Vital Signs Flashcards
afebrile
The state of normal body temperature.
Normal oral temp
Oral: 97.6-99.6
Factors Affecting Body Temperature
Age, Environment, Time of Day
Factors Affecting Pulse Rate
Age: generally decreases
ANS: Sympathetic increases, Parasympathetic decreases
Medications
Tachycardia
Pulse >100bpm
Bradycardia
Pulse <60bpm
Normal Pulse Rate
60-100 bpm
Regularly Irregular Pulse
Irregular but consistent pulse rhythm.
Irregularly Irregular Pulse
Irregular and inconsistent rhythm
Ex: atrial fibrillation
Factors Affecting respiration
Age - Child to adult decreases, increases with aging Medications Stress Exercise Altitude (faster) Gender
Tachypnea
> 20 breaths per minute
Bradypnea
<12 breaths per minute
Apnea
Absence of breathing
Eupenea
Normal breathing rhythm
Biot Respirations
Regular deep respirations interspersed with periods of apnea caused by damage to the pons due to stroke, trauma, or uncal herniation
Cheyne-Stoke Respirations
A period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all.
Kussmaul Respirations
A deep, rapid breathing pattern associated with metabolic acidosis.
Stridor
Harsh inspiratory that could be compared to crowing.
Think children with croup or aspiration of a foreign object.
Wheezing
A continuous high-pitched musical sound
Rhonchi
A continuous low-pitched snoring sound
Crackles
discontinuous popping or clicking sounds heard in cases of pneumonia or pulmonary edema.
Sighs
breaths of deep inspiration and prolonged expiration.
Occasional can be normal
Systolic Blood Pressure
Pressure in veins during heart ejection
Diastolic Blood Pressure
Pressure in arteries when heart is filling
Pulse Pressure
Difference between systolic and diastolic pressures
Orthostatic Hypotension
Drop of 20 mmHg systolic or 10 mmHg diastolic AND increase of heart rate by 10 bpm when moving from lying to sitting or sitting to standing
Orthostatic Hypotension Causes
Hypovolemia or failure of autonomic nervous system
Normal BP
systolic <120, diastolic < 80
Hypertension
> = 140/90 (either)
Normal O2 saturation
> 90% and note whether pt is on O2)
Normal axillary temp
Axillary: 96.6-98.6
Normal rectal temp
Rectal: 98.6-100.6
Normal respiratory rate
12-20 respirations per minute
When do we take vital signs
- at presentation
- set frequency (provider orders)
- change in status
Factors affecting temperature
age, diurnal variations, exercise, hormones, stress, environment
List temperature sites from most to least accurate
rectal oral axillary tympanic temporal
tympanic temp
ear
Where is oral thermometer placed
sublingual posterior pocket (needs to be supported)
temporal temp
forehead
fever s/s
> 100.4 photosensitivity/glassy eyes increased HR RR thirst drowsiness, malaise, weakness decreased appetite warm skin, sweating shivering, cold, clammy skin
what to monitor with fever
vital signs
i/o
WBC values
comfort interventions for fever
blankets, fluids, nutrition, oral hygiene, tepid sponge bath, dry clothes
hypothermia
<95
clinical signs shared by fever and hypothermia
shivering, drowsiness
temperature considerations
is this route appropriate (medically and developmentally)
are there environmental considerations
is there user error/equipment issues
with age, do pulses go up or down?
down (slower)
You should not take bilateral pulse in which site?
carotid
pulse assessment components
rate 60-100
rhythm regular/irregular
bilateral equality same on both sides
quality 0-4+ (2+ normal)
quality measures of pulse
absent 0 weak, easily obliterated 1+ Normal 2+ Increased full volume 3+ Bounding 4+
When you find an irregular pulse, what immediate assessment steps do you take?
apical pulse, full minute assessment
Assessment technique pulse
2 fingertips (index and middle)
light pressure
count for 60 seconds (or 30x2)
Assess same site other side for comparison
How long to assess an apical pulse
60 seconds
location of apical pulse
5th intercostal space, mid clavicular line
when to use apical pulse
weak radial, irregular, brady/tachy, cardiac meds, pulse deficit, infants/children
pulse deficit
variation between apical and distal pulse
movement of gases in and out of lungs
ventilation
intake of air into lungs
inspiration (inhalation)
movement of gases from lungs to atmosphere
expiration (exhalation)
movement of O2 and CO2 between alveoli and red blood cells
diffusion
movement of RBCs in pulmonary capillaries
perfusion
type of normal breathing
diaphragmatic and costal/thoracic (up and down movement of diaphragm or ribs)
normal stimulus to breathe
CO2 ↑
apnea
absence of respirations for at least 10-15 seconds
respiration assessment elements
rate, rhythm, depth, quality (automatic, quiet, effortless vs. dyspnea)
dyspnea
difficulty breathing
systole
ventricular contraction
diastole
ventricular rest
determinants of blood pressure
cardiac output
peripheral vascular resistance
blood volume
vessel elasticity
inverse or direct relationship between blood pressure and heart rate in hypovolemia
inverse
symptoms of shock
cool, clammy skin
fast thready pulse
↓ urine output
confusion
preparation for blood pressure reading
- no caffeine or nicotine for 30”
- sit at rest for 5”
- select correct cuff size
- sitting, both feet on floor
- no talking
- place cuff correctly and snugly
- support client arm at heart level
misc causes of erroneous BP readings
unidentified auscultatory gap
failure to use same arm consistently
white coat syndrome
cuff causes of erroneous BP readings
cuff size
cuff deflation rate
insufficient inflation
client prep causes of erroneous BP readings
arm not supported or at heart level
client has just eaten, smoked, exercised, emotional upset
sudden ↓ in BP when client moves from lying to sitting or sitting to standing
orthostatic (or postural) hypotension
- drop of 20 in systolic or 10 in diastolic
- increase of 10 bp with postural change
wait 2 minutes in between before BP and HR measures
how to palpate blood pressure
- without auscultation
- inflate cuff and record pressure when first pulsation is felt (systolic).
- Record as xx mmHg palpated
- can’t assess diastolic
