Chapter 8: Assessing General Health Status And Vital Signs Flashcards
What is the average oral temperature range for an adult?
96.6-99.5°F (oral)
What is the average pulse range for an adult?
60-100 beats per minute
What is the average blood pressure for an adult?
120/80 mmHg
What is the average oxygen saturation range for an adult?
95-100%
What is the average respiratory rate for an adult?
12-20 breaths per minute
What is the average pain level on a scale from 0-10?
0
What factors can alter vital signs?
Pain/Illness, stress, talking, chewing gum, anxiety, and movements
What equipment should you gather for a general health survey?
Thermometer, sphygmomanometer (blood pressure cuff), stethoscope, watch (second hand), pulse oximeter
What equipment should you gather for a general health survey?
Thermometer, sphygmomanometer (blood pressure cuff), stethoscope, watch (second hand), pulse oximeter
What should you do for preparation before assessing a patient?
Verify HCP order,
review patient history, previous vital signs,
ensure clean equipment, confirm patient identification (name, DOB, SSN, address, phone number),
hand hygiene,
ensure patient privacy,
and explain the procedure.
What are the methods for taking a temperature?
Oral, tympanic, temporal, axillary, and rectum
What is an important age consideration when taking a temperature in older adults?
Older adults have a lower core temperature (35-36.4°C or 95-97.5°F)
What is an important age consideration when taking a temperature in older adults?
Older adults have a lower core temperature (35-36.4°C or 95-97.5°F)
a shockwave produced by the forceful contraction of the
A pulse
How do you assess the radial pulse?
check rhythm and amplitude and Count the number of beats per minute
How do you assess pulse rhythm?
Assess for equal time between beats; if irregular, assess the apical pulse (auscultation).
How do you assess pulse amplitude?
Check for largeness and fullness of pulse, assess bilaterally for equality.
What are the different amplitudes of the pulse?
0 = not palpable
1 = weak, thread-like
2= expected, occulde with moderate pressure
3= Strong Difficult to obliterate
4= Very bounding (Finger will bounce) Can’t occulde
What does a 2+ pulse indicate?
Expected, occludes with moderate pressure.
What does a 3+ pulse indicate?
Strong, difficult to obliterate.
What does a 4+ pulse indicate?
Very bounding, the finger will bounce and can’t occlude.
What are factors to consider when assessing a patient’s pulse?
Recent activities, stress, activity, stimulants.
What is the respiratory rate range for an adult?
12-20 breaths per minute.
How should you begin counting respirations?
Begin counting at inhalation, count every subsequent inhalation, assess for 30 seconds x2.
How do you assess respiratory rhythm?
Observe pattern, regularity of breathing; if irregular, assess for a full 60 seconds.
How do you assess respiratory depth?
Observe excursion (movement of the chest wall), observe for equal bilateral expansion; expected is even, unlabored.
What are abnormal respiratory findings?
Shallow or extremely deep respirations, labored or gasping respirations.
What does oxygen saturation measure?
The percentage of oxygen that is bound to hemoglobin in the blood.
What is the average oxygen saturation range?
95-100%.
The pressure exerted on the walls of the arteries.
Blood pressure
Pressure on arteries during heart contraction
Systolic Blood Pressure(SBP)
Normal Systolic Range
120 mmHg.
Pressure on arteries during heart relaxation
Diastolic (DBP)
Normal Diastolic Range
80 mmHg
Heart contraction.
Systole
Heart relaxation.
Diastole
Amount of Blood pumped by the heart in one minute, measured in mi/min.
Cardiac Output (CO)
Amount of Blood pumped by the heart in one minute, measured in mi/min.
Cardiac Output (CO)
Amount of Blood pumped from the left ventricle during systole. Per beat.
Stroke Volume (SV)
Stretching of cardiac myocytes before contraction. Increased preload increases diastole.
Preload
Average arterial pressure during one cardiac cycle.
Mean Arterial Pressure (MAP)
Average arterial pressure during one cardiac cycle.
Mean Arterial Pressure (MAP)
2/3 DBP + 1/3 SBP
Calculation for Mean
Arterial Pressure.
CO - SV x HR
Calculation for Cardiac Output.
CO - SV x HR
Calculation for Cardiac Output.
Factors Affecting BP Definition:
BP changes require changes in CO or resistance.
Resistance in the circulatory system used to create BP.
Systemic Vascular Resistance (SVR) & Peripheral Vascular
Resistance (PVR) Definition:
Increased resistance =
hypertension
Decreased Heartrate
Dysrhythmia (bradycardia).
Decreased PVR/SVR Definition:
Vasodilation.
Increased heartrate
Tachycardia
Signs of Decreased PVR/SVR(Resistance)
-Lying Down
-Sepsis
-TBI (head injury)
-Systemic inflammatory response syndrome (SIRS)
POTS Definition:
Postural orthostatic tachycardia syndrome POTS)
What determines blood pressure
Blood pressure is determined by
cardiac output and arterial resistance.
BP = CO x PVR/SVR
What increases blood pressure
Anything increasing cardiac output (CO) and/or resistance
Prevalence of Hypertension
Over 100 million Americans have hypertension.
Consequences for Prolonged Hypertension
-Leads to vascular damage
-Left ventricular hypertrophy due to increased myocardial workload
Normal Blood Pressure Range
120/80 mmHg.
Pre-Hypertension Blood Pressure
SBP 120-129 mmHg & DBP < 80 mmHg
Hypertension Stage 1 Blood Pressure
SBP 130-139 mmHg or DBP 80-89 mmHg
Hypertension Stage 2 Blood Pressure
SBP ≥ 140 mmHg or DBP ≥ 90 mmHg
- Blood flow sounds auscultated while taking BP measurement
Korotkoff Sounds
Korotkoff Sounds Phase 1
first sound, repetitive
• Faint tapping, intensifies
Korotkoff Sounds Phase 2
-swishing, murmur
-Can be intermittent (HTN)
-If miss, underestimate SBP
Korotkoff Sounds Phase 3
-distinct, crisp sound
-Louder blood flow as reduce pressure
Korotkoff Sounds Phase 4
muffled blowing
softer
What are older adults core temperatures
(35-36.4°C or 95-97.5°F)
