What are the vital signs we assess? Temperature Pulse Respirations Blood Pressure Pain O2
What is a normal temperature? 37 C or 98.6 F
What is a normal pulse? 60-100 bpm
What is a normal respiration rate? 12-20 breaths per minute
What is normal blood pressure? 120/80 mmHg
How do we ask patient...
NU 231 Exam 1 Study Questions and
Correct Answers
What are the vital signs we assess? ✅Temperature
Pulse
Respirations
Blood Pressure
Pain
O2
What is a normal temperature? ✅37 C or 98.6 F
What is a normal pulse? ✅60-100 bpm
What is a normal respiration rate? ✅12-20 breaths per minute
What is normal blood pressure? ✅120/80 mmHg
How do we ask patients to rate pain? ✅on a 0-10 pain scale
children often use face scale
neonates: Neonatal Infant Pain Scale (NIPS) or Neonatal Pain, Agitation and Sedation
Scale (N-PASS)
Nursing action for abnormal vitals ✅- Always retake them first
- Report any abnormal findings
- Follow principles of delegation
- Validate abnormal findings and further assess
When do we assess vital signs? ✅-Upon admission to any healthcare facility.
-Based on policy and procedures.
- Any time there is a loss in consciousness
-Any time there is a change in the patient's condition.
-Before and after surgical or invasive diagnostic procedures.
-Before and after activity that may increase risk, such as ambulation after surgery.
-Before and after administering medications that affect cardiovascular or respiratory
functioning.
What are the sources of heat production? ✅- The primary source is metabolism.
- Hormones, muscle movements and exercise can all increase metabolism.
- Epinephrine and norepinephrine are released when additional heat is required and
alter metabolism
, - Thyroid hormone and shivering increases heat production
- Energy production decreases and heat production increases
What are the sources of heat loss? ✅- Skin (primary source)
- Evaporation of sweat
- Warming and humidifying inspired air
- Eliminating urine and feces
- Transfer of body heat to environment
How is body heat transferred to the environment? ✅Radiation
Convection
Evaporation
Conduction
What affects body temperature? ✅- Circadian rhythm: body temp. is lower in morning
and higher between 4 and 8pm
- Age & Gender: Older adults have less subcutaneous tissue, this leads to loss of
thermoregulatory function. New borns are more susceptible to heat loss. Women
experience more temp. fluctuations than men
- Physical Activity: Muscle movement increases temp.
- State of Health: Certain disease processes can result in a change of body temp.
- Environmental Temp.: Hypothermia and Hyperthermia
How is pulse regulated? ✅By the autonomic nervous system through the SA node of
the heart
Define pulse rate ✅The number of contractions over a peripheral artery in 1 minute
Parasympathetic stimulation vs. sympathetic simulation (HR) ✅Parasympathetic
Stimulation = decrease in HR
Sympathetic Stimulation = increase in HR
List 3 ways to assess pulse ✅1. Palpate the peripheral arteries
2. Auscultate the apical pulse with a stethoscope
3. Use a portable Doppler ultrasound
List the common pulse sites ✅Temporal
Carotid (often used during cardiac arrest)
Brachial (commonly done on infants)
Radial (normal for adults)
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