Chapter 4: Vitals Flashcards
Vital signs used for…
- determine general status of pt
- establish baseline
- monitor response to therapy
- observe for trends
- determine the need for ether evaluation or intervention
Four classic VS
- Temperature
- Pulse
- Respiratory rate
- Blood pressure
Additional observations aside from vitals
Height and weight LOC Level and type of pain General appearance Pulse oximetry
Frequency of VS measurements
- depends on its conditions
- baseline measurements
On admission
At beginning of each shift
Before and after procedure
Anytime patients conditions change
Based on protocol or physician orders
As often as necessary for patient safety
Trends in vs
- isolates measurements provides limited information
- normal vs for patient depends on age, presence of chronic disease, treatment protocols
Trend = baseline + measurements over time (multiple-day graph)
Cardiopulmonary distress suggested by..
- laboured, rapid, irregular, shallow breathing
- coughing, choking, and wheezing
- chest pain, and or cyanosis
comparing VS information
- Shows change in patient’s condition
- Comparing changes in VS, signs, and symptoms
- Establishing differential diagnosis
- Determining if patient is improving or deteriorating
key to expert assessment
Shows change in patient’s condition
Comparing changes in VS, signs, and symptoms
Establishing differential diagnosis
Determining if patient is improving or deteriorating
signs of hypoxemia (5)
- general clinical presentation
- impaired coordination or cooperation
- cool extremities (can be felt while taking the heart rate and blood pressure)
- diaphoresis (profuce sweating) - sensorium (LOC) –> decreased mental function, imparied judgement, confusion, loss of conciousness
- decreased pain perception - respiration –> increased rate and depth of breathing, difficulty breathing, use of accessory muscles
- HR –> tachycardia, arrhythmia (irregular heart rate, especially during sleep)
- BP –> increased BP initially
general clinical impression
Gives clues to levels of distress and severity of illness
Information about personality, hygiene, culture, and reaction to illness
May dictate order of care, physical examination
cardiopulmonary distress suggested by:
- Labored, rapid, irregular, or shallow breathing
- Coughing, choking, and/or wheezing
- Chest pain and/or cyanosis
anxiety may be suggested by:
- Restlessness
- Fidgeting
- Tense look
- Difficulty communicating
pain may be suggested by:
Drawn features
Moaning and guarding
Shallow breathing and/or refusal to take deep breath
head to to inspection (5)
Hearing Smelling Seeing Touching Perception
pain
- fifth vital sign
- Pain intensity scales:
Ranking of 1 to 10
Quantifies a subjective measure - Corresponding facial expressions and verbal description to assess pain level
- Find associated symptoms as well as alleviating and aggravating factors
LOC
Pain intensity scales
Ranking of 1 to 10
Quantifies a subjective measure
Corresponding facial expressions and verbal description to assess pain level
Find associated symptoms as well as alleviating and aggravating factors
normal VS for a patient depend on (3)
age, presence of chronic disease, treatment protocols
glasgow coma scale
best eye response
best verbal response
best motor response
temperature
Normal:
37 C ( 36.5 -37.5) Depending on location
Daily variations (1°-2° F)
Lowest in morning
Highest late afternoon
Normal increase during exercise, ovulation, and first months of pregnancy
Balance of heat production and loss
Dissipation through sweating, peripheral vasodilation, and hyperventilation
oral, axillary, rectal, ear temperatures
oral - 36.5 - 37.5
axillary - 35.9 - 36.9
rectal - 37.1 - 38.1
ear - expected to be very close to rectal if measured correctly
fever
Elevation of temperature (febrile)
- From normal activities (exercise) = hyperthermia
- From disease (infection) = fever
Body temperature of > 39° C usually indicates infection
Not all infections result in fever
Immuno-compromised patients may not be able to generate fever despite infection
O2 and CO2 in fever
Increases O2 consumption and CO2 production
O2 consumption and CO2 production increase 10% for each 1C elevation in body temperature
Patients with limited respiratory function may develop respiratory failure in response to fever
hypothermia
Body temperature below normal - Head injury - Cold exposure Compensatory mechanisms - Shivering - Peripheral vasoconstriction Reduces O2 consumption and CO2 production Slow and shallow breathing
measuring body temperature
Sites: Mouth, ear, axilla, rectum
Rectal temperature: Body core temperature
Rectal in comatose patients
Axillary: Safe and accurate in infants and small children
pulse
Evaluate:
- Rate, rhythm, and strength
Normal rate: 60-100 beats/min for adults
The younger the patient, the faster the rate
tachycardia
> 100 beats / min
- anxiety, hypoxemia, exercise, fever, anemia
bradycardia
- diseased heart, athletes, medication side effects
arrhythmia
irregular rhythm
newborn, 1 yr, preschool, 10 years, adult, athlete pulses
new born - 90-170 1 yr - 80 - 160 preschool - 80 - 120 10 years - 70 - 110 adult - 60-100 athlete - 40 - 60
newborn, 1 yr, preschool, 10 years, adult, athlete RRs
new born - 35 to 45-70 w/ excitement 1 yr - 25-35 preschool - 20-25 10 years - 15-20 adult - 12-20 athlete - 12-20
Measurement of Pulse Rate
Right radial artery = Most common site Index and middle fingers Avoid thumb: examiner’s own pulsation Central pulses if hypotension present Carotid, femoral Pulse counted for a full minute If regular, counted for 15 sec × 4 or 30 sec × 2
Pulse Rate, Pattern and Grade
Regular, regularly irregular, irregularly irregular
Irregularly irregular is unfavorable finding
Bigeminy
Rhythm coupled in pairs
Trigeminy
Rhythm grouped in three beats
pulse deficit
Auscultated – Palpated
- pulse rate is not synchronized with heart rate
volume of pulse described as…
bounding, full, normal, weak, thready, absent
pulses paradox
Strength decreases with inspiration
pulsus alterans
strong and weak pulses
- left ventricular systolic impairment
pulse grade scale
4+ bounding, not obliterated by pressure
3+ increased, not easily obliterated
2+ brisk, expected (normal)
1+ diminished (thready), weaker than expected, easily obliterated
0 absent, unable to palpate
RR and pattern sensitive marker of…
acute respiratory distress
tachypnea
rate above normal
- atelectasis, hypoxxemia, hypercapnia
- anxiety, pain, exertion, metabolic acidosis
bradypnea
rate below normal
- uncommon
- head injury, hypothermia, side effect of medications (narcotics), drug overdose
apnea
absence of spontaneous ventilation
eupnea
normal rate and depth of breathing
hypopnea
decreased depth of breathing
hyperpnea
increased depth of breathing with or without increased respiratory rate
sighing respiration
normal rate and depth of breathing with periodic deep and audible breaths
intermittent breathing
irregular breathing with periods of apnea
cheyne-stokes
Cheyne–Stokesrespiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea.Crescendo and decrescendo.
