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Nursing Basics

Nursing Basics Vitals

QuestionAnswer
How does age affect temperature and respiration? With age temperature decreases and respiratory increases.
Adult normal temperature 97F to 99.5F
Rectal Temperature Most accurate temperature. Usually 1F higher.
Axillary Temperature The least accurate reading. 1F to 2F lower
Tympanic Temperature 0.5F to 1F higher
Temperature Fluctuates Temperature fluctuates with rest and activity.
Celsius to Fahrenheit multiply C temp by 1.8 and then add 32
Fahrenheit to Celsius subtract 32 from F temp and then divide by 1.8
What you need to take temperature thermometer, disposable probe or thermometer sheath, gloves and lubricant if taking rectal temp.
How to take a temperature Explain procedure,wash hands,if you are taking oral wait 20-30mins if pt drank, smoke, or ate
Taking Rectal Temp adult Position pt on left side with leg flexed. lift buttocks insert 1 1/2 cm. hold in place wipe away any feces from pt and thermometer
Taking rectal temp for infant only insert thermometer 1/2 of centimeter. hold thermometer in place to prevent tissue damage
Taking axillary temp put on gloves, use tissue to pat dry, ask pt to reach across chest an grab opposite shoulder
Taking tympanic temp for children up to age 1 pull ear straight back for adults and children older than 1 pull ear up and back
Taking infants temperature Foe infants younger than three months , take three readings and use the highest one
Contraindication for oral temp young children and infants and pts who are unconscious, disoriented, prone to seizures, or who must breathe through their mouth
Contraindication for rectal temp pts with diarrhea, recent rectal or prostatic surgery or injury, or recent myocardial infarction because it could stimulate vagus nerve
Nasal oxygen and taking oral temp Nasal oxygen only raises oral temp by 0.37F so it is ok to take oral temp
How does age affect temperature and respiration? With age temperature decreases and respiratory increases.
Adult normal temperature 97F to 99.5F
Rectal Temperature Most accurate temperature. Usually 1F higher.
Rectal Temperature Most accurate temperature. Usually 1F higher.
Rectal Temperature Most accurate temperature. Usually 1F higher.
Axillary Temperature The least accurate reading. 1F to 2F lower
Axillary Temperature The least accurate reading. 1F to 2F lower
Tympanic Temperature 0.5F to 1F higher
Tympanic Temperature 0.5F to 1F higher
Rectal Temperature Most accurate temperature. Usually 1F higher.
Rectal Temperature Most accurate temperature. Usually 1F higher.
Temperature Fluctuates Temperature fluctuates with rest and activity.
Axillary Temperature The least accurate reading. 1F to 2F lower
Fahrenheit to Celsius subtract 32 from F temp and then divide by 1.8
Celsius to Fahrenheit multiply C temp by 1.8 and then add 32
Tympanic Temperature 0.5F to 1F higher
Fahrenheit to Celsius subtract 32 from F temp and then divide by 1.8
Tympanic Temperature 0.5F to 1F higher
How to take a temperature Explain procedure,wash hands,if you are taking oral wait 20-30mins if pt drank, smoke, or ate
What you need to take temperature thermometer, disposable probe or thermometer sheath, gloves and lubricant if taking rectal temp.
How to take a temperature Explain procedure,wash hands,if you are taking oral wait 20-30mins if pt drank, smoke, or ate
Temperature Fluctuates Temperature fluctuates with rest and activity.
Celsius to Fahrenheit multiply C temp by 1.8 and then add 32
Taking Rectal Temp adult Position pt on left side with leg flexed. lift buttocks insert 1 1/2 cm. hold in place wipe away any feces from pt and thermometer
Taking rectal temp for infant only insert thermometer 1/2 of centimeter. hold thermometer in place to prevent tissue damage
Celsius to Fahrenheit multiply C temp by 1.8 and then add 32
Taking Rectal Temp adult Position pt on left side with leg flexed. lift buttocks insert 1 1/2 cm. hold in place wipe away any feces from pt and thermometer
Fahrenheit to Celsius subtract 32 from F temp and then divide by 1.8
Fahrenheit to Celsius subtract 32 from F temp and then divide by 1.8
Taking rectal temp for infant only insert thermometer 1/2 of centimeter. hold thermometer in place to prevent tissue damage
Taking axillary temp put on gloves, use tissue to pat dry, ask pt to reach across chest an grab opposite shoulder
What you need to take temperature thermometer, disposable probe or thermometer sheath, gloves and lubricant if taking rectal temp.
