1: Vital signs Flashcards
What is the first step of the nursing process?
Assessment!
most common objective assessment done by nurses
Vital signs
objective assessment
When nurses asses an individual
Subjective assessment
When a patient tells us the problem
Range for temperature
98.6-100.4 F
Range for pulse
60-100 bpms
range for respirations
12-20
range for blood pressure
<120/<80
Pulse/heart rate reflects
Heart contraction. beats/min
Cardiac output
blood flow per minute
Radial
wrist
Apical
apex of the heart, 4th-5th ICS
carotid
along sternocleidomastoid muscle
Places for circulation assessment rather than vitals
- brachial
- femoral
- popliteal
- posterior
- doralis pedis
Assess all four for pulse
Rate
Rhythm
Strength
Symmetry
what do you do if you palpate an irregular pulse
Listen to apical pulse for a full minute
Stroke volume
amount of blood the LV pumps out with each contraction
Cardiac output=
(Heart rate)(stroke volume)
what will happen to the Cardiac output when someone is dehydrated
heart rate increases, therefore CO increases
what will happen to the CO if a med decreases the HR?
Decrease in CO
Bradycardia
slow, less than 60bpm
Tachycardia
fast, more than 100 bpm
how to assess rhythm
regular or irregular?
- regularly irregular (predictable)
- irregularly irregular (unpredictable)
how to assess quality of pulse
Bounding (4+) Strong (3+) Normal (2+) Diminished (1+) Absent (0)
actors influencing pulse rate
- exercise
- temperature
- emotions
- medications
- hemorrhage/fluid loss
- postural changes
- pulmonary conditions
improved physical condition =
Decrease heart rate
fever affects on HR
Fever= Increase in HR
Hypothermia affects on hr
Hypothermia decreases HR
Emotions affect of HR
pain/anxiety = increases HR
Hemorrhage/fluid loss affects on HR
Increases Heart rate
change from standing to sitting affects on HR
Sit to stand increases HR
impaired O2 could lead to
increased HR
if circulation is compromised, what may be present
pallor or cyanosis
pallor
paleness of skin
cyanosis
bluish or grayish discoloration due to excessive CO2 and deficient O2
systolic pressure
peak pressure exerted against arterial walls as ventricles contract & eject blood
Diastolic pressure
Minimum pressure exerted against arterial walls between cardiac contractions when the heart is at rest
Pulse pressure
difference between the systolic and diastolic pressures
Blood pressure is the result of interaction of
- Cardiac output
- peripheral vascular resistance
- blood volume
- blood viscosity
Decrease in radius =
increase in resistance, increase blood pressure
increase in radius =
decrease in resistance = decreased pressure
increase in blood volume=
increase in blood pressure
Decrease in blood volume =
Decrease in Blood pressure
physiological factors that influence BP
age stress ethnicity gender medications activity weight smoking
2 ways of measuring BP
- indirect or noninvasive
2. direct method
Indirect method or noninvasive
external devices like a BP cuff
direct method
- done in critical care setting
- catheter threaded into an artery
- connected to electric monitoring system
1st korotkoff sound
systolic BP
5th korotkoff sound
silence, corresponding with diastole
which do you use to assess BP?
Systolic number
What is more common, hypertension or hypotension?
