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Measuring Vital Signs

Subjects : health-sciences, emergency-medicine

Instructions:

Answer 50 questions in 15 minutes.
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1. Measurement of oxygen
20-30
Cheyenne-Stokes
hypoxia
oximetry

2. What are the 5 vital signs?
Hypothermia
temperature - pulse - respiration - blood pressure - and pain level.
constant
Wash hands - don gloves - lubricate probe - Insert .5 to 1.5 inches. Hold in place for 3 to 5 minutes.

3. Macine that measures oxygen in the blood by determining the percentage of hemoglobin that is bound with oxygen.
96.5 to 97.5
low
oximeter
popliteal

4. If blood becomes thicker - like when excessive blood cells are manufactured what happens to BP?
Sinoatrial node (SA NODE)
about 1 degree higher than oral temperatures
the BP goes up because more pressure is needed to push the thicker fluid through the vascular system.
about 1 degree lower than oral temperatures

5. Normal body temperature ranges?
Diaphoresis
if its hot bp can lower because of vasodilation. if its cold it can rise because of vasoconstriction.
97.5 to 99.5
30-80

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

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7. Decreased levels of oxygen in the blood - often seen in patients wo are under medical sedation - who are recovering from anesthesia or abdominal surgery - or who are in a weak or debiliated condition.
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
constant
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
hypoxemia

8. respirations become faster and deeper - then slower and shallower wit a period of apnea - called the death rattle.
about 1 degree higher than oral temperatures
postoperative patients wo have been cooled during surgery - newborn infants whose skin is exposed to cool room temperatures - elderly or debiliated patients - and those exposed to cold temperatures for prolonged periods.
Cheyenne-Stokes
120/70

9. When warm skin touches a cool object - heat is lost to the object.
Tachypnea
blood pressure is lowest in the morning. and higher in the afternoone
uncooperative patient - children - combative patients - dementia
Conduction

10. The lower pressure exerted on the artery when the heart is at rest inbetween contractions.
oximetry
wheeze
Diastolic pressure
12-20

11. Strong and regular ( even beats wit moderate force)
in the alveoli - tiny thin-walled sacs
remittent
temperature - pulse - respiration - blood pressure - and pain level.
+2

12. The temperature is continuously elevated with less than 1 degree of variation within a 24-hour period.
fever
constant
BMR
Brachial

13. Average blood pressure should be
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
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
Blood pressure increases because there is more volume of blood in the vascular system.

14. By measuring the blood pressure you obtain vital info about what?
palpate
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
Hyperthermia related to infection or excessive heat exposure
Irregular

15. Side of forehead
Nursing interventions to reduce fever
in the alveoli - tiny thin-walled sacs
Temporal
Tachypnea

16. What happens whens vasoconstriction causes peripheral vascular resistance to rise?
120-139/80-89
Kussmaul's respiration
the blood pressure will rise in order to push the blood along.
arrhythmia

17. Are infants blood pressure low or high?
low
the blood pressure will rise in order to push the blood along.
temperature - pulse - respiration - blood pressure - and pain level.
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients

18. What affects does aging do to the respiratory rate?
It may rise slightly as decreases in vital capacity and respiratory reserve occur.
the blood pressure will rise in order to push the blood along.
Feeble
Stertor

19. Shallow for two or three breaths with a period of variable apnea. occur in patients with increased intracranial pressure.

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20. While measuring the BP certain sounds may be heard that relate to the effect of the blood pressure cuff on the arterial wall.
Korotkoff sounds
in the alveoli - tiny thin-walled sacs
higher
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.

21. Bend of elbow
apnea
Stroke volume
hemorrhage - vomiting - diarrhea - burns - and myocardial infarctions.
Brachial

22. Whats the best position to take a rectal temperature?
Defervescence - lowering of the body temperature to normal. The person feels warm and the skin may be moist.
Systolic pressure
Core Temperature
left Sims position

23. Head injury BP?
30-80
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.
97.5 to 99.5

24. Those at risk for hypothermia include
hypotension
postoperative patients wo have been cooled during surgery - newborn infants whose skin is exposed to cool room temperatures - elderly or debiliated patients - and those exposed to cold temperatures for prolonged periods.
Eupnea
remittent

25. Absence of breathing
blood pressure is lowest in the morning. and higher in the afternoone
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
apnea
in the alveoli - tiny thin-walled sacs

26. How does emotional stress raise the body's temperature?
30-80
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.
arrhythmia
The emotions increase hormone secretion - and the body activities required for this increase heat production.

