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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
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1. Pulse above 100 beats per minute
tachycardia
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
shallow or slow breathing
stridor

2. Are infants blood pressure low or high?
Pons and Medulla of the brainstem
Korotkoff sounds
determine if the patient has a known heart arrhythmia - perform hand hygiene - expose the left chest - warm the stethoscope in hand for a min or 2 - locate the apex of the heart by palpating for the 5th intercostal space at the midclavicular line. li
low

3. A normal - relaxed breathing pattern
Eupnea
16-20
+3
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds

4. How is pulse best found?
Korotkoff sounds Phase V: Silence
by placing the flat part of the first fingers against the tendon - or cord - on the thumb inside of the inner wrist and ten rolling the fingers slightly outward into the little trough on the thumb inside the wrist.
120/70
Stroke Volume

5. Difference between the apical and radial pulse - this requires two people to count the radial and apicial pulses at the same time to determine whether there is a what?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
the effectiveness of the heart contractions - the amount of blood in the system - and the presence of any obstruction or interference of blood to the blood vessels
3 in the right lung and 2 lobes in the left
hypertension

6. Korotkoff sounds Ausculatatory gap:
men - African Americans - under a lot of stress - obese
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
Temperature will remain below 102 degrees with use of hypothermia blanket
in the alveoli - tiny thin-walled sacs

7. Stage 2 hypertension
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
left Sims position
Vascular resistance drops and the blood pressure decreases
^160/^100

8. No pulse palpable or heard on ausculation
Respiration
Biot's respirations
in the alveoli - tiny thin-walled sacs
absent

9. Whisting sound of air forced past a partial obstruction - as found in asthma or emphysema.
wheeze
low BP
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
96.5 to 97.5

10. When the vascular walls lose elasticity - as with arteriosclerosis and aging what happens to BP?
apnea
stridor
It increases to push the blood through more rigid pathways.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

11. Taking axillary temperature
Biot's respirations
oximeter
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
place the thermometer in the center of the patients dry axilla. Ask patient to hold the arm tightly against the chest. Leave in place 3-8 minutes.

12. Alternating rise and fall of the temperature.
Tachypnea
12-20
intermittent
hypertension

13. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
palpate
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Pons and Medulla of the brainstem
stridor

14. When warm skin touches a cool object - heat is lost to the object.
bradypnea
Conduction
Axillary.
^160/^100

15. Elderly respiration
16-20
The pulse rate gradually diminishes from birth to adulthood
about 1 degree lower than oral temperatures
The emotions increase hormone secretion - and the body activities required for this increase heat production.

16. A pattern of breathing in which there is an increase in the rate and the depth of breaths and carbon dioxide is expelled - causing te blood level of carbon dioxide to fall. this condition is seen after sever exertion - during high levels of anxiety o
Stroke volume
+2
Pulse
Hyperventilation

17. Obtaining the correct size for a cuff for BP?
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
72 bpm
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

18. What affects does aging do to the heart rate?

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19. Murmur or swishing sounds that increase as the cuff is deflated
remittent
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Korotkoff sounds Phase II Swishing
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

20. How does external respiration occur?
Temporal
It will also fall
Core Temperature
1) ventilation - Which is the movement of air in and out of the lung. 2) dispersion of air throughout the bronchial tree of the lungs; 3) diffusion of oxygen and carbon dioxide molecules across the alveolar membranes; 4) perfusion - the movement of b

21. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
stridor
Feeble
Diastolic pressure
It uses large muscles in the body - which create body heat by burning up the glucose and fat in the tissues - muscle action generates heat and core temperature rises.

22. Strong and regular ( even beats wit moderate force)
men - African Americans - under a lot of stress - obese
+2
Evaporation
popliteal

23. Side of neck
96.5 to 97.5
Core Temperature
carotid
hypotension

24. Snoring sound produced when patients are unable to cough up secretions from the trachea or bronchi
Hypothermia
constant
96.5 to 97.5
Stertor

25. How does menstrual cycle and pregnancy raise the body's temperature?
wheeze
The pulse rate gradually diminishes from birth to adulthood
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
16-20

26. Average blood pressure should be
Acute anxiety stimulate the nervous system - raising the pulse.
about 1 degree lower than oral temperatures
shallow or slow breathing
120/70

27. Groin area
Rhonchi
Femoral
Blood pressure increases because there is more volume of blood in the vascular system.
Increases as body tries to remove excess heat

28. Stress & emotions. BP?
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
from drug therapy - a neurologic problem or dehydration.
popliteal
higher

