Vital Signs Flashcards
list the 6 vital signs
temperature,
pulse,
blood pressure,
respiratory rate,
oxygen saturation,
pain
you should measure vital signs when
- on admission
- per physician order (routine, Q4h)
- any change in patient’s condition
- before and after any major procedure
- during blood transfusion
- after medication or interventions that affect vital signs
normal temperature ranges
96.8 -100.4
- oral/tympanic/temporal: 97.6 - 99.6
- rectal: 98.6 - 100.4
- axilla: 96.6 - 98.6
a, o/t/t, r AOTTR
normal pulse range
60-100 beats per minute
normal respirations range
12-20 breaths per minute
normal blood pressure
less than 120/80 mmHg
Pre-hypertensive: Systolic 120-139, diastolic 80-89
Hypertensive: Systolic > 140, diastolic > 90
Hypotensive: Systolic < 90 and symptomatic!
pre-hypertensive blood pressure
systolic: 120 - 139
diastolic: 80 - 89
hypertensive blood pressure
systolic: greater than 140
diastolic: greater than 90
hypotensive blood pressure
systolic: less than 90 and symptomatic
body temperature is heat ____ and heat ______
heat produced and heat lost
list the temperature sites
oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery, urinary bladder
neural and vascular control of temperature regulation is where in the brain
anterior/posterior hypothalamus
the _____ metabolic rate produces heat as well as ____
- basal metabolic rate = metabolism creates heat when energy is being used (number of calories you burn as your body performs basic (basal) life-sustaining function)
- shivering
heat loss occurs in these 5 processes
- radiation
- conduction
- convection
- evaporation
- diaphoresis
radiation definition
transfer of heat from surface of one object to surface of another without direct contact between the two
- heat loss
conduction definition
transfer of heat from one object to another with direct contact
- heat loss
convection definition
transfer of heat away by air movement
- heat loss
evaporation definition
transfer of heat energy when a liquid is changed to a gas
- heat loss
diaphoresis definition
visible perspiration
- heat loss
6 factors affecting body temperature
- age: very young and very old have less temp control, so will need warmer environment
- hormonal level
- environment: prolonged exposure to environment is going to overwhelm hypothalamus
- exercise
- circadian rhythm: ex: in sleep, temp is lowest bc least work by circadian rhythm
- temperature alteration: ex: fever
fever aka pyrexia
- usually not harmful if below 102.2 F
- important defense mechanism
- temp should be taken several times throughout the day
- results from an alteration in the hypothalamic set point
- causes increase in metabolism and oxygen consumption
- increased heart rate and respiratory rate
body becomes overwhelmed and the hypothalamus set point changes = fever
febrile = fever, afebrile = no fever
FUO = fever of unknown origin
hyperthermia
inability to promote heat loss or reduce production
too much heat
heatstroke
- dangerous heat emergency / high mortality rate
- body temp 104 F or more
- important: dry, hot skin (no sweating)
- confusion, excess thirst, muscle cramps
- vital signs: increased HR, decreased B/P
- no sweating
heat exhaustion
diaphoresis (visible perspiration) results in excess water and electrolyte loss,
need to replace
hypothermia
- prolonged exposure to cold decreases body’s ability to produce heat
- can be accidental or intentional
- temps: less than 86 - 96.8 F
conversion between Fahrenheit and Celsius
C = (F - 32) x 5/9
F = (9/5 x C) + 32
round only to one decimal point
oral temperature
- temp easily influenced by hot or cold foods
- one of the most frequently used methods of attaining temperature
- approximately one degree lower than core temp.
- may be glass (mercury) or electronic
rectal temperature
Placement of thermometer
- adult: insert 1.5 inches
- child: insert 1 inch
- infant: insert 0.5 inch
placement of thermometer into feces may give inaccurate readings
axillary temperature
armpit
- considered safest
- must be left in place 5-10 minutes
- moisture in axillary area may reduce the temp.
tympanic temperature
ear
- one of the most rapid means of measurement
- unaffected by PO intake
- must remember to remove hearing aides before using
temporal temperature
middle of forehead, down side of face (over temporal artery), behind the ear
- most accurate compared to core temp.