27. When should rectal temperatures be used?
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
Pulse pressure
Korotkoff sounds Phase III: Knocking
pulse deficit - the radial pulse subtracted from the apical pulse equals the pulse deficit.

28. Irregular pulse - a period of normal rhythm broken by periods of irregularity or skipped beats.
Relapsing
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
arrhythmia
hyperoxia

29. Sex BP?
males have higher bp - until menopause then they are the same
Cardiac Output
16-20
Nursing interventions to reduce fever

30. Elderly respiration
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
Crisis
16-20
Korotkoff sounds

31. right arm vs. left arm/ arm vs. leg BP?
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.
low
variation of about 5-10 between arms. and a 10-40 difference in systolic pressure with leg & arm.
palpate

32. An example of a nursing diagnoses
absent
The emotions increase hormone secretion - and the body activities required for this increase heat production.
low
Hyperthermia related to infection or excessive heat exposure

33. 2nd stage of fever is?
Febrile stage - the body temperature rises to a new set point established by the hypothalamus and remains there until there is a resolution to the cause of fever.
Biot's respirations
Hyperthermia related to infection or excessive heat exposure
Cardiac Output

34. Crowing sound on inspiration caused by obstruction of the upper air passages - as occurs in croup or laryngitis
Stimulants increase the pulse rate. Depressants decrease the pulse rate.
the lungs
stridor
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.

35. How does increased body temperature increase the pulse?
Hyperventilation
The pulse rate increases at the rate of 7-10 beats for each degree of temperature
Temporal
the proper cuff is 21% bigger than the diameter of the arm. the inflatable bladder should go around 3/4 of the arm.

36. Heat is lost from the body by evaporation. resulting in a daily loss of 800mL of water from skin and lungs.
Evaporation
60 to 70 mL
BMR
It doesn't change in a healthy elderly patient but the pattern rhythm may be slightly irregular.

37. How cardiac contractions are normally initiated by the electrical impules emerging from what?
30-80
silence as cuff deflates for 30 to 40 mm Hg; common with hypertension and elderly patients
orthostatic hypertension
Sinoatrial node (SA NODE)

38. How is pulse best found?
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
Stertor
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.
Hyperthermia related to infection or excessive heat exposure

39. Groin area
Biot's respirations
Pulse
Femoral
blood pressure is lowest in the morning. and higher in the afternoone

40. Substances tat cause fever
the rate - the rhythm - and volume
restlessness & apprehension - confusion - dizziness - and change in level of consciousness - cyanosis or skin color changes - particularly around the mouth and in the nail beds
pyrogens
intermittent

41. Gradual return to a normal temperature
lysis
^160/^100
Tall - slender people mayy ave a slower pulse rate than short - stout persons
oximeter

42. The temperature of the deep tissues of the body
3 in the right lung and 2 lobes in the left
Tall - slender people mayy ave a slower pulse rate than short - stout persons
Vascular resistance drops and the blood pressure decreases
Core Temperature

43. Shock - hemorrhage - low cardiac output - inadequate volume of blood?
low BP
Temporal
blood pressure is lowest in the morning. and higher in the afternoone
72 bpm

44. High BP
permanent damage to the heart - the brain - the kidneys - and the retina of the eye - may cause strokes
hypertension
oximeter
97.5 to 99.5

45. How does external respiration occur?
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
systolic pressure indicated by faint - clear sound that gradually grow louder.
Convection
the lungs

46. Breathing is an involuntary automatic function controlled by the respiratory center located where?
bradypnea
Increases as body tries to remove excess heat
Biot's respirations
Pons and Medulla of the brainstem

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

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48. Axillary temperature are
Axillary.
men - African Americans - under a lot of stress - obese
about 1 degree lower than oral temperatures
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.

49. The temperature falls to normal and then rises again in a repeating pattern.
97.5 to 99.5
Nursing interventions to reduce fever
Respiration
Relapsing

50. Murmur or swishing sounds that increase as the cuff is deflated
30 seconds and multiplied by 2. unless the person is very sick or has resp. problems you should count for one full minute.
It will also fall
Korotkoff sounds
Korotkoff sounds Phase II Swishing

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Measuring Vital Signs

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