CH. 30 Vital Signs
What does Brachial Pulse assess?
Circulation of lower arm
Korotkoff phases
Phase 1- A sharp thump Phase 2- A blowing or whooshing sound Phase 3- A crisp, intense tapping Phase 4- A softer blowing sound that fades Phase 5- Silence
What does Apical Pulse assess?
Auscultate Apical Area
Adolescent Vital Signs
P 60-90 R 16-22
What position is necessary for rectal temperature?
Sim's Position with the upper leg flexed for comfort
Severe Hyopthermia
less than 86.0
Pulse Pressure
30 to 50 mm Hg
PH
7.35-7.45
Reasons that oral route aren't accurate for older adults
Missing teeth and poor muscle control
Which task can be delegated to nursing assistive personnel (NAP)?
Respiration frequency Pulse Sat Pulse frequency
For which patient is it contraindicated for BP palpation?
Patients with conditions such as cardiac shunts, arteriovenous fistulas, and intravenous catheters make the upper extremities inaccessible for BP measurement, so these patients' BP should be obtained from the lower extremity.
What vita sign should be assessed in hypothermia patients, and why?
Patients with hypothermia should be assessed for pulse rate and rhythm because hypothermia causes bradycardia and dysrhythmias.
PaO2
80-100 mm Hg
The acceptable range of maximum concentration of carbon dioxide (EtCO2) by capnography is:
35-45 mm Hg
Moderate Hypothermia
86-93.2
Mild Hypothermia
93.2-96.8
SaO2
95%-100%
Average Temperature
96.8-100.4 F 36-38 C
Axillary Temperture
97.7 F 36.5 C
Oral/Tympanic Temperature
98.6 F 37 C
Rectal Temperature
99.5 F 37.5 C
When is a fever not considered harmful? Adults vs. Children
Adults: If the Temperature is below 102.2° F Children: If the Temperature is below 104° F
Temporal Artery
Assess Pulse in Children
While assessing a patient with heart disease, the nurse observes that the radial pulse is 50 beats per minute. Which nursing interventions should the nurse perform immediately?
Assess both radial pulses. Asses apical and radial pulse simultaneously Assess all peripheral pulses
Ulnar Pulse
Assess circulation of hand and Allen's test.
Popliteal Pulse
Assess circulation of lower leg.
Dorsalis Pedis Pulse
Assess circulation to foot
Posterior Tibial Pulse
Assess circulation to foot
Radial Pulse
Assess hand circulation and to assess character of pulse.
What does Radial Pulse assess?
Assess peripheral circulation Assess circulation of hand
Femoral Pulse
Assess pulse during cardiac arrest or shock when other pulses are non-palpable. Assess circulation to leg
Carotid Artery
Assessed during shock or cardiac arrest
What step in the nursing process involves determining signs and symptoms, as well as other factors related to the condition? or the nurse should determine the appropriate site for measuring temperature?
Assessment
What would be most helpful in determining your priority nursing intervention
Baseline Vital signs
While assessing the oral temperature of a patient using an electronic thermometer, the nurse asks the patient to close his or her lips. What is the rationale behind this instruction?
Closing the lips after placing the thermometer into the mouth helps maintain the proper position of the thermometer.
The nurse checks for the presence of earwax in a patient's ear canal before measuring tympanic membrane temperature with an electronic thermometer. What is the rationale behind this action?
Earwax on the lens cover blocks a clear optical pathway and lowers tympanic temperature by 0.3 degrees.
What step in the nursing process involves comparing the oxygen saturation readings with the previous baseline values?
Evaluation
The nurse is caring for a patient with a temperature of 39.5° C (103.1° C). Which nursing interventions should be implemented to manage the patient's condition?
Heat loss should be maximized in patients with a fever by keeping patient clothing and bed linens dry. The patient's metabolic rate should be increased by providing measures to stimulate appetite and by providing well-balanced meals regularly. The nurse should provide the patient with at least 8 to 10 glasses of fluids containing at least 8 oz in each glass for patients to replace fluid lost through insensible water loss and sweating.
What step in the nursing process involves the nurse performing the planned task? or the nurse should implement appropriate treatment strategies?
Implementation
For which patients does the nurse measure blood pressure (BP) by palpation?
Indirect measurement of BP by palpation is useful for patients whose arterial pulsations are too weak to create sounds; especially in conditions such as severe blood loss and decreased contractility.
Infant Vital Signs
P 120-160 R 30-60
The nurse is measuring the blood pressure of a patient. The nurse palpates the artery distal to the cuff and inflates the cuff rapidly to a pressure 30 mm Hg above the point at which the pulse disappears. What is the rationale behind this action?
Palpating the artery distal to the cuff, and inflating the cuff rapidly to a pressure of 30 mm Hg above the point at which the pulse disappears prevents a false-low reading.
What step in the nursing process involves explaining the purpose of a procedure to the patient? or the nurse should plan the patient's assessment procedures?
Planning
Which nursing interventions should be provided for patients with fever?
Provide Oxygen supplementation Identify febrile episodes Reduce external covering
The registered nurse delegates an nursing assistive person (NAP) to measure the temperature of an intubated patient. Which route selected by the NAP would be correct in this condition?
The oral route is the reliable route to measure temperature in patients who are intubated.
The nurse is assessing a patient for blood pressure (BP) and identifies that the patient's BP is inadequate for perfusion and oxygenation of tissues. Which interventions should be provided immediately in this situation?
The patient should be positioned in the supine position to enhance circulation and restrict airway if the BP is decreased.
Which priority nursing intervention should be implemented for a patient with hypothermia?
The priority intervention for patients with hypothermia is to prevent a further decrease in body temperature. Therefore, the first intervention is to remove the patient's wet clothes and replace them with dry ones.
When measuring the axillary temperature of a patient, how can the nurse ensure proper positioning of the probe against the blood vessels in the axilla?
To ensure proper positioning of the probe against the blood vessels in the axilla, the probe should be placed into the center of the axilla. The arm should be lowered over the probe and placed across the chest.
The registered nurse is teaching a student nurse about the interventions to be followed when the blood pressure is above the acceptable range. Which statement by the nursing student indicates effective learning?
When blood pressure is above the acceptable range, the nurse should verify the correct size and placement of the cuff, because the cuff size may alter the readings if not placed properly.
Which intervention does the primary health care provider order the nurse to perform when blood pressure is insufficient for adequate perfusion and oxygenation of tissues?
When blood pressure is not sufficient for adequate perfusion and oxygenation of tissues, the nurse should increase the rate of intravenous infusion or administer vasoconstricting drugs
While assessing the body temperature of a patient after treatment, the nurse observes that the temperature has dropped 1 degree below the normal range. Which interventions should the nurse follow in this situation?
When the temperature has dropped 1 degree below the normal range after treatment, the nurse should immediately eliminate any drafts, provide extra blankets for warmth, and monitor the apical pulse rate.
While assessing the axillary temperature, the nurse raises the patient's arm away from the torso. What is the rationale behind this action?
While measuring a patient's axillary temperature, the nurse should inspect the skin for lesions and excessive perspiration, as lesions may alter the local skin temperature.