Vital Signs/Respiration/Pain

Question 1

What are Vital Signs?

Answer 1

Measurements of the body’s most basic functions

Question 2

Why are vital signs important?

Answer 2

Gives a glimpse of the patient’s well-being

Question 3

What are baseline vital signs?

Answer 3

patient’s norm

Question 4

What are textbook vital signs?

Answer 4

provides a gauge or clue

Question 5

What is the first impending sign of distress involving vital signs/system? What are the signs?

Answer 5

Respiratory system
- increased RR/decreased RR
-O2 levels may drop
-SOB
-Anxiety

Question 6

What is SBAR?

Answer 6

Interdisciplinary communication -
Situation: YOUR name first, state what floor you’re on, who the. pt’s doctor is
Background: patient’s info (dob, name, history)
Assessment: vital signs, etc
Recommendations: ex. pt needs a consult from physician

Question 7

When do we use SBAR?

Answer 7

to report changes in patient status to the provider, update

Question 8

What is HERO?

Answer 8

Hopkins Event Reporting Online

Question 9

When do we use HERO?

Answer 9

to report adverse events, like medical errors or fall

Question 10

What is a Sentinel Event?

Answer 10

an event that is life-changing or life-threatening.

Question 11

How does circadian rhythm relate to body temperature?

Answer 11

fluctuate within 2 degrees throughout 24hrs

Question 12

With circadian rhythm, when is body temp the lowest?

Answer 12

3am, sleeping, decreased metabolism, minimal activity

Question 13

With circadian rhythm, when is body temp the highest?

Answer 13

4-6pm, active, moving, eating, increased metabolism

Question 14

What are core body temp methods? (routes)

Answer 14

Rectal (one degree higher than oral), Tympanic (bc shares blood supply with hypothalamus), Temporal artery (bc shares blood supply as pulmonary artery)

Question 15

Why is oral not a core body temp?

Answer 15

too many outside factors, such as the patient eating something hot/cold

Question 16

What is the best method of taking an infant’s temp?

Answer 16

Temporal Artery - more accurate & non-invasive

Question 17

What is the most common method of taking temp (not for infants)?

Answer 17

Oral

Question 18

What are the characteristics of a pulse? (5)

Answer 18

-Strength
-Rhythm
-Regularity
-Quality
-Rate/Frequency

Question 19

What is the average adult pulse?

Answer 19

60-100bpm

Question 20

What would a newborn’s pulse rate be?

Answer 20

infants have increased BMR, so increased pulse - 130-160bpm

Question 21

What is Tachycardia?

Answer 21

> 100bpm

Question 22

what is Bradycardia?

Answer 22

<60bpm (except trained athletes would be 40-60bpm)

Question 23

What does the quality of the pulse mean?

Answer 23

Strong: easily palpated
Weak: harder to palpate disappears when touched
Thready: hard to palpate
Bounding: overly strong

Question 24

What is pulse deficit? What should the pulse deficit be?

Answer 24

difference b/w apical and peripheral pulse - there should NOT be a deficit (should be equal)

Question 25

Where would you assess a pulse on a person with a shoulder injury?

Answer 25

Radial pulse - most distal pulse and to ensure there's perfusion to the end of the limb

Question 26

How long should you count a pulse and where is it typically in an adult?

Answer 26

30s multiple by 2 - at the radial artery

Question 27

How long should you count an irregular pulse?

Answer 27

for a FULL minute

Question 28

When do you auscultate a pulse?

Answer 28

- can't palpate - children under 5y/o

Question 29

How/where should you auscultate an infant's pulse?

Answer 29

with a stethoscope, apical, at 5th intercostal space, midclavicular line

Question 30

What is Eupnea?

Answer 30

normal breathing - normal rate, rhythm and depth

Question 31

What is normal RR in an adult?

Answer 31

12-20bpm

Question 32

What is a newborn's RR?

Answer 32

30-60bpm

Question 33

What is the first response to hypoxia?

Answer 33

-increased RR -depth of breathing increases

Question 34

Do newborns have a higher or lower RR than adults? Why?

Answer 34

higher bc newborns have higher BMR

Question 35

What is apnea?

Answer 35

stops breathing for 10-15s (true apnea)

Question 36

What is dyspnea?

Answer 36

an increased effort to breathe

Question 37

What is the range for a normal BP systolic?

Answer 37

100-119 systolic

Question 38

What is the range for a normal BP diastolic?

Answer 38

60-79 diastolic

Question 39

What is pulse pressure? What is the normal range?

Answer 39

difference b/w the systolic and diastolic - measures how hard the heart is working - normal range: 40-60mmhg (>60mmHg = increased risk of CV disease)

Question 40

What are the Korotkoff sounds?

Answer 40

Turbulence sound during a manual BP - first sound is systolic, last sound is diastolic (5th sound for an adult)

Question 41

What is the 4th Korotkoff sound in children?

Answer 41

diastolic BP - up to age 13

Question 42

What is the auscultatory gap? How do we find it?

Answer 42

is a period of diminished or absent Korotkofff sounds during manual measurement of BP - Put the cuff on and find a radial pulse. Pump the cuff until we can no longer feel the pulse. For instance, if you no longer feel the pulse at 120mmHg, add 30mmHg to the number where the pulse disappears. That is the auscultatory gap. That number is where we pump the cuff to when we are taking a manual BP

Question 43

What is orthostatic hypotension? When could this happen?

Answer 43

Patient suddenly stands up or has sudden change in movement - BP drops - when the pt gets OOB

Question 44

What are the parameters for orthostatic hypotension?

Answer 44

a change of at least 20mmHg systolic or at least 10mmHg diastolic

Question 45

What is the best way to assess pain?

Answer 45

Verbal report/Self-report

Question 46

What are some pain scales?

Answer 46

Numeric 0-10; Faces; CRIES; etc.

Question 47

Who in the hospital manages the patient's pain?

Answer 47

Care team

Question 48

What are some pain interventions the nurse can employ?

Answer 48

medication, bathing, positioning, hygiene, deep breathing, relaxation, distraction, massage, hold/cold