Chapter 13 Vital Signs And Monitoring Devices Flashcards
Whats the Most important part of patient assessment
Chief Complaint
Vital signs
outward signs of what is going on inside the body, including:
- respiration
- pulse
- skin color
- temperature
- and condition (Capillary refill in infants and children),
- pupils
- and Blood Pressure
- SpO2
Tachycardia
Fast/rapid Heart rate any pulse rate above 100 beats per minute
Bradycardia
Slow/below normal Heart rate any pulse rate below 60 beats per minute
pulse rate
the number of pulse beats per minute
pulse
the rhythmic beats felt as the heart pumps through the arteries
what is a high pulse rate and at what trending HR would you consider something to be seriously wrong?
if HR is 150 or trending at 120 or below 50 something may be seriously wrong
-high priority-
Pulse Quality
The Rhythm (regular or irregular) and Force (Strong or weak-thready) of the pulse
Ventricular assist device
An implanted device in the chest that helps the heart move blood through the circulatory system
- propels blood continuously and not in waves
- Patient will have NO PULSE
Serious Respiratory Rates are?
Above 24 breaths/min
or Below 10 breaths/min
Respiratory Quality
Normal or Abnormal character of breathing
- Normal
- Shallow
- observed by slight movement in chest or abdomen - Labored
- increase in work of breathing (in and out), use of accessory muscles (nasal flaring, retractions, - Noisy
- obstructed breathing (stridor, gurgling, weeping, crowing, snoring)
Respiratory Rhythm
The regular or irregular spacing of breaths
Cyanotic (blue-grey) Color signify’s
Lack of O2 from inadequate breathing or heart function
Pale Color signify’s
Constricted blood vessels resulting in:
- blood loss
- shock
- hypotension
- emotional distress
Jaundiced (yellow) Color signify’s
abnormalities of the liver
Mottled (blotchy) Color signify’s
Occasionally in patients with shock
Flushed (red) Color signify’s
exposure to heat, emotional excitement
Pupil abnormalities suggest
- drug use
- head injury
- eye injury
Systolic Blood Pressure
pressure created when the heart contracts and forces blood into the arteries
Diastolic Blood Pressure
pressure remaining in the arteries when the left ventricle of the heart is relaxed and filling
mmHg
Millimeters of Mercury
sphygmomanometer
The cuff and gauge used to measure blood pressure
Hypertension
High blood pressure
When an Adult has a:
- SBP of 140 or greater
- DBP of 90 or greater
Hypotension
Low blood pressure
SBP of 90 or less
Palpation
Listening
Auscultation
Feeling
A Healthy temperature is?
equal or greater than 96F or less than 100F
Pulse Oximeter
an electronic device for determining the amount of oxygen carried in the blood, know as the oxygen saturation (SpO2)
Oxygen Saturation (SpO2)
the ratio of the amount of oxygen present in the blood to the amount that could be carried, expressed as a percentage.
SpO2 Readings
- 96-100 is normal
- 91-95 indicates mild hypoxia
- 86-90 indicate moderate hypoxia
- 85 or less indicates severe hypoxia
types of situations a pulse oximeter may be inaccurate
- patient exposed to carbon monoxide (CO)
- patient in shock or hypothermic
- excessive moving
- anemia, hypovolemia, and certain kinds of poisoning
Normal Glucose Readings
- at least 60-80 mg/dL
- no more then 120-140 mg/dL
