Class 8 - Vital Signs and Assessment Flashcards
afebrile
the end of a fever
antecubital fossa
elbow pit
apical pulse
one of the 8 common arterial pulse sites. it can be found in the left center of your chest, just below the nipple
axillary
armpit
baseline
info sound at the beginning of a study or other initial known value which is used for comparison with later data
bradycardia
slow HR
bradypnea
slow breathing
diastolic
“bottom number” pressure in the arteries when the heart rests between beats
tachypnea
shallow breathing, take more breaths than normal in a given moment
laboured breathing
abnormal respiration: increased effort to breathe, including the use of accessory muscles of respiration, grunting, or nasal flaring
cheyne-stokes breathing
respiratory congestion, variety of breathing. respiratory rate and depth are irregular, characterized by alternating periods of apnea and hyperventilation. respiratory cycle begins with slow, shallow breaths that gradually increase to abnormal rate and depth. this pattern reverses, breathing slows and becomes shallow, climaxing in apnea before respiration resumes
febrile
a fever
hypertension
high blood pressure, long term condition
hypotension
low blood pressur
pulse deficit
inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site
systolic
“first number”
peak of maximum pressure when ejection occurs at contraction
tachycardia
abnormally fast HR
tachypnea
fast breathing
turgor
degree of elasticity of skin
peripheral pulse
a pulse recorded in the arteries (radial or pedal) in the distal portion of the limbs
holistic/comprehensive assessment
should consider all of the patients needs in order to identify actual and potential problems
quick priority assessment
carried out to gain an abbreviated overall assessment
focused or selective assessment
uses knowledge of the patients history and presenting problem
sources of info
primary and secondary
assessment data
objective and subjective
vital signs
important measurements of an individuals condition
- includes temperature, pulse respirations and BP
- accuracy in measurement and reporting vital signs is critical.
to analyze vital signs you must use knowledge of the clients
- Usual values (baseline)
- Medical History
- Current Therapies
- Prescribed Medications
when should vital signs be assessed?
- AM and when admitted (baseline)
- PRN - condition- fall- distress
- surgery
- as ordered
temperature assessment
- a measurement of body heat
- the balance between heat produced by the body and what you are losing
signs of pyrexia
- chills
- shivering
- flushing
- thirst
- dry skin
- decreased output
- warm skin
- diaphoresis
- tachycardia
- tachypnea
- headache
- disorientation
- irritability
- photosensitivity (sensitive to light)
factors that affect temperature
- age
- exercise
- hormone level
- circadian rhythm (body over 24 hours)
- stress
- environment
tympanic route
- easily accessible site, leaves disruptive
- rapid results
- unaffected by oral intake or smoking
- requires proper positioning
- measurement is more variable
- taken in the ear
precluding oral route
- unconscious patient/intubated/jaw wired shut (oral surgery or injury)
- disoriented, shivering, teeth chattering, at risk for seizure, coughing
- infants/caution in young children
- patients with hyperactive gag reflex
- mouth breather/ after smoking
rectal temperature may have to be taken if client….
- is unconscious or semiconscious
- is not able to breath through the nose
- is confused
- has facial paralysis
- has a sore mouth
- is prone to seizures
axilla temperatures
are taken under the arm
- least accurate of the three methods
- average axilla temp: 36.5 degrees
- must hold in place for several minutes
pulse assessment
brachial, radial, apical temporal, popliteal, femoral, carotid, tibial, dorsalis pedis
find landmark for vital signs
- the beat of the heart as felt through a peripheral artery
- includes the number of heart beats as well as strength and rhythm
taking a pulse…
- usually assess radial pulse (inside the wrist at the base of thumb)
- most accurate if measured for 1 minute
- assess pulse volume and strength for each beat
- note any abnormalities in rate and rhythm
respirations
- inhaling sends oxygen to all body cells and exhaling rids the body of CO2
- the rate of respirations increases or decreases according to the oxygen needs of the body
normal respiration
12-20
low respiration
less than 10
high respiration
over 24
bradypnea
low rate of breathing
tachypnea
high rate of breathing
apnea
no breaths
eupnea
good breathing
dyspnea
bad breathing
orthopnea
shortness of breathing when laying flat
assessing respirations
- observe the rate and rhythm over a minute
- note the depth and character
- normally respirations will increase if patient is being observed
oxygen saturation (sp02)
- assessed with a pulse oximeter
- estimates arterial blood oxygen saturation
- if number seems weird, check equipment
normal range of oxygen saturation
95%-100%
life threatening range of oxygen saturation
less than 70%
surgical range of oxygen saturation
92%
medical range of oxygen saturation
90%
COPD range of oxygen saturation
88%
blood pressure
the force exerted on the walls of the arteries by the pulsing blood under pressure from the heart
optimal blood pressure
< 120/80
normal blood pressure
<130/85
high normal blood pressure
130-139 systolic, 85-89 diastolic
grade 1 hypertension blood pressure
140-159 systolic, 90-99 diastolic
grade 2 hypertension blood pressure
160-179 systolic, 100-109 diastolic
grade 3 hypertension blood pressure
180+ systolic, 110+ diastolic
pulse pressure
difference between systolic and diastolic, the force that the heart generates
orhtostatic
low BP when you stand up from sitting or laying down
measure BP
2 fingers
- give clients a few minutes to rest before checking
- be sure you’re using the appropriate size cuff
- patient is sitting or lying position with forearm at heart level, palm up
- legs uncrossed
2 step BP
- palpate brachial pulse
- position centre of cuff about 2.5 cm above pulse
- palpate while pumping to 30mm above when pulse disappears
- deflate slowly, still palpating, note when pulse rappers
- deflate completely, leave cuff in place, wait 30 seconds.
- this is your estimated (palpated) systolic bp
- rapidly inflate cuff to 30 mmHg above palpated systolic pressure
- place stethoscope over brachial artery
- let pressure fall slowly and smoothly, note the point when the first clear sound is heard (sys. BP)
- note the point at which the sound becomes muffled or disappears (diastolic BP)
- listen 10-20 mmHg further, then deflate cuff quickly
