Vital Signs Flashcards by Chris Letts

afebrile

The state of normal body temperature.

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Normal oral temp

Oral: 97.6-99.6

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Factors Affecting Body Temperature

Age, Environment, Time of Day

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Factors Affecting Pulse Rate

Age: generally decreases
ANS: Sympathetic increases, Parasympathetic decreases

Medications

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Tachycardia

Pulse >100bpm

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Bradycardia

Pulse <60bpm

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Normal Pulse Rate

60-100 bpm

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Regularly Irregular Pulse

Irregular but consistent pulse rhythm.

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Irregularly Irregular Pulse

Irregular and inconsistent rhythm

Ex: atrial fibrillation

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Factors Affecting respiration

Age - Child to adult decreases, increases with aging
Medications
Stress
Exercise
Altitude (faster)
Gender

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Tachypnea

> 20 breaths per minute

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Bradypnea

<12 breaths per minute

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Apnea

Absence of breathing

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Eupenea

Normal breathing rhythm

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Biot Respirations

Regular deep respirations interspersed with periods of apnea caused by damage to the pons due to stroke, trauma, or uncal herniation

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Cheyne-Stoke Respirations

A period of fast, shallow breathing followed by slow, heavier breathing and moments without any breath at all.

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Kussmaul Respirations

A deep, rapid breathing pattern associated with metabolic acidosis.

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Stridor

Harsh inspiratory that could be compared to crowing.

Think children with croup or aspiration of a foreign object.

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Wheezing

A continuous high-pitched musical sound

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Rhonchi

A continuous low-pitched snoring sound

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Crackles

discontinuous popping or clicking sounds heard in cases of pneumonia or pulmonary edema.

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Sighs

breaths of deep inspiration and prolonged expiration.

Occasional can be normal

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Systolic Blood Pressure

Pressure in veins during heart ejection

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Diastolic Blood Pressure

Pressure in arteries when heart is filling

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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