Chapter 11: Vital Signs, Monitoring Devices, and History Taking Flashcards
vital signs
“signs of life,” outward signs that give clues to what is happening in the body
- respiration
- pulse
- skin
- pupils
- blood pressure
- pulse oximetry
baseline vital signs
the first set of measurements you take, subsequent measurements can be compared to them
sphygmomanometer
blood pressure cuff
respiratory rate
assessed by observing the patient’s chest rise and fall, determined by counting breaths in 30 seconds and multiplying by 2
respiratory quality
tidal volume, how well air is moving in and out…
normal quality (respiratory)
an adequate tidal volume
abnormal quality (respiratory)
inadequate tidal volume
stridor
harsh, high pitch sound
respiratory rhythm
irregularity or regularity of respirations
cheyne strokes
the respiratory rate and tidal volume gradually increase and gradually decrease followed by a period of apnea up to 10 seconds, repeats
biot
like Cheyne strokes but tidal volume does not change
apneustic
prolonged periods of inhalation
ataxic
an irregularly irregular pattern of rate and tidal volume
agonal
long periods of apnea with a gasping breath in between
kussmaul
a rapid respiratory rate with a deep and labored tidal volume
central neurogenic hyperventilation
a sustained deep and rapid respiratory rate of at least 25 breaths per minute but with a regular pattern
popliteal artery
in the crease behind the knee
tachycardia
greater than 100 bpm in adults
bradycardia
less than 60 bpm in adults
to take pulse rate
1) position patient (sit or lay down)
2) use tips of two fingers, feel artery gently, avoid using thumb
3) count number of beats in 30 seconds, multiply by 2
strong pulse
a pulse that is both full and normally strong
bounding pulse
abnormally strong
weak pulse
does not feel full, may be difficult to find and palpate, may also be rapid
thready pulse
weak and rapid pulse
regular pulse
normal pulse that occurs at regular intervals with a smooth rhythm
irregular pulse
occurs at irregular intervals. regularly irregular = the irregular beat occurs at a regular interval, has a pattern. irregularly regular = has no predictable pattern, chaotic rhythm
pulse paradoxus
a decrease of pulse strength during the inspiratory phase, indication of severe cardiac or respiratory injury/illness or significant blood loss
conjunctiva
mucous membranes that line the eyelid
paleness/pallor
sign of extreme vasoconstriction, blood loss, both, shock…
blue gray color / cyanosis
inadequate oxygenation, poor perfusion, often appears in fingertips and around mouth
red color / flushing
sign of heat exposure, peripheral vasodilation, late finding in carbon monoxide poisoning
yellow color / jaundice
liver diseas
mottling
discoloration similar to cyanosis, occurs as a blotchy pattern
hot skin
fever or exposure to heat
cool skin
inadequate circulation, shock, cold exposure
cold skin
extreme exposure to cold
clammy
cool and moist skin
diaphoresis
profuse sweating
capillary refill time
the time it takes compressed capillaries to fill up again with blood
dilated pupils
use of certain drugs (LSD, amphetamines, atropine, cocaine)
constricted pupils
central nervous system disorder, use of narcotics, glaucoma medications, brightly lit environment
consensual reflex
pupils have the same reaction to light
fixed pupil
one that does not react
blood pressure
pressure that is exerted on the walls of the arteries by the blood flowing through them
prehypertension (adult)
121-139 mmHg
systolic hypertension (adult)
140 mmHg or above
pulse pressure
difference in systolic and diastolic blood pressure
auscultation
listening
palpation
feeling
orthostatic vital signs
place patient in supine position and measure blood pressure and heart rate, stand patient up and reassess after 2 minute, aka tilt test
