Quiz 4 - Vital Signs
Which sites are more reliable indicators of core body temperature?
Rectal and temporal sites
What part of the brain controls body temperature?
Hypothalamus
What is nonshivering thermogenesis (NST)?
Heat production through metabolic processes, especially in newborns
What is diaphoresis?
Visible sweating, which increases heat loss
What are the three main types of temperature alterations?
Fever, hyperthermia, and hypothermia
What types of thermometers are commonly used?
Electronic and disposable thermometers
What are the three characteristics of the pulse?
Rhythm, strength, and equality
What is respiratory rate?
The number of breaths a person takes per minute
Normal range for body temp:
36-38 degrees Celcius
Blood pressure normal range:
90/60 to 120/80 mmHg
Oxygen saturation normal level:
95-100%
Normal respiratory rate:
12–20 breaths per minute (for adults)
Pulse (Heart Rate) normal range:
60–100 beats per minute
Respiratory assessment data aids in nursing diagnoses such as:
- Activity intolerance
- Ineffective airway clearence
- Anxiety
- Ineffective breathing pattern
- Impaired gas exchange
- Acute pain
- Ineffective tissue perfusion
- Dysfunctional ventilatory weaning response
Blood pressure is:
The force exterted on the walls of an artery by the pulsing blood under pressure from the heart.
Systolic blood pressure is:
The peak of maximum pressure when ejection occurs
- Is the top number in a blood pressure reading
Diastolic blood pressure is:
What the arteries exert whhen the ventricles relax
- Is the minimal pressure exerted against the arterial walls
- Is the bottom number in a blood pressure reading
Elevated diastolic pressure may indicate issues like ______
Hypertension
How do artifical nails/polish interfer with O2 levels?
Interfer with accuracy; opaque coatings decrease light transmission or can abosorb light emissions
Factors that influence blood pressure:
- Age
- Stress
- Gender
- Daily variation (steep increase in morning, peak in late afternoon, decrease at night during rest)
- Medications (opiod analgesics, intravenous fluids, antihypertension medications)
BP threshold for high risk of cardiovascular disease:
SBP ≥ 120
The most common alteration in blood pressure is:
Hypertension
Factors to assess before taking vital signs:
Exercise, smoking, eating or drinking in the past hour
Risk factors for alteration in blood pressure:
- Cardiovascular disease
- Renal disease
- Diabetes
- Circulatory shock
- Acute or chronic pain
- Toxemia of pregnancy
- Post-op conditions
High blood pressure symptoms:
- Headache
- Flushing of face
- Nosebleed
- Fatigue
Low blood pressure symptoms:
- Dizziness
- Mental confusion
- Restlessness
- Paleness
- Cool extremities
Have patient rest for ___ minutes before blood pressure is measured in sitting/lying down
Have patient rest for ___ minutes before blood pressure is measured standing up
5
1
Can a patient speak during blood pressure measurement?
No
The 5 Korotkoff sounds:
1. First sound: The initial tapping sound, indicating the systolic blood pressure (when blood starts flowing again as pressure is released).
2. Second sound: A softer, swishing sound due to turbulent blood flow.
3. Third sound: A crisp tapping as blood flow becomes less turbulent.
4. Fourth sound: A muffled, soft sound as the blood flow slows further.
5. Fifth sound: The disappearance of the sound, marking the diastolic blood pressure (when blood flow returns to normal and is no longer turbulent).
The fifth Korotkoff sound is the:
Diastolic pressure in adults
Arm below heart level will cause:
False high reading