Hypertension
What causes hypertension
- thickening of walls
- loss of elasticity
- family history
- risk factors
Normal rang for BP
less than 120/80
Elevated BP
120-129 and <80
Hypertension stage 1
Systolic:130-139 or Diastolic:80-89
Hypertension stage 2
> 140 or >90
Hypotension
systolic BP <90
symptoms of hypotension
- pallor
- clamminess
- confusion
- increased HR
- decreases urine output
orthostatic or postural hypotension
sudden drop in BP when going from a lying to sitting/standing
Conditions not appropriate for electronic BP measurement
irregular heart rate vascular obstruction shivering/tremors seizures inability to cooperate blood pressure less than 90 systolic
Temp range for oral
98.6
average rectal temp
99.5
axillary temp
97.7
Etiology of hypotension
Vascular dilation, inadequate pumping of heart, loss oxblood volume (Hemorrhage/dehydration)
Clinical presentation of hypotension
- Pallor
- Clamminess
- Confusion
- Increased HR
- Decreased urine output
- weakened pulse
Orthostatic or postural hypotension
sudden drop of BP on moving from a lying to a sitting or standing position
Patient conditions not appropriate for ELECTRONIC blood pressure measurement
- irregular heart rate
- peripheral vascular obstruction
- shivering/tremors
- seizures
- inability to cooperate
- blood pressure less than 90 mmHg systolic
Benefits of patient measurement of BP
- Detection of new problems (pre-hypertension)
- Patients with hypertension can provide to their health care provider info about patterns of BP
- Self-monitoring helps adherence to therapy
Disadvantages of patient measurement of BP
- Improper use risks inaccurate readings
- Unnecessary alarming of patient
- Patients may inappropriately adjust medications
Three processes of respiration
- ventilation
- diffusion
- perfusion
Ventilation
flow of gasses in and out of lungs; the amount of air in the alveoli
Diffusion
Gas exchange between alveoli & pulmonary capillaries
Perfusion
Flow of blood in the pulmonary capillaries
Hypoxemia
Low O2
How is respiration controlled
medulla
Respiratory rate:
Breaths/minute
Ventilatory depth
Deep/normal/shallow
Ventilatory rhythm
regular/irregular
Ventilatory assessment with diffusion and perfusion
O2 saturation
Apnea
Cessation of breathing –> respiratory arrest
Bradypnea
< 12/min
Tachypnea
> 20/min
Hyperventilation
Increase rate and depth
Hypoventilation
Decreased rate and depth
Effort for dyspnea
Labored breathing
Effort for orthopnea
inability to breathe when horizontal. many sleep in recliners rather than laying flat
SOB
Shortness of breath
Abnormal patterns of breathing q
Cheyne-stokes
Biot
Kussmauls
Cheyne-stokes
- Irregular rate/depth
- Apnea/hyperventilation
- slow/shallow increases to abnormally fast/deep and then reverses
- Common among those who are actively dying
Biot
Shallow 2-3 breathes… apnea and repeats
Kussmauls
Deep, regular, increases rate
- high acidity in blood
- Diabetes with a high blood sugar
What does hyperventilation result in?
Excess loss of CO2 (hypocapnea)
What happens to CO2 during hypoventilation
Co2 is retained (Hypercapnea)
Normal measurement of oxygen saturation
95-100%
How are Arterial blood gases (ABGs) measured?
Directly measures the partial pressure of O2, CO2 and blood PH
What does oxygen saturation assess
diffusion and perfusion of oxygen
How does light influence oximetry accuracy
bright light directly on the probe can throw off oximetry
How does shivering/tremors influence oximetry accuracy
Movement makes it difficult to pick up signal
How does pulse volume influence oximetry accuracy
sensor detects pulsatile flow, when BP is low the pulse may be too weak
how does vasoconstriction influence oximetry accuracy
reduces blood flow and the sensor may not detect signal
How does carbon monoxide poisoning influence oximetry accuracy
may give a falsely high saturation reading since CO binds very well to hemoglobin and displaces oxygen
What happens to the pulse when O2 levels are low
Increases
Factors that influence respirations
exercise acute pain anxiety smoking medications
What causes low BP?
shock, dehydration, hemmorhage
How to measure temperature
Heat produced-minus-heat lost
Temperature is influenced by
physiological cycles
age, activity, environment, basal metabolic rate
site of measurement
Afebrile
Person with a normal temperature
Conduction
transfer with direct contact
Example of conduction
Ice packs/cool cloths
radiation
transfer from one surface to another without direct contact
Example of radiation
heater/fireplace
Convention
transfer away through air movement: fan to cool
Evaporation
transfer when liquid id converted to gas
How does heat move through the concentration gradient
MOVES DOWN!!! from warmer to cooler
which endocrine gland controls/influences temperature
Pituitary Gland
Pyrexia
Fever
Abnormal temperature
100.4 due to alteration in hypothalamic set point
What kind of reaction is a fever
A functional reaction, which can sometimes me good
How can a fever be good?
often in response to pyrogens (fever producing cytokines)
Pyrogens induce _____
Secretion of chemical mediators
How is hyperthermia different from fever
Hyperthermia is caused due to dysfunctional thermoregulation. NOT INTENDED AND NOT EVER GOOD
Hypothermia
Core temperature below normal
Can you exceed 100% for SpO2?
No!
Malignant Hyperthermia is
Genetically predisposed
Heat exhaustion _____ heat stroke?
Precedes heat stroke
vital signs delegation
nurses can delegate activity of vital signs but it is their responsibility to interpret
