Chapter 11 Flashcards
Vitals you take on everyone
Respiration
Pulse
Skin
Pupils
Blood pressure
potentially spo2
sounds audible with stethoscope
wheezing
rales
rhonchi
Wheezing
Constriction (narrowing) and inflammation reducing the internal diameter of the bronchioles in the lung
rales
crackling/Fluid surrounding and filling the alveoli
Rhonchi
mucus blocking the larger bronchioles
abnormal respiratory patterns
cheyne stokes
biot
apneustic
ataxic
agonal
kussmaul
central neurogenic hyperventilation
cheyne stokes
respiratory rate and tidal volume gradually increase and gradually decrease followed by a period of apnea for up to 10 seconds. The pattern then repeats itself.
biot
Similar to Cheyne Stokes except that the tidal volume doesn’t change, but the respiratory pattern is interrupted by a period of apnea
apneustic
characterized by prolonged periods of inhalation.
ataxic
irregularly irregular pattern of rate and tidal volume.
agonal
Long periods of apnea with a gasping breath interposed.
Kussmaul
A rapid respiratory rate with a deep and labored tidal volume
central neurogenic hyperventilation
sustained deep and rapid respiratory rate of at least 25 breaths per minute but with a regular pattern.
adult HR
60-100
adolescent 12-15 yr old hr
60-100
school age 6-11 hr
75-118
preschool age 3-5 hr
80-120
toddler age 1-2 hr
98-140
infant 1-12 month hr
100-180
neonate birth-1month hr
100-205
tachycardia
heart rate >100
Bradycardia
heart rate<45
neonatal bradycaardia
heart rate<100
Rapid, regular, and full pulse potential problems
Exertion, fright, fever, high blood pressure, or very early stage of blood loss
Rapid, regular, and thready pulse potential problems
Reliable sign of shock, often evident in early stage of blood loss
slow pulse potential problems
Head injury, barbiturate or narcotic use, some poisons, possible cardiac problem or other medical conditions such as hypothyroidism
strong pulse
a pulse that is both full and normally strong
weak pulse
a pulse that doesn’t feel full or may be difficult to find and palpate. A weak pulse may also be quite rapid. The general term for a weak, rapid pulse is “thready.”
bounding pulse
abnormally strong pulse
irregular pulse
occurs at irregular intervals, which may indicate a cardiac disease. An irregular pulse can be regularly irregular or irregularly irregular
regular irregular pulse
is one in which the irregular beat occurs at a regular interval and has a pattern.
irregular irregular pulse
has no predictable pattern and presents as a chaotic rhythm.
pulsus paradoxus
decrease in the strength of the pulse during the inspiratory phase of the patient. This may be an indication of a severe cardiac or respiratory injury or illness, or significant blood loss.
pallor skin color potential problems
Vasoconstriction, blood loss, shock, heart attack, fright, anemia, fainting, or emotional distress
cyanosis skin color potential problems
inadequate oxygenation or perfusion (shock), inadequate respiration, or heart attack
flushing skin color potential problems
Heat exposure or carbon monoxide poisoning (late)
jaundice skin color potential problems
liver disease
hot skin temp potential problems
fever or heat exposure
cool skin temp potential problems
poor perfusion or cold exposure
cold skin temp potential problems
extreme cold exposure
wet/moist skin potential problems
Shock, heat emergency, or diabetic emergency
abnormally dry skin potential problems
Spinal injury, dehydration, heat stroke, poisoning, or hypothyroidism
dilated pupils potential problems
Cardiac arrest (pupils will also be fixed), drug use such as LSD, amphetamines, or cocaine
constricted pupils potential problems
CNS disorder, or drug use
unequal pupil potential problems
Stroke, head injury, artificial eye (occasionally a normal finding), eye drops, or eye trauma
nonreactive pupil potential problems
Cardiac arrest, brain injury, eye drops, or drug intoxication or overdose
average adult bp
120/80
adult prehypertension
121-139/81-89
adult systolic hypertension
bp > 140
adult diastolic hypertension
bp>90
child age 1-10 bp
lower limit of a normal systolic blood pressure would be calculated by taking 70 plus 2 x child age/diastolic blood pressure is normally two-thirds the systolic blood pressure
pulse pressure
difference between the systolic blood pressure and the diastolic blood pressure ex 120-80= 40
narrow pulse pressure
pulse pressure is less than 25 percent of the systolic blood pressure
widened pulse pressure
pulse pressure is greater than 50 percent of the systolic blood pressure
orthostatic vital signs/tilt test
This is done by placing the patient in a supine position and measuring his blood pressure and heart rate, then standing the patient up and, after 2 minutes, reassessing the blood pressure and heart rate.
positive orthostatic vital signs
If, while the patient is standing, the heart rate increases by greater than 10–20 bpm and the systolic blood pressure decreases by 10–20 mmHg as compared to the readings taken while the patient was supine, it is a positive orthostatic test, which typically indicates a significant loss of blood or fluid volume
if patient is stable how often do you take vitals
15 min if possible
if patient is unstable how often do you take vitals
every 5 minutes
