Chapter 29 Vital Signs
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newborn pulse average
Factors affecting body temp.
- diurnal variations (circadian rhythm)
Factors affecting pulse
- hypovolemia (decrease of blood volume), when dehydrated
- position changes
Factors affecting blood pressure
- diurnal variations
- disease process
Blood pressure categories
- Normal 120/80
- Prehypertension 120-39/80-89
- Hypertension stage 1 140-159/90-99
- Hypertension stage 2 > 160/ > 100
sites for measuring body temperature
- tympanic membrane
- skin/temporal artery
Nursing care for fever
- monitor vital signs
- assess skin color and temp.
- monitor lab results
- remove excess blankets
- provide liquid
- measure intake output
- oral hygiene
- tepid sponge bath
101.5 or above
Define apical pulse
left midclavicular line 5th intercostals space, left sternal border
Nine pulse sites
- posterior tibial
- dorsalis pedis
Characteristics of pulse
- arterial wall elasticity
- bilateral equality
5 phases of Korotkoff sounds
- Phase 1- sharp tapping
- Phase 2-a swishing or wooshing sound
- Phase 3- a thump softer than the tapping on phase 1
- Phase 4-a softer blowing muffled sound that fades
- Phase 5-silence
Normal SPO2 (O2 saturation)
- <70% is life threatening
take an apical pulse to:
confirm the rate and determine the actualcardiac rhythm for a client with an abnormal rhythm
radial pulse would:
reveal the heart rate and suggest an arrhythmia.
For clients in shock, use:
the carotid or femoral pulse.
The radial pulse is adequate for determining:
change inorthostatic heart rate caused by body position changes.
The radial pulse isappropriate for:
routine postoperative vital sign checks for clients with regularpulses.
Which type of fever is a client experiencing when the body temperature alternates at regular intervalsbetween periods of fever and periods of normal or subnormal temperatures?
With intermittent fever, the body temperature alternates at regularintervals between periods of fever and periods of normal or subnormaltemperatures. During a remittent fever, such as with a cold or influenza, a widerange of temperature fluctuations (more than 2°C [3.6°F]) occurs over the 24-hourperiod, all of which are above normal. A relapsing fever is characterized by short,febrile periods of a few days interspersed with periods of 1 or 2 days of normaltemperature. During a constant fever, the body temperature fluctuates minimallybut always remains above normal.
What type of fever would the nurse document if the client had a wide range of temperature fluctuationsover normal for a period of 24 hours?
A remittent fever widely fluctuates above normal over a 24-hour period. An intermittent fever rises above normal between periods ofnormal or subnormal temperatures. A relapsing fever is short, febrileperiods of a few days interspersed with 1–2 days of normal temperature. Aconstant fever remains above normal.
The posterior tibial pulse site is on the medial surface of the ankle, where the posterior tibial arterypasses behind the
b. Medial malleolus
.c. Inguinal ligament.
- medial malleolus
- a.Rationale: Pulse sites: The posterior tibial site is on the medial surface of theankle, where the posterior tibial artery passes behind the medial malleolus. Thepopliteal site is where the popliteal artery passes behind the knee. The pedal (dorsalis pedis) site is where the dorsalis pedis artery passes over the bones of thefoot, on an imaginary line drawn from the middle of the ankle to the space betweenthe big and second toes. The radial site is where the radial artery runs along theradial bone, on the thumb side of the inner aspect of the wrist.
For a client with a previous blood pressure of 138/74 and a pulse of 64, approximately how long shouldthe nurse take to release the blood pressure cuff in order to obtain an accurate reading?
a. 30–45 seconds
b. 3–3.5 minutes
c. 10–20 seconds
d. 1–1.5 minutes
- 30-45 seconds
- a.Rationale: If the cuff is inflated to about 30 mmHg over previous systolicpressure, that would be 168. To ensure that the diastolic pressure has beendetermined, the cuff should be released slowly until the mid-60s mmHg (and thencompletely) for someone with a previous reading of 74. The cuff should bedeflated at a rate of 2 to 3 mm per second. Thus, a range of 90mm Hg willrequire 30 to 45 seconds.
