Nursing Vitals Delegation and Assessment Quiz

Circadian Rhythms and Body Temperature

• Circadian rhythms are physical, mental, and behavioral changes that follow a 24-hour cycle and happen naturally
• Examples of circadian rhythms include:
  • Lower body temperature and blood pressure in the morning
  • Higher body temperature and blood pressure in the evening
• Factors that affect body temperature:
  • Circadian rhythms
  • Age or gender (peds and elderly are more sensitive and need more coverings)
  • Physical activity (e.g., running a mile)
  • State of health (e.g., severe infection)
  • Environmental temperature (e.g., walking in 102°F heat)

Vital Signs

• The six vital signs are:
  • Temperature
  • Pulse
  • Respiration
  • Blood pressure
  • Pulse oximetry
  • Pain
• The frequency of vital sign assessment:
  • Every 4 hours, unless there is a change in condition
• Seven times to assess vitals:
  • On admission
  • Based on policy and procedures
  • Change in condition
  • Change in or loss of consciousness
  • Before or after surgery or other invasive diagnostic procedure
  • Before or after activity that may increase risk
  • Before or after administering meds that affect cardio and respiratory

Blood Pressure

• Regulation of blood pressure:
  • Nerve regulation
  • Cardiac output
  • Stimulation of the vagus nerve
  • Sympathetic stimulation
  • Baroreceptors in the heart
  • Renin-angiotensin-aldosterone system
• Factors that affect blood pressure:
  • Age
  • Circadian rhythm
  • Sex
  • Food intake
  • Exercise
  • Weight
  • Emotional state
  • Body position
  • Race
  • Drugs and medications

Temperature Assessment

• The five ways to take a temperature:
  • Oral
  • Rectal
  • Axillary
  • Tympanic
  • Forehead
• Contraindications for taking a temperature:
  • Oral: eating, chewing gum, facial surgery, trauma, pediatrics, or inability to open and close mouth
  • Rectal: thrombocytopenia (low platelets)
  • Axillary: environmental factors
  • Tympanic: ear infections, earwax, or discharge
  • Forehead: scar tissue or wearing a hat

Hygiene and Skin Care

• Hygiene assessment for skin:
  • Cleanliness and intactness
  • Capillary refill and contour of the nail bed
  • Swelling, inflammation, lesions
• Hygiene assessment for perineal and vaginal areas:
  • Color lesions, swelling, inflammation, excoriation, tenderness, discharge
  • Anal cracks, nodules, distended veins, masses, or polyps
  • Odor
• Steps to oral hygiene:
  • Moisten the mouth
  • Clean the mouth
  • Care for dentures
  • Brush and floss teeth
  • Use mouthwash
• Proper eye care:
  • Cleaning from inner to outer with wet, warm cloth
  • Use artificial tear solution every 4 hours if blink reflex is absent
  • Care for eyeglasses, contacts, or artificial eyes
• Ear and nose care:
  • Wash external ear with washcloth-covered finger
  • Perform hearing aid teaching and care
  • Clean nose by having patient blow it if both nares are patent
  • Remove crusted secretions around nose by applying warm, moist compress### Hygiene Assessment
• Hygiene assessment for nails and feet: cleanliness and intactness, capillary refill and contour of the nail bed, swelling, inflammation, lesions of the feet
• Hygiene assessment for perineal and vaginal areas: color, lesions, swelling, inflammation, excoriation, tenderness, discharge, anal cracks, nodules, distended veins, masses, or polyps, odor

Oral Hygiene

• Steps to oral hygiene: moisten the mouth, clean the mouth, care for dentures, brush and floss teeth, use mouthwash
• Potential oral problems: dental caries, plaque, or periodontal disease, loose teeth

Eye Care

• Proper eye care: cleaning from inner to outer with wet, warm cloth, use artificial tear solution every 4 hours if blink reflex is absent, care for eyeglasses, contacts, or artificial eyes

Ear and Nose Care

• Ear and nose care: wash external ear with washcloth-covered finger, not Qtips, perform hearing aid teaching and care, clean nose by having patient blow it if both nares are patent, remove crusted secretions around nose by applying warm, moist compress

Hair Care

• Hair care for patients on anticoagulant therapy: use electric razors, not regular razors, assist with caring for beards and mustaches, as well as assisting with unwanted hair removal