Taking axillary temp put on gloves, use tissue to pat dry, ask pt to reach across chest an grab opposite shoulder
Taking axillary temp put on gloves, use tissue to pat dry, ask pt to reach across chest an grab opposite shoulder
How to take a temperature Explain procedure,wash hands,if you are taking oral wait 20-30mins if pt drank, smoke, or ate
Taking tympanic temp for children up to age 1 pull ear straight back for adults and children older than 1 pull ear up and back
How to take a temperature Explain procedure,wash hands,if you are taking oral wait 20-30mins if pt drank, smoke, or ate
Taking Rectal Temp adult Position pt on left side with leg flexed. lift buttocks insert 1 1/2 cm. hold in place wipe away any feces from pt and thermometer
Taking infants temperature Foe infants younger than three months , take three readings and use the highest one
Contraindication for oral temp young children and infants and pts who are unconscious, disoriented, prone to seizures, or who must breathe through their mouth
Taking Rectal Temp adult Position pt on left side with leg flexed. lift buttocks insert 1 1/2 cm. hold in place wipe away any feces from pt and thermometer
Contraindication for oral temp young children and infants and pts who are unconscious, disoriented, prone to seizures, or who must breathe through their mouth
Taking rectal temp for infant only insert thermometer 1/2 of centimeter. hold thermometer in place to prevent tissue damage
Contraindication for rectal temp pts with diarrhea, recent rectal or prostatic surgery or injury, or recent myocardial infarction because it could stimulate vagus nerve
Contraindication for rectal temp pts with diarrhea, recent rectal or prostatic surgery or injury, or recent myocardial infarction because it could stimulate vagus nerve
Taking tympanic temp for children up to age 1 pull ear straight back for adults and children older than 1 pull ear up and back
Taking axillary temp put on gloves, use tissue to pat dry, ask pt to reach across chest an grab opposite shoulder
Taking infants temperature Foe infants younger than three months , take three readings and use the highest one
Taking tympanic temp for children up to age 1 pull ear straight back for adults and children older than 1 pull ear up and back
Contraindication for rectal temp pts with diarrhea, recent rectal or prostatic surgery or injury, or recent myocardial infarction because it could stimulate vagus nerve
Taking infants temperature Foe infants younger than three months , take three readings and use the highest one
Nasal oxygen and taking oral temp Nasal oxygen only raises oral temp by 0.37F so it is ok to take oral temp
Contraindication for oral temp young children and infants and pts who are unconscious, disoriented, prone to seizures, or who must breathe through their mouth
Contraindication for rectal temp pts with diarrhea, recent rectal or prostatic surgery or injury, or recent myocardial infarction because it could stimulate vagus nerve
Nasal oxygen and taking oral temp Nasal oxygen only raises oral temp by 0.37F so it is ok to take oral temp
What is a pulse the pulse reflects the amount of blood ejected with each heartbeat
Normal adult pulse between 60 to 100 beats per minute
For cardiovascular emergencies which site should you palpate the femoral or carotid artery
Pulse rate beats per minute
Pulse rhythm pattern or irregularity of the beats
When to use Doppler ultrasound if pulse is faint or weak
What you need to take a pulse watch with second hand, stethoscope if taking apical pulse, Doppler ultrasound flow detector if necessary
How to take a pulse explain to pt, wash hands, make sure pt is comfortable and relaxed
Taking radial pulse Place pt in sitting or supine position. with arm at side or across chest
Taking pulse in children under 3 For infants and children under three it's best to take apical pulse. Don't forget to warm the bell of scope.
Normal pulse pattern rhythm 60 to 80 bets per minute, neonates 120 to 140beats per minute
Tachycardia rhythm more than 100 beats
Bradycardia rhythm less than 60 beats per minute
Irregular uneven time intervals between beats
Absent pulse not palpable scores 0
Weak or thready pulse hard to feel, easily obliterated by slight finger pressure +1
Normal pulse easily palpable, obliterated by strong finger pressure, +2
Bounding pulse readily palpable, forceful, not easily obliterated by pressure +3
Respiration exchange of oxygen and carbon dioxide between the atmosphere of the body
What you need to take a respiration second hand watch
How to take respirations Best time to take respirations is right after taking radial pulse. don't tell him what you are doing the rate.
Watch movement of respirations 1 respiration is the rise and fall of the chest. count for 60 secs. observe chest movements for depth if patient inhales a small amount it is shallow, if inhales a large amount it is deep
Note accessory muscle use during respiration scalene, sternocleidomastoid, trapezius, latissimus dorsi. this indicates weaknesss of daiphragm
Breath sounds stertor, stridor, wheezing, expiratory grunting
Stretor snoring sound due to large secretions in bronchi
Stridor inspiratory crowing could be caused by foreign body obstruction
Wheezing sounds like whistling caused by partial obstruction
Signs of dyspnea anxious facial expression, flaring nostrils, heaving chest wall, and cyanosis.
Stridor in infants when listening observe for sterenal, substernal, and subcostal retractions
Expiratory Grunt in infants Imminent respiratory distress.
Expiratory grunt in older adults Partial airway obstruction
Neonates RR 30 to 80 breathes per minute
Toddlers 20 to 40 breathes per minute
School age Children and older 15 to 25 breathes per minute
Adult Rate 12 TO 20 breathes per minute
Apnea Absence of breathing
Bradypnea Slow regular respirations of equal depth
Cheyne-stokes Fast deep respirations for 30 to 170 seconds with periods of apnea
Eupnea Normal rate and rhtymn
Kussmaul fast mo0re than 20 breathes per minute, deep, labored respirations without pause
Tachypnea Rapid respirations,rate rises with body temp at about 4 bpm for each Fahrenheit above normal
Documenting Respirations Record rate, depth, rhythm an sound of the patient's respirations.
Blood Pressure Systolic(l ventricle contracting)and diastolic (l ventricle relaxing)
Pulse pressure Difference between systolic - diastolic
Increased Blood Pressure Blood Pressure rises with age, weight gain, prolonged stress, and anxiety.
What you need for BP Sphygmomanometer, stethoscope, or dynamap
Getting ready to take BP Choose appropriate size cuff, or it may lead to false reading.
How to do BP Pt arm should be extended at heart level. Make sure pt is relaxed and comfortable.
Dont's with BP Do not take a BP with shunt, IV in arm, injury, or mastectomy.
Neonate BP Systolic 50 to 52. Diastolic 25 to 30. mean 35 to 40
3 years BP systolic 78 to 114. diastolic 48 to 78.
10 years BP Systolic 90 to 132. Diastolic 56 to 86
16 years BP Systolic 104 to 108. Diastolic 60 to 92
Adult BP Systolic 90 to 130. Diastolic 60 to 85
Older Adult BP Systolic 140 to 160. diastolic 70 to 90
Taking more tan one BP Wait at least 30 seconds between taking a second BP
Weight Pt should be weighed at the same time each day before breakfast.
Created by: eboniquedevon