Questions and Answers on Vital Signs

What are vital signs? What 3 body functions do they measure?

Vital signs refers to the clinical dimensions which include respiration, body temperature, blood pressure and pulse. The body functions measured are; blood circulation, breathing and heart rate.

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List factors that may influence and alter a person's vital signs

Factors which may alter a person's vital signs include: lifestyle, gender, age, medications, heredity and pain.

Identify the sites used to measure temperature.

Temperature of a human body is measured from the following sites: mouth, skin, ear, under the arm, and rectum.

Why is oral temperature preferred by most individuals?

Oral temperature is preferred by most individuals because it is the most comfortable.

Identify reasons an oral temperature should NOT be take.

Oral temperature should not be taken when the patient is unconscious. This is because there is a likelihood of the individual not following the instructions associated with the procedure such as "not biting the thermometer". An unconscious patient may unknowingly bite the thermometer leading to oral injury.

When should taking an oral temperature be DELAYED 20-30 minutes?

Taking of oral temperature should be delayed for 20-30 minutes after eating, this it to allow the mouth to cool down.

When is taking a rectal temperature NOT advisable? When is it recommended?

Rectal temperature is not advisable when the patient is suffering from cardiac conditions. This is because there is a possibility that the thermometer could cause the stimulation of the vague nerve hence resulting in cardiac arrhythmia. Rectal temperature is however recommended for irrational patients or those who cannot comfortable breathe when their mouths are closed. The method is also recommended for infants.

What depth is a rectal thermometer recommended for an infant? child? for an adult?

The recommended depth for a rectal thermometer is between 0.5 and 1 inch.

Define: tympanic temperature.

Tympanic temperature is the temperature of the tympanic membrane.

Define: temporal temperature.

Temporal temperature is the temperature of the forehead.

Identify the normal adult range for:

a. Oral temperature: the oral temperature range for a normal adult is 36.5 degrees Celsius to 37.2 degrees Celsius.

b. Axillary temperature: auxiliary temperature for normal adults is 35.5 to 37.0 degrees Celsius

c. Rectal temperature: rectal temperature for normal adults is 34.4 to 37.8 degrees Celsius.

Define:

a. Pulse rate: pulse rate refers to the heartbeat speed as measured using the heart contractions per minute.

b. Pulse rhythm: is the heartbeat as measured through peripheral artery walls

c. Pulse amplitude: pulse amplitude refers to the pulse parameter magnitude.

List the 7 bilateral pulse points (CH 16 p 349) used to count the pulse (heart) rate.

Describe how to take an apical pulse.

To take an apical pulse, the first intercostal space has to be located which is the space between the first and the second rib (left side of the body or chest). After that, one has to count to the fifth intercostal space located between the fifth and the sixth rib then draw a lined to the left nipple. Once the area of apical pulse is identified, one has to place the stethoscope with the diaphragm touching the body. The duration of measure should be one minute.

The normal pulse range is ____60____to __100 beats per minute______

Define:

a. Respiratory rate: the number of breaths taken by an individual per minute.

b. Respiratory rhythm: routine cycle of oscillation which entail expiration and inspiration. The process is characterized by neuron sending impulses from the brain to the diaphragm and chest muscles.

c. Depth of respiration: depth of reparation refers to the amount air taken in per respiration.

d. Dyspnea: Dyspnea refers to the difficulties in breathing.

e. Apnea: Apnea refers to the cessation in breathing which appear temporarily.

f. Cyanosis, cyanotic: Cyanosis refers to bluish casting of mucosal and skin membranes while cyanotic refers to

Normal adult respiratory range is _12__to ___20 breaths per minute_______

Identify and describe:

a. the parts of a sphygmomanometer

The parts of a sphygmomanometer include: the bladder, manometer, cuff, bulb, and valve. The bladder is the part which feels with air to allow arterial occlusion by compression the arm. The manometer is for air pressure measurement, the cuff holds the bladder around the arm or any other limb, the bulb enables pumping of air into the cuff while the valve enables one to control the deflation of the cuff.

b. parts of the stethoscope

The parts of the stethoscope include: ear tips, ear tubes, tubing, headset, stem, chest piece diaphragm and bell. The ear tips are placed in the ears to allow sound reception, ear tubes are the connecting parts between the synthetic tubing and the ear tips. The tubing conveys sound from the diaphragm to the ear tubes, while the headset enhance the sound quality. The headset comprises of the ear tips, tension springs, and the ear tubes. The stem on the other hand connects the chest piece to the tubing whereas the chest piece is used in the listening of sounds. The diaphragm is the part that picks up sound frequencies from the body of the patient while the bell allows one to focus on a narrower area.

The normal Systolic range for adult blood pressure is _____120___to __139_______

The normal Diastolic rang for adult blood pressure is _______80____to ______89______

Define

a. Hypertension: Hypertension refers to systolic blood pressure of above 140 and diastolic blood pressure of above 90.

b. Hypotension: it is referred to as low blood pressure with systolic and diastolic blood pressure below 90 and 60 mm Hg respectively.

Define

a. Acute pain: acute pain refers to a pain that lasts less than three months.

b. Chronic pain: chronic pain is a pain which lasts more than three months

Describe 10 NONVERBAL signs of pain.

Nonverbal sings of pain include:

• Hand movements which indicate distress
• Restlessness
• Crying
• Low appetite
• Increased sleep
• Agitation
• Heightened confusion
• Generating fewer sounds
• Sweating
• Slow movement

Pain is totally subjective. Read Box 24-2 Reporting Pain. What are the common methods used to measure pain. List 5 questions to ask your patient to gather information and detail about the pain before reporting to the nurse.

The common methods use in the measurement of pain include the verbal rating scale, the visual analogue scale, numerical rating scale, face or picture scale and behavioral measurements. The questions to ask the patient include:

• Where is the pain?
• Does it affect any other place?
• When did you start experiencing the pain?
• How long have you had the pain?
• What is the severity of the pain?