Vital Signs
What is the normal temperature range
36-38
What are the categories for Braden scale
moisture, activity, friction & Shear, nutrition, mobility, sensory
what does SLIME stand for
single line initial mistaken entry
where is s1 loudest
apex
Why is pinching the skin not the best assessment for hydration status
older people have thinner less elastic skin
What is the range for Sp02
95-100
What are the elements of gcs
LOC, pupillary reaction, eye opening, verbal response, motor response
What does OPQRSTUV stand for
onset, palliative/ provoke, quality, radiation, severity, treatment, understanding, values
What does a pulse deficit indicate
can indicate a fib and cardiac arrythmias
what are two examples of adventitious sounds
crackles and wheezing
How do you straighten an ear canal for a tympanic temp
up and out
Why do we not chart bowel movements in the VS flowsheet
has to be witnessed and has its own flowsheet
What does ADPIE stand for
assessment, diagnosis, planning, intervention, evaluation
What is the mitral valve also known as
bicuspid
what are the signs of SOB
(3 signs)
cyanosis, nasal flaring, accessory muscle use, tripoding,
How do you take a temporal temperature
temp to temp artery and behind the ear
What are the strengths of the pulses
+1, +2, +3, +4
What does SBAR stand for and when do we do it?
situation, background, assessment, recommendation
The mitral is also known as
apical
what angle do we need to have the HOB for JVD
30
What numbers are hypertension
<90 and <139
Which one is worse as per GCS? abnormal flexion or abnormal extension
abnormal extension
What does PERRLA stand for
pupils are equal and reactive to light and accomodation
what is s3
gallop - vibration during the rapid filling of left ventricle
whats the difference between adduction and abduction
adduction is adding to midline and abduction is moving away from body