What vital signs do we take? - Answers BP, RR, HR, T, O2 sat (pain)
Why do we take vital signs? - Answers Measures system functioning
When should we take vital signs? - Answers When patient is showing symptoms something is
wrong, after interventions are given, if a vital sign is abnormal retake. Schedule by clinical
judgement.
Normal heart rate for adults - Answers 60-100 bpm
<60 bpm is bradycardia
>100 bpm is tachycardia
Normal BP for adults? - Answers 120/80
<90/60 hypotension
>130/90 hypertensive
Normal RR for adults? - Answers 12-20 breaths per minute
<10 hypoventilation
>20 hyperventilation
Normal O2 saturation for adults - Answers 95-100%
<95%=hypoxemia
(at higher elevations 90-95% is normal)
Normal temperature - Answers 98.6-100.4 degrees Fahrenheit
<97.8 hypothermia
>100.4 febrile temperature
What does vasoconstriction cause in relation to temperature? - Answers shivering
What can vasodilation cause in relation to temperature? - Answers radiation, convection,
sweating
What methods can we use to take temperature? - Answers Oral, rectal, skin, temporal artery,
axillary, tympanic, indwelling devices
, What factors can impact temperature? - Answers Circadian rhythm, age, activity, hormones,
stress, environment, sensation
An increase in temperature by 1 degree increases metabolism by ____% - Answers 1%
Symptoms of heat exhaustion - Answers hot, diaphoretic skin
Symptoms of heat stroke - Answers hot dry skin, hypotension
hypothermia levels - Answers mild (32-35C)
moderate (28-32C)
Severe (<28C)
When should I take cultures with a fever? - Answers BEFORE antibiotics
As a nurse what can we do for fevers? - Answers cultures, oxygen, fluids, nutrition, maximize
heat loss. antipyretics
As a nurse what can we do for heatstroke/exhaustion? - Answers cardiovascular support, rapid
cooling
As a nurse what can we do for hypothermia? - Answers remove wet clothing, hot liquid intake
(avoid alcohol)
What arteries can we use to find pulse? - Answers Carotid, brachial, femoral, popliteal, posterior
tibial, dorsalis pedis
How long do we listen for apical pulses? - Answers a FULL MINUTE
How long do you count for IRREGULAR pulses? - Answers A FULL minute
Where do we listen for apical pulse? - Answers 5th intercostal space (between 5th and 6th rib)
midclavicular (lub dub=one beat)
What can cause bradypnea? - Answers narcotics, carbon monoxide, etc.
What can cause tachypnea? - Answers asthma, anxiety, pain, infection
What is measured with an SpO2? - Answers diffusion and perfusion
What can influence our respiration? - Answers Exercise, pain, anxiety, positioning, medications,
near injury
What is the formula for calculating cardiac output? - Answers stroke volume x rate = cardiac
output
What influences our blood pressure? - Answers age, stress, ethnicity, gender, circadian rhythm,