Temperature
Regulates body temperature
What is the hypothalmus?
Normal range for adult pulse
What is 60-100 bpm
The normal range for adult respirations
What is 12-20 breaths per minute?
The range for systolic and diastolic pressure
What is systolic 100-140 and diastolic 60-90?
The first thing you do if you get a vital sign you are not sure about or abnormal reading
What is repeat?
If still not sure have someone else check it for you then you may have to call MD
Normal range for temperature
What is 97-99.6 degrees Fahrenheit?
These are 3 ways to assess pulse
What are palpation, auscultation, and doppler?
Term for difficult, labored respirations, or shortness of breath
What is dyspnea?
This is a decrease in blood pressure when changing positions such as lying to sitting or standing
What is orthostatic hypotension?
This is not considered a vital sign but is often a measurement that is done at the same time
What is oxygen saturation?
These are 2 age groups where temp is greatly affected
What the very young and old?
This pulse site is obtained by auscultation and counted for a full minute
What is the apical pulse
The 4 things to note/assess with respirations
What is rate, depth, rhythm, and quality?
Most common site (artery) to assess B/P
What is the brachial artery?
These are some nursing interventions for an elevated body temperature (hyperthermia)
What are?
Continue to assess temp and skin color, cover when shivering then remove blankets, encourage fluids, limit activity, promote ventilation/circulation, antipyretics, cool cloths to areas of body, tepid sponge bath, cooling blanket, and provide dry clothing and linens
The most accurate and reliable method to obtain body core temperature
What is rectal temp?
The 3 things to note/document when assessing a pulse
What is rate, rhythm, and volume?
This is what you document in nurses note to describe respirations if they are "normal"
What is 12-20 rate, and even and unlabored?
This is what happens if the cuff size is not correct
What is make the reading inaccurate?
Too high - small cuff
Too low - big cuff
This is the scale to use to measure pulse volume
What is?
0=absent, 1=thready, 2=weak, 3=normal -strong, and 4=bounding
If you get an abnormally high or low reading when checking
What is recheck?
The difference between apical and radial pulses
What is pulse deficit?
The absence or lack of breathing
What is apnea?
These are at least 3 nursing interventions for abnormal B/P reading
What are?
Repeat, eliminate background noise, appropriate position, use manual cuff if electronic machine, assess pt, appropriate cuff size, arm position, may have to give meds, compare with baseline, report to MD
What are?
Brachial artery, popliteal, and radial