biots
iots: Biot’srespiration is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.
kussmauls
Kussmaul breathingis a deep and laboredbreathingpattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.
measurement of RR
Watching abdomen or chest wall movement
Can be done as you assess radial pulse
Avoid telling the patient you are counting RR
Must assess for a minimum of 60 sec. to determine regularity or pattern
When regular = Count for 30 sec × 2
Assess depth and pattern
BP
Force exerted against arterial walls
Systolic: peak force during ventricular contraction
Diastolic: force during ventricular relaxation
Normal: 120/80 mm Hg
Pulse pressure = P systolic – P diastolic
Normal: 35-40 mm Hg
<30 mm Hg: poor peripheral perfusion
systolic
peak force during ventricular contraction
diastolic
force during ventricular relaxation
normal BP
120/80
hypertension
Hypertension
BP of >140/90 mm Hg
Risk factor for heart, vascular, renal disease
Major modifiable risk factor for stroke, CAD, CHF, peripheral vascular disease
Cause in most cases is unknown
hypotension
Hypotension
BP of <90/60 mm Hg
If symptomatic: dizziness, fainting
Causes: left ventricular failure, blood loss, peripheral vasodilation
Orthostatic hypotension: resulting from changes in posture
optimal BP
< 120 / < 80
Normal BP
<130 / < 85
stage 1 - mild
140-159 / 90-99
stage 2 - moderate
160-179 / 100-109
stage 3 - severe
> = 180 / >= 110
high normal
130-139 / 85-89
length of bladder should cover…
80% distance around arm in an adult
100% distance around arm in a child
too wide bladder
underestimate
too narrow/short
overestimate
korotkoff sounds
Korotkoff sounds: blood flow in arteries resumes
Five phases (I–V)
First sound (phase I) = systolic pressure
Disappearance of sounds (phase V) = diastolic pressure
If discrepancy between muffling (phase IV) and disappearance (phase V): record both pressures
korotkoff sounds vitals (5)
phase 1 - first appearance of clear, repetitive tapping sounds; coincides approximate with the reappearance of the palpable - systolic p pulse
phase 2 - sounds are softer and longer, with the quality of an intermittent murmur - auscalotroy gap may appear
phase 3 - sounds become crisper and louder
phase 4 - sounds are muffled, less distinct, and softer - diastolic p in pregnant women, pt with high CO or peripheral vasoldilation, and some small children
phase 5 - sounds disappear - diastolic p in adults + children
auscultory gap
Occasionally, the Korotkoff sounds disappear during
Phases II or III and reappear as the cuff pressure decreases.
The period of silence is called the auscultatory gap and is
most common in older patients with high blood pressure.
The auscultatory gap can generally be eliminated by elevat
ing
the arm overhead for 30 seconds before inflating the
cuff then bringing the arm to the usual position to con
tinue
measurement.
erroneously high BP
- too narrow cuff
cuff applied to tightly or too loosely - excessive pressure in cuff during measurement
- incomplete deflation of cuff b/w meausuremts
erroneously low BP
too wide a cuff
effects of the RR cycle on BP
systolic pressure decreases 2-4 mmHg
pulsus paradoxus
Pulsus paradoxus: if BP drops >10 mm Hg during inspiration
- Asthma, cardiac tamponade are two common causes
Pulsus paradoxus in asthma signifies a more severe case
skin assessment
- Moisture ( Diaphoresis)
- Temperature
- Texture ( rough or smooth)
- Mobility ( how easily it lifts) and Turgor
- ( Speed it returns to place)
- Lesions
- Edema
capillary refill
Press on the fingernail and watch for refill
Less than 3 seconds is normal
Skin should be warm , dry and pink
Digital Clubbing
digital clubbing
Nail clubbing, also known as digital clubbing or clubbing, is a deformity of the finger or toe nails associated with a number of diseases, mostly of the heart and lungs.
stages of clubbing
- no visible clubbing
- mild clubbing
- moderate clubbing (apparent at glance)
- gross clubbing (resembling a drumstick)
skin color
Depends on 4 pigments , melanin, carotene, oxyhemoglobin and reduced hemoglobin Indication of Perfusion and Oxygenation Cyanosis results from the presence of 50gm/L of reduced Hgb Polycythemia and anemia?
peripheral edema
Press firmly but gently for at least 5 seconds. Over the dorsum of the foot Medial Malleolus Over the shins Four point scoring from slight to marked