Skin Care

• Purposes of bathing: cleanses the skin, acts as a skin conditioner, helps to relax a person, promotes circulation, increases sensation, serves as musculoskeletal exercise, stimulates rate and depth of respirations, promotes comfort, provides person with sensory input, helps improve self-image/self-esteem, strengthens nurse-patient relationship
• What to do during perineal and vaginal care: assess for problems and related treatments, perform a physical assessment of genitalia, perform care in a matter-of-fact and dignified manner according to procedure, cleanse vaginal area with plain soap and water

Safe Patient Handling and Mobility (SPHM)

• Variables leading to patient handling injuries: uncoordinated lifts, high exertion, awkward or static postures, manual lifting and transferring, repetitive movements or tasks, standing for long periods of time
• The 8 main variables leading to back injury in health care workers: uncoordinated lifts, manual lifting and transferring of patients without assistive devices, lifting when fatigued or after recent back injury recovery, repetitive movements, standing for long periods of time, transferring patients, repetitive tasks, transferring/repositioning uncooperative or confused patients
• Proper way to lift: use your legs, not your back, squat down to pick up objects, not bend over

Vital Signs

• The six vital signs: temperature, pulse, respiration, blood pressure, pulse ox, pain
• How often should patients' vitals be taken at minimum: every 4 hours, unless there is a change
• Four ways to transfer heat to external environments: radiation, convection, evaporation, conduction

Body Temperature

• Factors affecting body temperature: circadian rhythms, age or gender, physical activity, state of health, environmental temperature
• Afebrile: without fever
• Pyrexia: with fever (febrile)

Pulse

• Tachycardic: pulse rate above 100
• Bradycardic: pulse rate below 60
• Normal pulse rate: 60-100 BPM

Blood Pressure

• Regulation of blood pressure: nerve regulation, cardiac output, stimulation of the vagus nerve, sympathetic stimulation, baroreceptors in the heart, renin-angiotensin-aldosterone system

• How to take a blood pressure: using a stethoscope and sphygmomanometer, or using an electronic or automated device

• Factors affecting blood pressure: age, circadian rhythm, sex, food intake, exercise, weight, emotional state, body position, race, drugs and medications### Mechanical Lateral-Assist Devices

• Types of mechanical lateral-assist devices include transfer chairs, powered stand-assist and repositioning lifts, and powered full-body lifts.

Patient Positioning

• Patients must be positioned every 4 hours to prevent bed sores.
• Fowler's position: sitting with legs straight in front of them.
• Supine or dorsal recumbent position: laying flat on their back with legs straight or slightly bent.
• Side lying or lateral position: laying on their side with legs straight.
• Sim's position: laying on their side with the opposite leg up and bent in front of them.
• Prone position: lying face down.

Transfer and Ambulation

• To help transfer a patient, have them cross their arms and feet.
• Mechanical aids for walking include walkers, canes, braces, and crutches.
• Proper positioning of crutches prevents axillary nerve damage.

Vital Sign Norms in Adults

• Pulse rate: 60-100 (average: 80)
• Respirations: 12-20 breaths per minute
• Blood pressure: less than 120/80
• Oral temperature: 35.8-37.5°C (96.4-99.5°F)
• Pulse strength:
  • Grade 0: absent, unable to palpate
  • Grade +1: diminished, weaker than expected
  • Grade +2: normal, brisk, expected
  • Grade 3+: bounding

Heat Transfer

• Radiation: dissemination of heat by electromagnetic waves (e.g., body gives off heat waves from uncovered surfaces)
• Convection: dissemination of heat by motion between areas of unequal density (e.g., oscillating fan blowing cool air)
• Evaporation: conversion of a liquid to a vapor (e.g., body fluid in the form of sweat vaporizing from skin)
• Conduction: transfer of heat to another object during direct contact (e.g., body heat transferred to an ice pack, causing it to melt)

Fevers

• Intermittent fever: temperature returns to normal between exacerbations, at least once every 24 hours
• Remittent fever: temperature does not return to normal and fluctuates a few degrees
• Sustained or continuous fever: temperature remains above normal with minimal variations
• Relapsing or recurrent fever: temperature returns to normal for one or more days with one or more episodes of fever

Pulse and Respiratory

• Pulse:
  • Tachycardic: pulse rate above 100
  • Bradycardic: pulse rate below 60
  • Normal pulse rate: 60-100 BPM
  • Amplitude and quality: strong or weak pulse
• Respiratory:
  • Normal rate: 12-20 breaths per minute
  • Eupnea: normal, unlabored respiration
  • Tachypnea: increased respiratory rate
  • Bradypnea: decreased respiratory rate
  • Apnea: periods of no breathing
  • Dyspnea: difficult or labored breathing
  • Orthopnea: changes in breathing when sitting or standing