When auscultating the blood pressure, the nurse notes the following: silence from 200 mmHg to 180mmHg; a thumping sound continuing down to 150 mmHg; muffled sounds continuing down to 130mmHg; soft thumping sounds continuing down to 105 mmHg; muffled sounds continuing down to 95mmHg; and then silence again. The nurse records the blood pressure as __________ (use the systolic/1st diastolic/2nd diastolic convention).
- a.Rationale: In phase 1, the first sound is a clear tapping when deflation of the cuffbegins. Phase 2 has a muffled, swishing sound. In phase 3, blood is flowingfreely via an increasingly open artery; sounds are more crisp and more intense butsofter than in phase 1. Phase 4 sounds become muffled and have a soft blowingquality. In phase 5, the last sound is heard, followed by silence.
Body heat that is lost when the nurse turns on the air conditioning at the client’s request is what type ofloss?
- Rationale: Convection is heat lost by air currents. Radiation is transfer of heatfrom one object to another. Conduction is transfer of heat from a warmer moleculeto one of a lower temperature. Vaporization is the continuous evaporation ofmoisture from the respiratory tract and the skin.
The nurse is admitting the postoperative client to the surgical unit following abdominal surgery. Theclient is in stable condition, but suffered significant blood loss during the surgical procedure. Which of thefollowing assessment findings would the nurse anticipate if hypovolemia continued?(Select all that apply.)Note: Credit will be given only if all correct choices and no incorrect choices are selected
.a. Flushed face
a.Rationale: If a client is hypovolemic, the blood pressure will decrease due toblood loss, and the heart rate will increase in an attempt to compensate. Theclient may be restless and anxious as a result of the hypovolemia and hypoxia.Headache and a flushed face are signs of hypertension.
The nurse noted that the client with laryngeal obstruction has stridor. This means that the sound is
:a. A continuous, high-pitched whistling sound
.b. A snoring respiration
.c. A gurgling sound
.d. A shrill, harsh sound heard during inspiration.
Rationale: Air passing through an obstructed airway upon inspiration is shrill andharsh and is called stridor. A wheeze is a continuous, high-pitched musicalsqueak or whistling sound. Stertor is a snoring or sonorous respiration. Bubblingis a gurgling sound.
While assessing a client at the beginning of the shift, the nurse obtains a pulse oximeter reading of 86%.The client is not receiving any supplemental oxygen and is responsive to questions. Which of the followingclient assessments would the nurse expect to find that would correlate with the pulse oximeter reading?
.a. Decreased urine output
b. Increased pulse rate
d. A febrile body temperature
e. Cyanotic oral mucous membranes
f. Bounding brachial pulses
Increased pulse rate,c.Tachycardia,d.A febrile body temperature
a.Rationale: A reading of 86% is low. The nurse should look for other signs andsymptoms of hypoxemia: dusky nail beds, increased pulse rate (tachycardia), andcyanotic oral mucous membranes.
One factor that will affect an oxygen saturation reading is:
.b. Low hemoglobin.
c. CO2 level.
Rationale: Factors that can affect the oxygen saturation level are: lowhemoglobin, circulation, activity level, and CO.
Which of the following can cause an erroneous low blood pressure result?
a. Cuff wrapped too loosely or unevenly
b. Assessing immediately after a meal or while the client smokes or has pain
c. Arm above heart level
d. Bladder cuff too narrow
arm above heart level
Rationale: Having the arm above heart level can cause an erroneous low bloodpressure result. Having the cuff wrapped too loosely or unevenly, having thebladder cuff too narrow, and assessing immediately after a meal or while theclient smokes or has pain can cause an erroneous high blood pressure result.
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