1.3 Vital Signs Flashcards
When to check vitals
- Admission to healthcare facility
- Based on policy/procedures
- Change in patients condition
- Loss of consciousness
- Before and after surgical/invasive procedure
- Before/after activity that can increase risk (ambulance ride)
- Before administering medication that affect cardiovascular and respiratory function
Normal Vital Signs
Oral Temp - 37C, 98.6F
Pulse Rate - 60-100 (80 avg)
Respirations - 12-20
Blood Pressure - 120/80
Variations in Temperature
Temperature varies by age, sex, physical activity, state of health, environmental temperature.
Varies during time of day
- Lowest early morning
- Highest late afternoon
Heat Production/Heat Loss
Heat Production - Metabolism. Epinephrine and Norepinephrine are released to rapidly later metabolism for increased heat production. Thyroid hormone also increase metabolism. Shivering
Heat Loss - Skin. Opens to release heat into environment or close to retain heat. Controlled by sympathetic nervous system.
Methods of Temperature Taking
Oral - Mouth. Nothing to eat/drink 15-30 min prior. Not used in children under 5
Rectal - Rectum. 1 inch deep for child, 1.5 inch for adult.
Axillary - Armpit. Used when Oral and Rectal cannot be. Temperature affected by air temperature and perspiration
Tympanic - Ear. Quick and easy. Pinna pulled up for adults, ear lobe pulled down for children under 3.
Temporal - Forehead. Start on right or left and move across forehead.
Variation in Temperature between methods
Oral - Gold Standard
Rectal - Higher due to closed cavity
Axillary - Lower due to perspiration and air
Temporal - Lowest due to exposure of skin to air
Average temperature per method
Oral - 37C, 98.6F Rectal - 37.5C, 99.5F Axillary - 36.5C, 97.7F Tympanic - 37.5C, 99.5F Temporal - 34.4C, 94.0F
Factors Affecting Temperature
Circadian Rhythm - Predictable fluctuations in body temperature and BP. (Lower in AM, Higher in PM)
Age/Biological Sex - Older adults may be lower in temp. Very old/very young are sensitive to changes in environmental temperature. Women temperature fluctuates more than men because of hormones. Usually warmer.
Physical Activity - Physical exertion increases body temperature. Increased metabolism.
State of Health
Environmental Temperature
Mechanisms of Heat Transfer
Radiation - Diffusion of heat by electromagnetic waves. Body gives off heat from uncovered surfaces.
Convection - Dissemination of heat by motion between areas of unequal density. (Fan)
Evaporation - Sweat
Conduction - Transfer of heat to another object during direct contact. (Ice Pack)
Afebrile/Pyrexia/Febrile/Hyperpyrexia
Afebrile - Normal Body Temperature
Pyrexia - Fever
Febrile - Elevated Body Temperature (Fever)
Hyperpyrexia - Equal or greater than 41C/106F. (Emergency)
Types of Fevers
Intermittent - Temp returns to normal at least once every 24 hours
Remittent - Temp does not return to normal and fluctuates few degrees up and down
Sustained/Continuous - Temp stays above normal with little variation
Relapsing/Recurrent - Temp returns to normal for one or more days with episodes of fever every few days
Pulse
Controlled by autonomic nervous system/SA node
Sympathetic - Speeds Heartrate
Parasympathetic - Slows Heartrate
Pulse Rate - Number of contractions in 1 minute
Pulse Sites
Temporal - On the temple (Forehead) Carotid - Neck Brachial - Inner elbow Radial - Inner wrist closest to thumb Femoral - Groin/Abdomen Popliteal - Behind Knee Posterior Tibial - Inner Ankle Dorsalis Pedis - On top of foot
Apical Pulse
Left side of chest over point of heart.
Check when patient takes medication altering heartrate or peripheral pulse is difficult to take. (Irregular, feeble, extremely rapid)
Count heartbeat for a full minute.
