Vital signs

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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


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