VITALS
VITALS
VITALS
TERMS
TERMS
TERMS
100
NORMAL TEMPERATURE RANGE FOR AN ADULT
96.8 - 100.4
100
NORMAL ADULT HEART RATE
60 - 100 bpm (BEATS PER MINUTE)
100
MY NORMAL RATE IS 12-20 FOR AND ADULT BUT I CAN GO AS HIGH AS 26 FOR AN OLDER ADULT
WHAT IS NORMAL RESPIRATORY RATE
IF THE RATE IN THE OLDER ADULT IS 26 THERE MUST BE NO EVIDENCE OF DISTRESS OR ILLNESS TO BE CONSIDERED A NORMAL RATE
100
PYREXIA
FEVER
100
FEBRILE
FEVER
100
APNEA
NO RESPIRATIONS - NOT BREATHING
200
ORAL, AXILLARY, RECTAL, TYMPANIC, TEMPORAL
WHAT ARE TYPES OF THERMOMETERS AND WAYS WE MEASURE A PATIENTS TEMPERATURE
200
FOR WHICH TEMPERATURE METHODS WOULD YOU WEAR GLOVES FOR?
ORAL & RECTAL
ANTICIPATE GUARANTEED EXPOSURE TO BODY FLUIDS
200
HOW LONG DO YOU MEASURE AN APICAL PULSE FOR
1 MIN
200
AFEBRILE
WITHOUT FEVER
200
HYPERTHERMIA
FEVER GREATER THAN 100.4
- INFECTION
- HEATSTROKE
200
HOW DO YOU DESCRIBE PULSE QUALITY?
Absent = 0
Weak or Thready = 1
Normal = 2
Bounding = 3
300
HOW DO YOU STRAIGTEN THE EAR CANAL FOR AN ADULT PRIOR TO PLACING THE TYPANIC PROBE?
PULL THE PINNA (EAR LOBE) UP THEN BACK
300
HOW FAR IS THE RECTAL PROBE INSERTED ON THE ADULT PATIENT
1 - 1.5 INCHES
PLEASE LUBRICATE IT - NEVER FORCE
THIS ENSURES IT PASSES THE INTERNAL SPHINCTER, REMEMBER TO HOLD ONTO THE PROBE THE ENTIRE TIME TO PREVENT INJURY
300
HOW DO YOU STRAIGTEN THE EAR CANAL FOR A CHILD PRIOR TO PLACING THE TYPANIC PROBE?
PULL THE PINNA (EAR LOBE) DOWN THEN BACK
300
HYPOTHERMIA
LOW CORE BODY TEMPERATURE <95
300
HEART RATE GREATER THAN 100
TACHYCARDIA
300
DYSPNEA
DIFFICULTY BREATHING
400
WHAT INSTRUCTIONS DO YOU GIVE A PATIENT WHEN PERFORMING AN ORAL TEMPERATURE?
KEEP THE TIP OF THE PROBE UNDER YOUR TONGUE, CLOSE YOUR LIPS TO HOLD IN PLACE, NOT YOUR TEETH, DO NOT BITE.
400
THE TEMPERATURE SITES THAT MEASURE CLOSEST TO THE PATIENTS INTERNAL TEMPERATURE
RECTAL
TYMPANIC
PULMONARY (DONE BY INVASIVE CATHETER)
400
IF THE PATIENT IS LAYING ON THEIR RIGHT LATERAL WHERE DO YOU PERFORM THE TEMPORAL OR TYMPANIC TEMPERATURE?
ON THE LEFT SIDE OR LEFT EAR
400
RESPIRATORY RATE LESS THAN 12
BRADYPNEA
400
APICAL RATE MINUS THE RADIAL RATE = ?
WHAT IS A PULSE DEFICIT
400
HOW DO YOU DESCRIBE PULSE OR RESPIRATORY RATE
NORMAL, TACHY, OR BARADY
500
WHEN DO YOU TAKE VITAL SIGNS?
TRY TO LIST 10
On admission to get a baseline of the patient's status
As scheduled by the HCP or agency policy, could be q4h, q8h, qshift
At the beginning of your shift to get baseline
Before, during, after surgery or invasive procedure
Before & after administering medications or therapies that affect the cardiovascular, respiratory, or temperature
Before, during and after nursing interventions that may affect vital signs such as
Patients first time OOB after bed rest
ROM exercises
Before, during and after BLOOD PRODUCT TRANSFUSIONS
When the patient reports change in SUBJECTIVE symptoms such pain, dizziness, numbness, tingling – or I feel funny/off/different
When you assess OBJECTIVE change in patient condition such as
Change in level of consciousness
Change in blood work – glucose levels
Sudden acute onset of INTENSE PAIN
Assessing patient during home care visit
500
HOW LONG DO YOU WAIT TO TAKE ORAL TEMPERATURE IF THE PATIET JUST ATE, DRANK, SMOKED, CHEWED GUM
20 - 30 MINS
500
MOUTH BREATHER, HIGH FEVER, LOW TEMPERATURE, AWAKE/UNCONSCIOUS, CANNOT FOLLOW COMMANDS, DIARRHEA, IMPACTED STOOL, EAR WAX, HEARING AID
THINGS THE NURSE MUST CONSIDER TO DETERMINE IF THE ROUTE SELECTED IS APPROPRIATE FOR THE PATIENT?
500
BRADYCARDIA
HEARTRATE BELOW 60 BPM
500
THE RN ASSESSES A RESPIRATORY RATE OF 28 BPM HOW WHOULD THIS RATE BE DOCUMENTED
TACHYPENIA
500
EUPNEA
NORMAL RESPIRATION
600
WHAT IS THE MOST APPROPRIATE POSITION TO PLACE THE PATIENT IN TO PERFORM A RECTAL TEMP
SIMS POSITION
600
HOW DO YOU LOCATE THE APEX OF THE HEART/PMI TO TAKE AN APICAL PULSE
LOCATE THE 5TH INTERCOSTAL SPACE THEN SLIDE OVER TO THE MIDCLAVICULAR LINE
600
HOW DO YOU PERFORM A PULSE DEFICIT ASSESSMENT?
2 PERSON PROCEDURE
1 AUSCULTATES APICAL PULSE FOR ONE MINUTE
1 PALPATES RADIAL PULSE FOR ONE MINUTE
APICAL ASSESSOR SAYS START WHEN READY TO BEGIN COUNT
PULSE DEFICIT = APICAL RATE - RADIAL RATE = PULSE DEFICIT
600
HOW DO YOU DESCRIBE PULSE OR RESPIRATORY RHYTHM?
REGULAR OR IRREGULAR
600
ORTHOPNEA
DIFFICULTY BREATHING WHEN SUPINE
600
WHEN ASSESSING THE RESPIRATORY STATUS WHAT IS MEANT BY RESPIRATORY EFFORT?
DEGREE OF WORK REQUIRED TO BREATHE