Most reliable in children under 2
Force of Pulse
Strength of heart's stroke volume. 0 - Absent Pulse 1+ - Weak, Thready 2+ - Normal 3+ - Full, bounding
Respirations
Movement of air in and out of lungs
Diffusion - Exchange of oxygen from alveoli and blood
Perfusion - Exchange of oxygen between blood and tissue
Regular Rate - 12-20
Assessing Respiration Rate/Depth/Rhythm
Assess by observing chest/shoulder rise/fall
Auscultation - Listening to breathing via stethoscope
(Count for 15-30 seconds than multiply)
Observe sternal notch if difficult to see chest/shoulder
Signs of Respiratory Disease
Orthopnea - Difficulty breathing
Tachypnea - Rapid Breathing
Blood Pressure
Systolic Pressure - Highest point of pressure when ventricle contracts
Diastolic Pressure - Lowest point of pressure when ventricle relaxes
Measured in mmHG
Pulse Pressure - (Stroke Volume) Systolic (minus) Diastolic.
Factors Affecting Blood Pressure
- Age/Gender/Race
- Circadian Rhythm
- Food Intake
- Exercise
- Weight
- Emotional State
- Body Position
Blood Pressure Readings
Normal - 120/80 Elevated - 120-129/80 Stage 1 Hypertension - 130-139/80-89 Stage 2 Hypertension - 140+/90+ Hypertensive Crisis - 180+/120+
Taking Blood Pressure
Done with stethoscope and sphygmomanometer
2 step method
- Palpate heart rate.
- Use cuff and pressurize until you no longer feel pulse
- Release pressure than repressurize until 20 mmHg above when you no longer felt pulse
- Take blood pressure
Assessing Weight
- Ask patient to remove heavy clothing (shoes/sweater)
- For repeated weights, try to take them at the same time of day each time
- Record weight in both kg and lb
BMI
Underweight - Less than 18.5
Normal Weight - 18.5 - 24.9
Overweight - 25 - 29.9
Obese - Greater than 30
Pain
Acute pain - Rapid onset, varies in intensity and duration
Chronic pain - Limited, Intermittent, or Persistent. Lasts beyond normal healing period. Remission and exacerbation are common.
Idiopathic pain - No identifiable cause
Pain
Acute pain - Rapid onset, varies in intensity and duration
Chronic pain - Limited, Intermittent, or Persistent. Lasts beyond normal healing period. Remission and exacerbation are common.
Idiopathic pain - No identifiable cause
Origin of Pain
Physical - Can be identified
Psychogenic - Cannot be identified
Referred - Perceived distant from point of origin
Transduction/Transmission/Modulation
Transduction - Activation of pain receptors
Transmission - Conduction along the pathways
Modulation - Inhibition or modification of pain
Responses/Factors to Pain
Sympathetic Nervous System governs response to pain
Factors influencing include
- Cultural/Ethnic variables
- Family/Sex/Gender/Age
- Religious Beliefs
- People to support
- Anxiety/other stressors
- Past pain experiences
Assessment/measure of pain
- Patient verbalization and description of pain
- Duration/location of pain
- Quantity/Intensity/Quality of pain
- Chronology of pain
- Aggravating/alleviating factors
- Physiological indicators of pain
- Behavioral response
- Effect of pain on activities and lifestyles
Assessment of pain (cont.)
Usually on a scale of 0-10
Neonates (newborn)
Neonatal Infant Pain Scale (NIPS)
Neonatal Pain, Agitation, Sedation Scale (N-Pass)
- Assesses posturing, ability to soothe, and respiratory patterns in baby.
Pharmacologic Interventions for Pain
Oral Medication Injectable Medication Patient-Controlled Analgesia (PCA) Local Anesthesia Epidural Anesthesia
Non-Pharmacologic Interventions for Pain
- Distraction
- Imagery
- Relaxation
- Massage
- Pressure/acupuncture
- Animal-facilitated therapy
Non-Pharmacologic Interventions for Pain
- Distraction
- Imagery
- Relaxation
- Massage
- Pressure/acupuncture
- Animal-facilitated therapy
