Vital signs
An electronic thermometer is inserted into the rectrum
1/2 inch
Let the person rest for ______ before taking the blood pressure
10 to 20 min
You must report any systolic pressure at above ___ and diastolic pressure at or above ___
120 mm Hg, 80 mm Hg
What is the normal respiratory rate for newborns
35
An apical pulse of72 is recorded as
72 Ap
If you take a rectal temperature,the normal range of the temperature would be
98.6 F to 100.6 F (37.0 C to 38.1 C)
Factors affecting blood pressure
>age >gender >blood volume >stress >pain >exercise >weight >race >diet >drug >smoking >alcohol >position
Thermometer
A device used to a measure temperature
Tachycardia
A rapid heart rate that is over 100 beats per minute
Glass thermometers have the following problems
A. Break easily, can injure rectum and colon B. Take 3 to 10 min C. Person can bite down and break then mercury can be swallowed
Rectal temperature are not taken if the person
A. Has diarrhea B. Has a rectal disorder or injury C. Has heart disease D. Had rectal surgery E. is confused or agitated
List how long the glass thermometer remains in place for these sites
A. Oral 2 to 3 minutes or as a required by center policy B. Rectal 2 min or as required by center policy C. Axillary 5 to 10 min or as required by center policy
Report blood pressure that have thaws readings
A. Systolic over 120 mm Hg Systolic below 90 mm B. Diastolic over 80 mm Diastolic below 60 mm
When you take a pulse, what observations should be reported and recorded
A. The pulse site B. Pulse rate C. Pulse deficit for apical-radial D. If the pulse is regular or irregular E. Pulse force-strong,full,weak
When counting respirations, observe, report, and record the following
A. The respiration rate B. Equality and depth C. If the respiration was were regular or irregular D. Has pain or difficulty breathing E. any respiratory noises F. Abnormal respiration patterns
What observations should be reported and recorded when counting respirations
A. The respirator rate B. Equality and depth C. If the respirations were regular or irregular D. Has pain or a difficulty breathing E. any resporatory noises F. An abnormal respiration pattern
Body temperature is balanced between
Amount of heat produced and the amount lost by the body
Stethoscope
Ann instrument used to listen to the sounds produced by the heart, lungs, and other body organs
BP
Blood Pressure
Respiration
Breathing air into and out of the lungs
You will find out the size of blood pressure cuff needed
By asking the nurse
A ____ pulse is taken during cardiopulmonary resuscitation (CPR)
Carotid
C
Centigrade
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 at least 15 or 20 minutes
Fever
Elevated body temperature
The apical pulse is taken
For a full minute
You need to feel the pulse to determines the
Force
ID
Identification
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
When getting ready to take the blood pressure position the person's arm
Level with the heart
If you are taking the temperature of an older person, you would expect the temperature to be
Lower than the normal range
Hg
Mercury
Mm Hg
Millimeters of mercury
Body temperature is lower
Morning
The blood pressure may not be taken
On an arm that has a dialysis access site
Persons in nursing centers usually have vital sings measured
Once a month
Each respiration involves
One lnhelation &a one exnelation
How long should you count an apical pulse
One minute
A pedal pulse is found
Over a foot bone
When taking the blood pressure,you place the stethoscope diaphragm
Over the bronchial artery at the inner aspect of the elbow
Systole
Period of heart muscle contraction
The nurse ask you to take a resident's temperature. How should you hold the adult's ear
Pull up and break on the adult ear to straighten the ear canal
The ____ pulse is used for routine vital sings
Radial
Which pulse is most commonly used
Radial
Unless otherwise ordered, take vital sings with the person
Sitting down, laying down, at rest
When you are taking a blood pressure, the person should be in a ____ or _____ position
Sitting, laying
To read a glass thermometer you should hold it at the
Stem and bring it to eye level to read it
Apical-Radial pulse
Taking the apical and radial pulse at the same time
TPR
Temperature, Pulse, Respiration
Vital signs
Temperature, pulse , respirations, and blood pressure
Blood Pressure
The amount of force exerted the walls of an artery by the blood
Systolic Pressure
The amount of force it takes to pump blood out of the heart into the arterial circulation
Body Temperature
The amount of heat in the body that is a balance between the amount of heat produced and amount lost by the body
The systolic pressure is
The amount of of force it takes to pump blood out of the heart into the arterial circulation
Pulse
The beat of the heart felt at an artery
Sphygmomanometer
The cuff and measuring device used to measure blood pressure
Pulse Deficit
The difference between the apical and radial pulse rates
Diastole
The period of heart muscle relaxation
Diastolic Pressure
The pressure in the arteries when the heart is at rest
You may count the radial pulse for 30 seconds and multiply by 2 if
The pulse is regular
Do not use your thumb to take a pulse because
Thumb has a pulse
When taking the radial pulse, place
Two or three fingers on the thumb side of the wrist over the radial artery
When taking a temperature for persons who are confused and resist care, the best choice would be to
Use a tympanic or temporal artery thermometer
Hard-to-feel pulses are described as
Weak, thready,feeble
Hypertension
When blood pressure measurements remain above a systolic pressure of 140 mm Hg ir a diastolic pressure of 90 mm Hg
Hypotension
When the systolic blood pressure is below 90 mm Hg and the diastolic pressure is below 60 mm Hg
Hypotension is
When the systolic pressure is below 90 mm Hg of the diastolic pressure is below 60 mm Hg
When using a stethoscope, you can help prevent infection by
Wiping the ear-pieces and diaphragm with antiseptic wipes before and after use
Febrile
With fever
Afebrile
Without fever
If you are taking vital signs on a person with dementia, it may be better if
You can take the pulse and respirations at one time, and the temperature and blood pressure at another time
What should you do if a person asks for their vital sing measurements
You can tell the person the measurements if the center if the center policy allows
Sites for measuring temperature are the
-mouth -rectrum -axilla -tympanic membrane (ear) -temporal artery (forehead)
Each respiration involves
1 inhalation and 1 exhalation
The pulse rate is the number of heartbeats or pulses felt in
1 minute
Mm
Millimeters
The blood pressure cuff is inflated _____ beyond the point where you last felt the radial pulse
30 mm Hg
Bradycardia
A slow heart rate; the rate is less than 60 beats per minute
A glass rectal thermometer has
A stubby tip color-coded in red
Which pulse is taken with a stethoscope
Apical pulse
What should you do if you are unsure of any vital sign measurement
Ask the nurse to redo it
Which site has the lowest baseline temperature
Axillary
An irregular pulse occurs when
Beats are not evenly, spaced or beat are skipped
The blood pressure may be higher in older persons because
Blood pressure increases with age
F
Fahrenheit
An apical-radial pulse is take by
Having one staff member take the apical pulse and a second staff member take the radial pulse at the same time
IV
Intravenous
Unless otherwise ordered, take vital sings when the person
Is lying or sitting
Pulse Rate
Is the number of heartbeats or pulse felt in 1 minute
You should not use hot water to clean a glass thermometer because
It causes substance to expand so much that it could break
What special measures are needed when taking a temperature using the axillary site
Make sure axillary is dry
When a pulse rate is 120 beats per minute
Report that the person has tachycardia