ADPIE - Nursing Process Correct Answer-Assessment
Diagnosis
Planning
Implementation
Evaluation
SMART goals Correct Answer-Specific, Measurable, Attainable,
Realistic, Timely
Why do we take vital signs? Correct Answer-Monitor patient status,
create a baseline
Temperature variations with age Correct Answer-Older adults: Temps
can be lower with a mean of 97.2 degrees F
Young children: Wider normal variations in infants and young children
because of less effective heat control mechanisms
Thermoregulation alteration factors Correct Answer-Age, exercise,
hormone levels, stress, circadian rhythm
Common sites of pulse measurement Correct Answer-Carotid: for quick
changes in condition
Apical: best for peds, must count for one minute
Brachial
, Radial: routine
How to measure pulse Correct Answer-Palpating the pulse with 2/3
fingers (never with your own thumb!)
Number of pulsations felt in 1 minute or 30 sec x 2
What we assess during pulse Correct Answer-Strength, rate, equality,
rhythm
BP Two Step Method Correct Answer-1. Palpate radial artery
2. Inflate cuff until pulse stops and inflate 30 more points
3. Deflate until you feel pulse again - that is the baseline systolic
4. Palpate brachial artery and place stethoscope
5. Inflate cuff to 30 past baseline systolic
6. Deflate - first sound you hear is systolic and last you hear is diastolic
Lifespan considerations Correct Answer-Aging adults:
- Less likely to be febrile, risk for hypothermia
- pulse: rhythm may be irregular
- Respirations: shallow, increased rate
- BP: high systolic readings