Guidelines for measuring vital signs - ANSWERSMeasure in unstable client
Review data (know client's baseline)
Interpret findings
Determine appropriate interventions (factoring in individual client information)
Assess equipment
Select appropriate equipment
Collaborate/delegate (verify communicate changes)
Techniques for assessing vital signs - ANSWERSTemperature
Pulse
Respirations
Pulse Oximetry
Blood pressure
Measuring BP
Height
Weight
Rectal temperature - ANSWERSused when other routes are not practical or for critical care
,-(0.7-1 degree F) higher than an oral temperature
Tympanic membrane temperature - ANSWERSeardrum using infrared emissions, quiz and non invasive,
low risk or cross contamination
Temporal artery temperature - ANSWERSuses infrared emission by sliding the probe across the forehead
and behind the ear
(1 degree F higher than oral)
Axillary temperature - ANSWERSused when oral temp cannot be obtained
(1 degree F lower than oral)
Normal temperature alterations - ANSWERSExercise
Gender (menstruation cycle)
Circadian rhythm (diurnal cycle)
Age
Environment
Abnormal temperature alterations - ANSWERSFever
Hyperthermia
Heatstroke
Heat exhaustion
Hypothermia
It is encouraged to not treat a temp. below 102.2 F with antipyretics.
Pulse - ANSWERSUse pads of first three fingers palpate radial pulse
,- Regular- count 30 sec.
- Irregular- count full 60 sec.
- Recorded per minute
- *60-100* is *normal*-athletes may be lower
- May increase in response to exercise, fever, or anxiety
Pules characteristics - ANSWERS*Rate*:
- tachycardia (rapid heart beat)
- bradycardia (slow heart beat)
*Rhythm*:
- regular
- irregular
*Strength*:
4: bounding
3: strong
2: normal
1: thready
0: absent
*Equality*: bilaterally
Respirations - ANSWERSShould be relaxed, silent, regular, and automatic
*10-20* per minute is *normal*
May be higher with exercise or anxiety
, Count for 30 seconds, 60 seconds if you suspect abnormality
Be sneaky!
Pulse oximetry - ANSWERSOxygen saturation in the blood (SaO2)
% of oxygenated hemoglobin
Expected range: *95% - 100%*
Equipment- Finger probe, earlobe probe, sensor pad
Blood pressure - ANSWERSForce of blood against vessel wall
Systolic - maximum pressure
Diastolic- resting pressure
*Normal = 120/80*
Hypertension risks- age, weight, exercise, stress
Factors that influence BP - ANSWERSCardiac output
Vascular resistance
Volume
Viscosity
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