Assessment of Vital Signs

Question 1

Observation of level of awareness:

Answer 1

Changes can be the result of hypoxia or hypercapnia ( excessive carbon dioxide in blood) or hypercarbic

Question 2

Observation of color

Answer 2

Cyanosis (peripherally-nail beds or centrally- lips are bluish) occurs with hypoxia

Question 3

Facial signs of respiratory fatigue or distress

Answer 3

Flared nostrils, focused or dilated pupils sweating

Question 4

Mouth breathing

Answer 4

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Question 5

Jugular vein engorgement

Answer 5

Sign of increased venous pressure and Rt ventricular heart failure

Question 6

Hypertrophy

Answer 6

of accessory mm of ventilation

Question 7

Supraclavicular or

Answer 7

intercostal retraction

Question 8

Pursed -lip breathing

Answer 8

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Question 9

Digital clubbing

Answer 9

Changes in fingers or toe nails; softening and rounding associated with chronic tissue hypoxia

Question 10

Edema

Answer 10

Sign of Rt ventricular failure

Question 11

symmetry of chest and trunk

Answer 11

Thats all just know its a sign for vital observation.

Question 12

Shape and dimensions of chest

Answer 12

• Barrel chest
• Pectus excavatum
• Pectus carinatum

Question 13

Barrel Chest

Answer 13

Upper chest circumference larger than lower chest, sterum is prominent, AP diameter is larger than normal- common in COPD upper chest breathers

Question 14

Pectus Excavatum

Answer 14

Funnel breast/breastbone sunken into chest

• Lower part of sternum is depressed and lower ribs flare out common in diaphragmatic breathers
• during ventilation abdomen protrude & there is little upper chest movement

Question 15

Pectus Carinatum

Answer 15

Pigeon Breast

-Deformity in which sternum is prominent and protrudes anteriorly

Question 16

Posture observation

Answer 16

With difficulty breathing, pt often lean forward on their hands or forearms when sitting or standing to stabilize and elevate shoulder girdle which assists in inspiration by increasing the effectiveness of the pectoralis and serratus anterior mm

-Note: postural deformities ( kyphosis and scoliosis ) which can restrict chest movements and ventilation.

Question 17

Breathing pattern

Answer 17

rate, regularity, and location

Question 18

Normal ration of inspiration to expiration

Answer 18

1:2 at rest, 1:1 with activity; with chronic lung disease it may be 1:4

Question 19

Normal sequence of inspiration

Answer 19

1. Diaphragm contracts and descends and abdomen rises
2. Followed by lateral costal expansion
3. Finally upper chest rises

Question 20

Dyspnea

Answer 20

Shortness of breath; distressed ,labored breathing

Question 21

Tachypnea

Answer 21

rapid, shallow respiration; decreased tidal volume but increased rate; use of accessory mm of inspiration; associated with restrictive or obstructive lung disease.

Question 22

Bradypnea

Answer 22

Slow rate with shallow or normal depth and regular rhythm maybe associated with drug overdose

Question 23

Hyperventilation

Answer 23

deep, rapid respiration; increased tidal volume and increased rate of reparation, regular rhythm

Question 24

Orthopena

Answer 24

abnormal condition in which a person must sit or stand to breathe deeply or comfortably

Question 25

Apnea

Answer 25

cessation of breathing in the expiratory phase

Question 26

Apneusis

Answer 26

Cessation of breathing in the inspiratory phase

Question 27

Cheyne Stokes

Answer 27

Cycles of gradually increasing tidal volumes, followed by a series of gradually decreasing tidal volumes, and then a period of apnea; sometimes associated with sever brain injury

Question 28

Paradoxical breathing with paralysis of intercostals mm and other accessory mm

Answer 28

The diaphragm contracts causing the abdomen to rise, while the upper chest collapses without the assistance of the intercostals ( unable to stop strong descent of the diaphragm); generally more pronounced with abdominal weakness or paralysis & in children.

Question 29

Paradoxical breathing with paralysis of the diaphragm & intact accessory mm

Answer 29

The intercostals contract and expand the thorax anteriorly, laterally, and primarily in the superior chest while the abdominal mm push up on the flaccid diaphragm to assist the intercostals in achieving maximal chest expansion; the abdomen draws in during inspiration while the upper chest expands; diaphragmatic paralysis will require some kind of assisted ventilation for at least some part of the day as the diaphragm normally supplies 75-80% of the total expansion necessary for adequate alveoloar ventilation.

Question 30

Cough

Answer 30

Effective cough is sharp and deep, ineffective may be soft, throaty, shallow, dry or moist

Question 31

Sputum

Answer 31

• Color: clear is normal, yellow or green indicates —infection, blood- streaked is described as hemoptysis.
• Consistency: viscous, thin, frothy
• Amount: varies with diagnosis.