Baseline Vital Signs (U3) Flashcards
What does it start with?
Chief complaint
What do measurements of vital body functions do?
Basis for initiating care and reevaluation of interventions
What do the measurements include?
Respiration, pulse, BP, temperature, pupils
What is the respiratory evaluation based on?
Quality, wheezing, and stridor
What is included in quality for respiration?
Breathing sounds, chest expressions, increased effort
Qualities in terms of breathing sounds?
Present, diminished, absent
Quality in terms of chest expression?
Unequal or symmetricalI
Quality in terms of increased effort?
Accessory muscles, nasal flaring, retractions (between ribs, clavicles), cyanosis, shortness of breath, altered mental state
What is wheezing?
High pitched whistling
What is stridor, and what is it caused by?
High pitch on inspiration, caused by obstruction on vocal cords/epiglottis
What are the two main sites for pulse?
Peripheral, and central
What is part of the peripheral pulse sites?
Radial, brachial, posterior tibial, dorsalis pedis
What is part of the central pulse sites?
Carotid and femoral
What does perfusion, in terms of skin, point to ?
Perfusion and oxygenation
What are the components of perfusion and skin?
Colour, temperature, moisture, capillary refill
Locations of assessment for skin colour?
Nail beds, oral mucosa, conjunctiva
What is a normal skin colour?
Pink
What are traits of abnormal skin colour?
Paleness, cyanotic, flushed, jaundiced
What is paleness caused by?
Poor circulation
What is cyanotic caused by and what does it look like?
Blue/grey, poor oxygenation/perfusion
What is a flushed look caused by?
Heat/CO exposure
What is jaundice caused by?
Liver/gallbladder problems
What are types of abnormal temperature?
Hot, cool, cold
What is hotness caused by in terms of temperature?
Fever/heat exposure
What is coolness caused by, in terms of temperature?
Poor perfusion/cold exposure
What is coldness caused by, in terms of temperature?
Extreme cold exposure/excessively dead (just dead)
What do you check for moisture in terms of temperature?
Diaphoresis/extremely dry
How to do a capillary refill?
Press on a patient’s nail bed till it’s blanched/white, release and count time till it returns to pink
Normal capillary refill?
Less than or equal to 2/3 seconds
Abnormal capillary refill?
More than 2/3 seconds
Why and how should you assess the pupils?
Easy way to assess neutral status, briefly shine a light in a patient’s eye
What is evaluated for pupils?
Diameter, reactivity to light, equal size
What is PERRL?
Normal pupils,
Pupils
Equal
Round
Reactive to light
What are traits of abnormal pupils?
Constricted/pinpoint, dilated, unequal
What does constricted/pinpoint pupils mean?
Overdose, opiate
What does dilated pupils mean?
Sever lack of O2 (hypoxia), brain death, toxic substance
What does unequal pupils mean?
Brain injury
How to assess a stable and unstable patient’s vital signs?
Stable: every 4 hours (Q4H)
- Every 15 min if there’s medical intervention
Unstable: every 5 min (blood transfusion, PACU)
