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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
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1. Diurnal variation BP?
Relapsing
higher
blood pressure is lowest in the morning. and higher in the afternoone
The systolic blood pressure rises slightly because the arota and major arteries tend to harden with age. The diastolic pressure rises also.

2. Elevated temperature
tachycardia
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
fever
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

3. How should baby's temperature be taken?
Cardiac Output
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
16-20
Axillary.

4. 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.
pyrogens
Sinoatrial node (SA NODE)

5. Fast - deep respirations with abrupt pauses

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6. Drop in blood pressure when arising to a standing position.
orthostatic hypertension
Tachypnea
arrhythmia
It may rise slightly as decreases in vital capacity and respiratory reserve occur.

7. Bend of knee
higher
cardiac patients or patients who have had rectal surgery.
Hypothermia
popliteal

8. People most at risk for hypertension
120/70
bradypnea
Rhonchi
men - African Americans - under a lot of stress - obese

9. No pulse palpable or heard on ausculation
hypoxemia
absent
intermittent
hypoxia

10. What characteristics should be noted when checking the pulse?
the rate - the rhythm - and volume
The pulse rate gradually diminishes from birth to adulthood
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
orthostatic hypertension

11. Prehypertension
Diastolic pressure
120-139/80-89
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
uncooperative patient - children - combative patients - dementia

12. 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.
+2
low
20-30

13. Why would patients experience orthostatic hypotenstion?
from drug therapy - a neurologic problem or dehydration.
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.
men - African Americans - under a lot of stress - obese
Temperature will remain below 102 degrees with use of hypothermia blanket

14. 3rd stage of fever?
wheeze
The pulse rate gradually diminishes from birth to adulthood
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
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.

15. The difference between the systolic pressure and the diastolic pressure
Cardiac Output
Pulse pressure
72 bpm
about 1 degree lower than oral temperatures

16. Full and bounding (even beats wit strong force)
+3
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.

17. Continuous dry - rattling sounds heard on ausculation of the lungs caused by partial obstruction.
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
Rhonchi
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
absent

18. 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
120/70
lysis
Stroke volume
Hyperventilation

19. Fever above 100.2 F
Crisis
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
hypertension
pyrexia

20. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
fever
Cheyenne-Stokes
males have higher bp - until menopause then they are the same
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes

21. Side of forehead
Temporal
crackles
Hyperventilation
hyperoxia

22. Difficult and labored breathing - can often be accompanied by flared nostrils - anxious appearance - and statements such as I cant get enough air.
Systolic pressure
Feeble
dyspnea
Dorsalis pedis

23. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Blood pressure increases because there is more volume of blood in the vascular system.
Core Temperature
stridor
raises BP.

24. Slow and shallow breathing - leads to hypoxemia.
bradypnea
intermittent
Respiration
Relapsing

25. Lobes in the lungs?
carotid
Korotkoff sounds Phase II Swishing
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
3 in the right lung and 2 lobes in the left

26. 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.
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
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
Hypothermia
pyrogens

27. How does disease increase the body's temperature?
apnea
Because fever is a protective defense mechanisms that the body uses to fight pathogens and their toxins the inflammatory response produces fevers.
16-20
Crisis

28. Encourage a large fluid intake - lower room temperature - increase air circulation - remove items of clothes - control or reduce the amount of body activity - carry out physicians orders
Nursing interventions to reduce fever
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
when it is difficult to find or to count the radial pulse - or for patients with heart conditions for one full minute by placing stethoscope on the heart to count for a full minute.
Acute anxiety stimulate the nervous system - raising the pulse.

29. How does the time of day (circadian rhythm) affect the body's temperature?

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30. How is shock caused?
hypoxia
The emotions increase hormone secretion - and the body activities required for this increase heat production.
Sinoatrial node (SA NODE)
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.

31. Pulse lower than 60 beats per minute
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
Conduction
decrease BP - increase pulse rate - cold and clammy skin - dizziness - blurred vision - and apprehension.
bradycardia

32. Weak and regular (even beats wit poor force)
Convection
temperature - pulse - respiration - blood pressure - and pain level.
+1
Brachial

33. Pulse above 100 beats per minute
palpate
tachycardia
orthostatic hypertension
Apical

34. The volume of blood pushed into the aorta per heartbeat.
tachycardia
Nursing interventions to reduce fever
Stroke volume
Kussmaul's respiration

35. Blood pressure for any adult should be no higher than
120/80
Tall - slender people mayy ave a slower pulse rate than short - stout persons
hypotension
Temporal

36. Whats the best position to take a rectal temperature?
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
3 in the right lung and 2 lobes in the left
left Sims position
Nursing interventions to reduce fever

37. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Systolic pressure
Korotkoff sounds
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

38. Does the respiration rate increase or decrease during fever?
Cardiac Output
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
the lungs
Increases as body tries to remove excess heat

39. Bend of elbow
Body temperature drops before ovulation and rises 1 degree above normal during ovulation. During pregnancy the body temperature is slightly higher.
Brachial
wheeze
20-30

40. BP at or lower 90/60.
in the alveoli - tiny thin-walled sacs
^160/^100
+1
hypotension

41. This affects the character of the pulse.
about 1 degree lower than oral temperatures
Stroke Volume
absent
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

42. Measurement of oxygen
oximetry
Tachypnea
from drug therapy - a neurologic problem or dehydration.
16-20

43. High BP
hypertension
Kussmaul's respiration
16-20
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

44. 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.
140-159/90-99
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
crackles
arrhythmia

45. What pulse is checked to determine whether there is any blockage of circulation in the artery up to that point - especially in patients who have had cardiac catherization using the femoral artery for the insertion of the catheter or those who had sur
tachycardia
hyperoxia
Pedal pulse
Stertor

46. Symptoms of hypoxia
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
Hyperthermia related to infection or excessive heat exposure
16-20
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.

47. An example of a nursing diagnoses
Hyperthermia related to infection or excessive heat exposure
bradypnea
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
60 to 70 mL

48. How do drugs affect pulse?
orthostatic hypertension
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Hyperthermia related to infection or excessive heat exposure
Korotkoff sounds

49. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
Korotkoff sounds Phase II Swishing
lysis
raises BP.
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.

50. 3 yr old
Systolic pressure
raises BP.
stridor
20-30

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Measuring Vital Signs

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