Chapter 29: Measuring Vital Signs

Let the person rest for ____________________ before taking the blood pressure.

10 to 20 minutes

A healthy adult has ___________________ respirations per minutes.

12 to 20

If you take a rectal temperature, the normal range of the temperature would be

98.6F to 100.6F (37.0C to 38.1 C)

Report blood pressure that have these readings. A. Systolic over ________________ Systolic below _____________ B. Diastolic over __________ Diastolic below __________

A. 120 mm Hg; 90 mm Hg B. 80 mm Hg; 60 mm Hg

BP

Blood pressure

_________________ is a slow heart rate; the rate is less than 60 beats per minute

Bradycardia

C

Centigrade

The period of heart muscle relaxation is

Diastole

________________ is the pressure in the arteries when the heart is at rest.

Diastolic pressure

An apical-radial pulse is taken by

Having one staff member take the apical pulse and a second staff member take the radial pulse at the same time. 1

When the systolic blood pressure is below 90mm Hg and the diastolic pressure is below 60mm Hg it is called

Hypotension

ID

Identification

mm

Millimeters

mm Hg

Millimeters of mercury

Body temperature is lower in the

Morning

The blood pressure may not be taken

On an arm that has a dialysis access site

A pedal pulse is found

Over a foot bone

When taking the blood pressure, you place the stethoscope diaphragm

Over the brachial artery at the inner aspect of the elbow

The nurse may mark the skin with an X where the ____________________ is found.

Pedal pulse

Which pulse is most commonly used?

Radial

One respiration is counted for each

Rise and fall of the chest

When you are taking a blood pressure, the person should be in a _______________________ or ____________________ position. Sometimes the doctor orders blood pressure in the ___________________ position.

- Sitting - lying - standing

When listening to the blood pressure, the first sound you hear is the ________________ pressure and the point where the sound disappears is the ____________________ pressure.

- Systolic; - diastolic

Blood pressure is controlled by

- The force of heart contractions - The amount of blood pumped with each heartbeat - How easily the blood flows through the vessels

When you read a Fahrenheit thermometer, the short lines mean _________________

0.2 (two-tenths) of a degree

Each respiration involves

1 Inhalation and 1 exhalation

The pulse rate is the number of heartbeats or pulses felt in

1 Minute

When taking an apical pulse, each lub-dub sound is counted as

1 beat

If a pulse is irregular, count the oulse for

1 minute

Respirations are counted for ____________________ if they are abnormal or irregular.

1 minute

An electronic thermometer is inserted into the rectum

1/2 inch

The blood pressure cuff is inflated _________________ beyond the point where you last felt the radial pulse.

30mm Hg

The adult pulse rate is between ___________________________ beats per minute.

60 and 100

The apical pulse of 72 is recorded as

72Ap

List how long the glass thermometer remains in place for these sites. A. Oral ____________________ or as required by center policy. B. Rectal ___________________ or as required by center policy. C. Axillary ___________________ or as required by center policy.

A. 2 to 3 minutes B. 2 minutes C. 5 to 10 minutes

You are responsible for A. Knowing B. Reporting

A. Normal vital sign ranges B. Abnormal measurements

List words used to describe: A. Forceful pulse B. Hard to feel pulse

A. Strong, full, bounding B. Weak, thready, feeble

You will find out the size of blood pressure cuff needed

By asking the nurse

A ___________________ pulse is taken during cardiopulmonary resuscitation.

Carotid

DUS

Doppler ultrasound stethoscope

When taking an axillary temperature, the axilla must be

Dry

If you are preparing to take an oral temperature, ask the person not to

Eat, drink, smoke, or chew gum for a least 15 to 20 mins.

_____________ Means with a fever.

Febrile

Elevated body temperature is

Fever

The apical pulse is taken

For a full minute

You need to feel the pulse to determine the

Force

___________________ is when the blood pressure measurements remain above a systolic pressure of 140mm Hg or a diastolic pressure of 90mm Hg.

Hypertension

Unless otherwise ordered, take vital signs when the person

Is lying or sitting

When getting ready to take the blood pressure, position the person's arm

Level with the heart

If you cannot feel a pulse or hear a blood pressure, you should never ____________________

Make up a measurement

You allow the person to have ________________ when you use the are for blood pressure or pulse that the person prefers

Personal choice and feel independent

The beat of the heart felt at an artery as a wave of blood passes through the artery is the

Pulse

The difference between the apical and radial pulse rates is the

Pulse deficit

The ______________ is the number of heartbeats or pulses felt in 1 min.

