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
