO2 (blood) Above 92% = SpO2 (pulse ox)

Question 51

What can impact level of O2

Answer 51

``` Impaired production of RBCs Decreased hgb Sickle cell disease Decreased blood volume Pulmonary disease Kidney failure Chemotherapy ```