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Dillon Ch 3
Approach to the Physical Assessment/Vital Signs
| Question | Answer |
|---|---|
| Identify the 6 measurements that can be considered vital signs | BP, Pulse (HR), Resp, Temp, SaO2 (Pulse ox), Pain |
| State a nursing diagnosis to describe an abnormal temperature reading | Nursing Diagnoses: Ineffective Thermoregulation (Hyperthermia / Hypothermia) |
| State a nursing diagnosis to describe an abnormal SaO2 reading | Nursing Diagnosis: Impaired Gas Exchange |
| Identify 4 means of heat loss or gain | Conduction, Convection, Radiation, Evaporation |
| Conduction is heat loss/gain by: | Direct contact |
| Convection is heat loss/gain by: | Air currents |
| Radiation is heat loss/gain by: | Ambient air temperature |
| Evaporation is heat loss/gain by: | Water loss through skin, lungs |
| Explain the difference in the Fahrenheit and Centigrade (Celsius) temperature scales | Fahrenheit temp scale is based on 32 for the freezing point of water and 212 for the boiling point of water. Celsius tempe scale is the scale based on 0 for the freezing point of water and 100 for the boiling point of water. F to C value: C=5/9(F-32) |
| Normal Adult VS ranges | Temp: 96.8F (36C) - 99.5F (37.5C) Pulse: 60-100 (Avg = 70-80) Resp: 12-20 BP: 120/80 |
| Normal Newborn VS ranges | Temp: 98.6F (37C) -99.8 (37.7C) Pulse: 120-160 Resp: 30-80 BP:50-52/25-30, Mean: 35-40 |
| Normal Aging Adult VS ranges | Temp: 96.5F (35.9C) - 97.5F (36.3C) Pulse: 60-100 Resp: 15-25 BP: 120/80 |
| Normal 3 yr VS ranges | Temp: 98.5F (36.9C) - 99.5F (37.5C) Pulse: 80-125 Resp: 20-30 BP: 78-114/46-78 |
| Normal 10 yr VS ranges | Temp: 97.5F (36.3C) - 98.6F (37C) Pulse: 70-110 Resp: 16-22 BP: 90-132/5-86 |
| Normal 16 yr VS ranges | Temp: 97.6F (36.4C) - 98.8F (37.1C) Pulse: 55-100 Resp: 15-20 BP: 104-108/60-92 |
| Normal Sa)2 value | 95-100% |
| Describe the skills needed in assessing respirations | Count Unobtrusively (While Palpating Radial Pulse) Count for 60 Seconds Observe the Rate, Rhythm, and Depth of Respirations |
| Understand the use of a pulse oximeter | -Noninvasive method of monitoring respiratory status -SaO2 reflects the percentage of hemoglobin molecules carrying oxygen |
| Korotkoff’s Sounds - 1st sound | As you deflate the BP cuff, a sound that occurs during systole (systolic BP) |
| Korotkoff’s Sounds - 2nd sound | As you further deflate the cuff, a soft swishing sound caused by blood turbulence |
| Korotkoff’s Sounds - 3rd sound | Begins midway through the BP and is a sharp, rhythmic tapping sound |
| Korotkoff’s Sounds - 4th sound | Similar to the third sound, but softer and fading |
| Korotkoff’s Sounds - 5th sound | Silence, corresponding with diastole (diastolic BP) |
| Systolic Pressure | Peak pressure exerted against arterial walls as the ventricles contract and eject blood Working pressure (SBP) |
| Diastolic Pressure | Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest Resting pressure (DBP) |
| Explain the importance of identifying trends and/or evaluating differing patterns in vital signs | The initial set of VS is the baseline, serial measurements are more reflective of health than one-time measurements. For example: a BP of 150/98 in a pt who was late to his appt may not be a reflection of his usual BP - it may be increased due to stress. |
| Terms for abnormal temperature | Hypothermia, Hyperthermia, Pyrexia |
| Hypothermia | Abnormally low body temp |
| Hyperthermia | Abnormally high body temp |
| Pyrexia | Fever |
| 6 Common Pulse Points | Apical: At the apex of the heart Carotid: Between midline and side of neck Brachial: Medially in the antecubital space Radial: Laterally on the anterior wrist Femoral: In the groin fold Popliteal: Behind the knee |
| Terms for abnormal pulse | Bradycardia, Tachycardia, Irregular, Bounding, Thready |
| Bradycardia | Abnormally low pulse/heart rate (<60 BPM in adults) |
| Tachycardia | Abnormally high pulse/heart rate (>100 BPM in adults) |
| Terms for abnormal respirations | Apnea, Bradypnea, Tachypnea, Dyspnea, hyperventilation, hypoventilation |
| Apnea | Cessation of breathing |
| Bradypnea | Abnormally slow respirations (<12 for adults) |
| Tachypnea | Abnormally fast respirations (>20 in adults) |
| Hyperventilation | Abnormally deep breathing |
| Hypoventilation | Abnormally shallow breathing |
| Term for abnormal SaO2 value | Hypoxia |
| Terms for abnormal BP values | Hypotension, Hypertension (pre-hypertension, Stage I hypertension, Stage II hypertension) |
| Classification of Pre-hypertension (BP values), of an adult | 120-139/80-89 |
| Classification of Stage I hypertension (BP values), of an adult | 140-159/90-99 |
| Classification of Stage II hypertension (BP values), of an adult | >160/>100 |
| Describe the techniques of obtaining height and weight | Height done routinely in clinics for adults – measure with pt’s back to the scale, shoes off, paper towel for infection control. Weight – routinely done on acutely ill patients! Balance scale, have void prior, same time of day, and with minimal clothing |
Created by:
MEPN 2013
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