Vitals and Measurements (Part 1)

Question 1

What are the vital signs?

Answer 1

• temperature
• pulse
• respirations
• blood pressure
• pain assessment

Question 2

What are the body measurements?

Answer 2

• height
• weight
• head circumference

Question 3

What does febrile mean?

Answer 3

fever (greater than 100.5)
- sign of inflammation or infection

Question 4

What is afebrile?

Answer 4

normal temperature (98.6-99.1F)

Question 5

What is pyrexia?

Answer 5

fever

Question 6

What is hyperpyrexia?

Answer 6

extremely high temperature

Question 7

What are the different ways to measure temperature?

Answer 7

• orally
• aurally (ear)
• temporally
• axillary
• rectally

Question 8

Which thermometer is the least accurate? What is the usual reading?

Answer 8

axillary (under arm)
- normal is 97.6

Question 9

What is the most accurate thermometer reading? What’s the normal reading?

Answer 9

rectally
- normal: 99.6

Question 10

How do you properly measure tympanic temperatures in an adult? In a child?

Answer 10

Adult: pull ear up and back
Child: pull ear down and back

Question 11

What is the normal pulse range?

Answer 11

60-100 bpm

Question 12

What is tachycardia?

Answer 12

fast heart rate
- > 100 bpm

Question 13

What is bradycardia?

Answer 13

slow heart rate
- < 60 bpm

Question 14

How do we manually measure pulse?

Answer 14

2 fingers at radial artery
- count for 1 minute
- or count for 30 seconds and multiply by 2 if pulse is regular

Question 15

What is apical pulse?

Answer 15

method used to obtain pulse in an infant with a stethoscope

Question 16

Where is the apex?

Answer 16

5th intercostal space between ribs on the left side of the sternum

Question 17

What are some major pulse points?

Answer 17

• superficial temporal artery
• common carotid artery
• brachial artery
• femoral artery
• popliteal artery
• posterior tibial artery

Question 18

What is respiratory rate?

Answer 18

indication of how well the body provides oxygen to the tissues
- one respiration = 1 inhalation and 1 exhalation

Question 19

What is normal respiratory rate in adults?

Answer 19

12-20 respirations per minute

Question 20

How should you check respiration?

Answer 20

watch chest rise and fall SUBTLY
- can use stethoscope
- count for one full minute
- determine quality of effort
- wheezing, rales, rhonchi?

Question 21

What is dyspnea?

Answer 21

difficult or painful breathing

Question 22

What is tachypnea?

Answer 22

rapid breathing

Question 23

What is bradypnea?

Answer 23

slow breathing

Question 24

What is hyperpnea?

Answer 24

abnormally rapid or labored breathing

Question 25

What is rales?

Answer 25

crackling sounds = fluid in the lungs - pneumonia - collapse of part or all of a lung - pulmonary edema

Question 26

What is rhonchi?

Answer 26

- deep rattling - partial obstruction of airway - asthma, acute bronchitis

Question 27

What is apnea?

Answer 27

period of breathing cessation - periods of increasing and decreasing depth of respiration between periods of apnea

Question 28

What are the 2 pressure measurements?

Answer 28

- systolic pressure: top number (when left ventricle contracts) - diastolic pressure: bottom number (when heart relaxes, minimum pressure exerted against the artery walls at all times)

Question 29

What is normal blood pressure?

Answer 29

less than 120/80

Question 30

What is the range for prehypertension?

Answer 30

120-139 mmHg systolic 80-89 mmHg diastolic

Question 31

What is the range for hypertension?

Answer 31

140/90 mmHg or more

Question 32

What are the 2 classifications of hypertension?

Answer 32

- essential: no identifiable cause; 95% of all hypertension - secondary: result of some other condition like kidney or heart disease

Question 33

What is blood pressure?

Answer 33

force at which blood is pumped against the walls of the arteries

Question 34

What is a sphygmomanometer?

Answer 34

blood pressure cuff and dial - aneroid - electronic

Question 35

What is an aneroid sphygmomanometer?

Answer 35

circular gauge for registering pressure - each line = 2 mmHg - need stethoscope and calibration

Question 36

What is an electric sphygmomanometer?

Answer 36

- digital screen - easy to use - costly but less accurate

Question 37

What is the purpose of a stethoscope?

Answer 37

amplifies body sounds

Question 38

Where should the cuff of the stethoscope be wrapped?

Answer 38

above the brachial pulse point

Question 39

What are the 5 phases of Korotkoff sounds?

Answer 39

1 - tapping sound; systolic pressure 2 - change to softer swishing sound 3 - resumption of a crisp tapping sound 4- sound becomes muffled 5 - sound disappears; diastolic pressure

Question 40

When can you be classified as normal reading?

Answer 40

Must be 2 consistent readings

Question 41

How can we get 2 consistent readings for blood pressure?

Answer 41

- allow patients to relax - not crossed feet

Question 42

Which arm should you avoid measurement in?

Answer 42

- arm on the same side as a mastectomy - arm with an injury or blocked artery - arm with an implanted device under the skin

Question 43

What happens if the cuff is too small?

Answer 43

artificially elevated blood pressure

Question 44

What happens if the cuff is too big?

Answer 44

artificially low bleed pressure

Question 45

What should we do if patient got a double mastectomy?

Answer 45

take femoral pulse