Pulse rate

The apical pulse rate is never less than the

Radial pulse rate

Which site has the highest normal range temperature?

Rectum

The cuff and measuring device used to measure blood pressure is a

Sphygmomanometer

To read a glass thermometer you should hold it at the

Stem and bring it to eye level to read it.

An instrument used to listen to the sounds produced by the heart, lungs, and other body organs is a

Stethoscope

When taking a tympanic membrane temperature on an adult, pull up and back on the ear to

Straighten the ear canal

_____________ is the period of heart muscle contraction

Systole

The amount of force it takes to pump blood out of the heart into the arterial circulation

Systolic pressure

A rapid heart rate is ____________________. The heart rate is over 100 beats per minute.

Tachycardia

TPR

Temperature, pulse, respirations

You may count the radial pulse from 30 seconds and multiply by 2 if

The pulse is irregular

Vital signs are taken when the person takes drugs that affect

The respiratory or circulatory system

A ______________________ is a device used to measure temperature.

Thermometer

When taking the radial pulse, place

Two or three fingers on the thumb side of the wrist over the radial artery.

When taking an oral temperature, place the bulb end of the thermometer

Under the tongue and to one side

When taking a temperature for persons who are confused and resist care, the best choice would be

Use a tympanic or temporal artery thermometer

Temperature, pulse, respirations, and blood pressure are

Vital signs

Persons in nursing centers usually have vital signs measured

Weekly

When using a stethoscope, you can help to prevent infection by

Wiping the ear-pieces and diaphragm with antiseptic wipes before and after use.

What should you do if a person asks for their vital sign measurements?

You can tell the person the measurements if center policy allows.

If you are taking vital signs on a person with dementia, it may be better if

You take the pulse and respiration at one time, and the temperature and blood pressure at another time.

Sites for measuring temperature are the

- Mouth - Rectum - Axilla (underarm) - Ear (tympanic membrane) - Temporal artery (forehead)

Without a fever is

Afebrile

When vital signs are taken, report to the nurse at once if

- Any vital sign has changed from a prior measurement - Vital signs are above or below the normal range

Measurements of the vital signs is important because they help the nurse ________________ and __________________ the person's care.

- Plan for - evaluate

If a glass thermometer breaks, ____________ at once because it may contain ___________ which is a ____________________.

- Report it to the nurse; - mercury; - hazardous substance

What observations should be reported and recorded when counting respirations?

- Respiratory rate - Equality and depth of respirations - If the respirations were regular or irregular - If the person experienced pain or difficulty in breathing - Any respiratory noises - Any abnormal respiratory pattern

When you take a pulse, what observations should be reported and recorded?

- The pulse site - Pulse rate less than 60 or more than 100 beats per minute (report at once) - Pulse deficit for an apical-radial pulse - If the pulse is regular or irregular - Pulse force—strong, full, bounding, weak, thready, or feeble

A glass rectal thermometer has

A stubby tip color-coded in red.

When using an electronic thermometer, what does the color of the probe mean? A. Blue B. Red

A. Used for oral or axillary temperature B. Used for rectal temperature

The ________________________ is taking the apical and radial pulse at the same time.

Apical-radical pulse

Which site has the lowest baseline temperature?

Axilla

The blood pressure may be higher in older persons because

Blood pressure increases with age

_____________ is the amount of force exerted against the walls of an artery by the blood.

Blood pressure.

The amount of heat in the body that is balance between the amount of heat produced and amount lost by the body is the

Body temperature

F

Fahrenheit

Tympanic membrane and temporal artery thermometers are used for confused persons because they are

Fast and comfortable

IV

Intravenous

Do not use your thumb to take a pulse because

It has a pulse

When counting respirations, the best way is to

Keep your fingers or stethoscope over the pulse site so the person thinks you are still counting the pulse.

If you are taking the temperature of an older person, you would expect the temperature to be

Lower than the normal range

When you take a rectal temperature, you ___________________ the tip of the thermometer or the end of the covered probe before inserting it into the rectum

Lubricate

HG

Mercury

When a pulse rate is 120 beats per minute, you

Report that the person has tachycardia

Breathing air into and out of the lungs is

Respiration