west coast university nurs 100 week 1 study guide latest 20222023
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West Coast University: NURS 100 Week 1 Study Guide Latest 2022/2023
Vital signs
1. Normal ranges:
a. Temperature
i. Adult: (98.6 – 100.4 F) Newborn: 97.7-
99.5 Elderly: 95.9 – 99.5 Infants: 98.7 – 100.5
ii. Rectal & Temporal – 0.9 HIGHER
iii. Auxillary & Tympanic – 0.9 LOWER
iv. Measure Rectal or Tympanic for core body temp
▪ No rectal for PT w/ Platelet disorder, bleeding, trauma (MI), diarrhea,
or infants < 3M
▪ Tympanic – Adult: ear UP/BACKChild: DOWN/BACK < 3YO.
▪ Metabolism – greatest source of heat in the body
▪ NO tympanic and rectal for inf < 3M!
v. Hypothermia: < 95 F
vi. Hyperthermia: > 104 F
vii. Fever/ Febrile: > 102.2
b. Pulse Rate
i. Adult: 60 – 100 Infant: 90 – 160 BPM Adolescent: 55- 105
0=absent, +1=weak, +2=normal, brisk, +3=strong, +4=bounding, full volume
ii. Tachycardia: > 120
iii. Bradycardia: < 60
iv. Pulse rate regulated through ANS
c. RR [arm across abd + semi fowlers]
i. Adults: 12 – 20 2-7 yo: 20 – 30 Newborn: 30 – 60
ii. Bradypnea: < 12 BPM (abnormal slow breathing)
iii. Tachypnea: > 20 BPM (abnormally fast)
iv. Apnea = periods of no breathing
v. Hypoventilation = shallow, slow breathing
vi. Hyperventilation = deep, fast breathing
vii. Kussmaul Respirations = Increased rate/depth in REGULAR pattern
viii. Cheyne-Stokes Respirations = irregular rate/depth in CYCLIC pattern
i. Adult: <120Elevated: 120-129 HTN1: 130-139 HTN2: 140+CRISIS: 180+
<8080 80-89 90+120+
d. BP
ii. Orthostatic Hypotension = drop in BP when changing position [dizziness,
weakness, fainting]
iii. Hypertension s/s: Tachycardia, Bradycardia, Pain – increased risk for stroke
(SALT bad)
▪ Consuming adequate: Mg, Ca, K can reduce BP
iv. Hypotension < 90
< 80
2. Considerations Prior to taking Vital Signs
a. Temperature – hot/cold liquids can affect oral temp – wait 30 mins
b. Pulse rate – reg/irreg (measure rate, rhythm, strength
c. RR – prevent PT from being aware you’re observing them (measure rate, rhythm,
depth)
d. BP – cuff too tight, small, big, loose; arm level at the heart; zeroing; cuff bladder
placement over brachial artery
I. Cuff bladder must be 2/3 of adult limb (80% arm circumference); Width at
40%
This study source was downloaded by 100000802531269 from CourseHero.com on 03-23-2023 19:47:13 GMT -05:00
, If cuff is too narrow = reading too high
II.
If cuff too loose = reading too low
III.
e. Pulse Location
I. Temporal, Carotid, Brachial, Radial, Femoral, popliteal, posterior tibial, pedal
II. Pulse Deficit = Apical – Radial Pulse
▪ ^heartbeats aren’t reaching peripheral arteries and too weak to be
palpated
th
▪ Apical pulse @5 intercoastal space @ midclavicular line use this site
for infant HR
f. Pulse Pressure Sounds – 5 Korotkoff
I. First sound = systole (heart contracts, filling atria with blood)
This study source was downloaded by 100000802531269 from CourseHero.com on 03-23-2023 19:47:13 GMT -05:00
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