29. When should rectal temperatures be used?
place the thermometer in the center of the patients dry axilla. Ask patient to hold the arm tightly against the chest. Leave in place 3-8 minutes.
When an accurate temperature cant be obtained orally and a tympanic or temporal artery thermometer are not available. It may be used when there is nasal congestion or there has been nasal or oral surgery - the patient is unable to keep their mouth cl
16-20
120/70

30. Whats the best position to take a rectal temperature?
about 1 degree lower than oral temperatures
pyrexia
left Sims position
Hypothermia

31. Full and bounding (even beats wit strong force)
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
+3
Radial
shallow or slow breathing

32. The volume of blood pushed into the aorta per heartbeat.
Stroke volume
tachycardia
dehydration - delirium - and convulsons may occur. Dehydration will occur because of lost with perspiration and more rapid breathing. Delirium and convulsions may occur because neurologic function is affected when the temperature in the brain rises.
Acute anxiety stimulate the nervous system - raising the pulse.

33. What are the 5 vital signs?
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.
temperature - pulse - respiration - blood pressure - and pain level.
Increases as body tries to remove excess heat
Hyperventilation

34. Enviromental temperature BP?
Diastolic pressure
Korotkoff sounds
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
tachycardia

35. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
Rhonchi
3 in the right lung and 2 lobes in the left
1) ventilation - Which is the movement of air in and out of the lung. 2) dispersion of air throughout the bronchial tree of the lungs; 3) diffusion of oxygen and carbon dioxide molecules across the alveolar membranes; 4) perfusion - the movement of b
+2

36. right arm vs. left arm/ arm vs. leg BP?
in the alveoli - tiny thin-walled sacs
120/80
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
Diastolic pressure

37. Both strong and weak beats occur within 1 minute
Irregular
Kussmaul's respiration
Crisis
72 bpm

38. Carbon dioxide is carried as bicarbonate ion in the blood until it reaches where?
12-20
the lungs
men - African Americans - under a lot of stress - obese
It uses large muscles in the body - which create body heat by burning up the glucose and fat in the tissues - muscle action generates heat and core temperature rises.

39. BP at or lower 90/60.
Hypothermia
palpate
hypotension
Relapsing

40. Symptoms of hypoxia
Pons and Medulla of the brainstem
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Korotkoff sounds
orthostatic hypertension

41. Bend of elbow
20-30
Dorsalis pedis
Brachial
Onset - which may occur gradually or suddenly. the body responds to a pyrogen by trying to conserve and manufacture heat to raise the set point for core temperature. The person will feel cold - and will add clothes or covers - curl up in a ball - and

42. Sex BP?
Core Temperature
120/80
stridor
males have higher bp - until menopause then they are the same

43. Subnormal body temperature the regulating center in the hypothalamus is greatly impaired when the temperature of the body falls below 94 degrees - at that point? sleepiness and coma are apt to develop.
96.5 to 97.5
Hypothermia
The body's temperature in the morning is usually low from inactivity of the muscles. The afternooon body temperature may be high-normal because of the body's metabolic processes - the patient's activity - and the temperature of the environment.
uncooperative patient - children - combative patients - dementia

44. Head injury or any increased intracranial pressure will depress the respiratory center and result in?
from drug therapy - a neurologic problem or dehydration.
shallow or slow breathing
raises BP.
Pons and Medulla of the brainstem

45. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Irregular
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
Respiration
dyspnea

46. Abnormal - nonmusical sound heard on ausculation of the lungs during inspiration; also called rales. Sound like hair rubbed between the fingers next to the ears.
Temporal
low BP
Acute anxiety stimulate the nervous system - raising the pulse.
crackles

47. How do emotions increase the pulse rate?
Korotkoff sounds Phase IV: Muffling
Acute anxiety stimulate the nervous system - raising the pulse.
Nursing interventions to reduce fever
fever

48. Stage 1 hypertension
140-159/90-99
When an accurate temperature cant be obtained orally and a tympanic or temporal artery thermometer are not available. It may be used when there is nasal congestion or there has been nasal or oral surgery - the patient is unable to keep their mouth cl
apnea
Rhonchi

49. How does disease increase the body's temperature?
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.
temperature - pulse - respiration - blood pressure - and pain level.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

50. How does physical exercise raise the body's temperature?
fever
oximetry
It uses large muscles in the body - which create body heat by burning up the glucose and fat in the tissues - muscle action generates heat and core temperature rises.
raises BP.

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Measuring Vital Signs

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