- fast read: 2-3 seconds
- ease of use
- fewer errors than tympanic
entire head of scanner has to touch skin for whole time
(there is also no-touch temperature that is taken 1 inch from the temple)
(disposable thermometers are also a thing)
you have delegated vital signs to the nursing assistant. the patient just finished a hot cup of coffee. the nurse’s most appropriate advice would be to ____. 2 hours later, patient’s temp is 102.6 F temporally. what are some interventions that would be appropriate for this patient?
c. wait 30 minutes and take an oral temperature
interventions:
tepid water bath, etc.
what do you do for a fever
- obtain blood cultures if ordered
- monitor VS, assess skin color, temperature, turgor and lab work
- reduce frequency of activities to lower O2 demand
- maximize heat loss
- extra fluids
- tepid water bath: never ice cold that shocks them, want to lower their temp. gently
- oral hygiene - mouths are gross and bacteria can form
- dry bed linens - so they don’t shiver
- antipyretic meds as ordered
pulse definition
- palpable or audible bounding of blood flow noted at various points of the body
- an indirect measure of circulatory status
on the stethoscope, you use the diaphragm for ____ pitch sounds and the bell for ___ pitch sounds
diaphragm is bigger side, high pitch
bell is smaller side, low pitch
radial pulse
on thumb and pointer finger side
check for 30 seconds, multiply by 2 to get minute rate
- most common for routine vital signs
- used for patient teaching
- assesses circulation status to the hand
- should be assessed together as well as once for pulse
apical pulse
use stethoscope?
fifth intercostal space, space between ribs, midclavicular
listen for full minute
- use if radial pulse is abnormal
- use if taking meds that affect HR
- if radial inaccessible (ex: casts on both wrists)
carotid pulse
neck
- use if patient condition suddenly worsens
- use if need pulse quickly
- do not measure bilateral (both sides) at same time
dorsalis pedis
start on top of foot, if don’t feel there move to between 2nd toe and big toe, if don’t feel there move behind ankle bone
- top of foot
- assesses status of circulation to foot
- via doppler if unable to palpate (don’t feel on top of foot)
- assess bilaterally, at the same time
pulse rate, rhythm, strength
- rate: baseline = 60-100 bpm, if abnormal obtain apical pulse
- rhythm: regular, irregular, dysrhythmia
- strength: 4+ (very strong), 3+, 2+ (normal), 1+, 0
- equality: should be equal on both sides?
sample documentation for pulse
- normal: radial pulse 82, regular rate and rhythm, 2+, pedal pulses 2+, equal bilaterally
- abnormal: radial pulse tachycardic at 112, irregular rate, diminshed at 1+. apical pulse 110, irregular rate and rhythm
right pedial pulse 1+, left pedal pulse 0, audible with doppler
you notice that a teenager has an irregular radial pulse. what would be the best action for you to take?
b. assess the apical pulse rate for 1 full minute
you are assessing your patient’s pedal pulses and you are unable to palpate a pulse on the right foot. what should you do?
get the doppler and use it to find the pulse on the right foot
gas exchange definition
the process of transporting oxygen into cells, transport of carbon dioxide out of cells
inspiration = air movement in, expiration = air movement out
related terms:
- ventilation
- respiration: gasses exchange in alveoli in lungs
- ischemia: insufficient oxygen supply, not enough O2 getting into tissues, resulting in cell injury or cell death, leads to hypoxia
- hypoxia: cells (tissues and organs) don’t have enough oxygen
- hypoxemia: arterial blood doesn’t have enough oxygen in it
- respiratory acidosis: not moving CO2 out of the cells, leading to increased CO2, buildup of CO2 in cells
ventilation
movement of gases into and out of the lungs, one category of gas exchange
- some newborns born early don’t have surfactin (allows the lungs to expand) meaning they don’t ventilate well, don’t pull oxygen in
- issues with this in patients with narrowed airways
transport
ability of hemoglobin, hemoglobin takes O2 and CO2 to and from the cells, one category of gas exchange
- lack of red blood cells means issues with transport
- people with anemia, blood loss from car accidents, major surgeries have problems with this
perfusion
allows CO2 and O2 to switch places or perfuse, heart perfuses the body, gets blood into the cells,
if issue with perfusion, there is problem with heart?
one category of gas exchange
(distribution of red blood cells to and from the pulmonary capillaries)
scope of concept
optimal gas exchange is very important
impaired gas exchange is an issue
absence of gas exchange is death
impairment of gas exchange occurs when the diffusion of gases (oxygen and carbon dioxide) becomes impaired because of:
- ineffective ventilation
- reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)
- inadequate perfusion
diffusion
(movement of oxygen and carbon dioxide between alveoli and red blood cells)
respiration: oxygenation (this is the slide that confuses people so meh)
- ventilation: movement of gases into and out of the lung
- diffusion: movement of oxygen and carbon dioxide between alveoli and red blood cells
- perfusion: distribution of red blood cells to and from the pulmonary capillaries
assessment of respiration
one inspiration and expiration = 1 beat
count pulse for 30 seconds and count respirations for 30 seconds, don’t tell that checking breaths
can put their arm that you’re checking across their chest to shoulder so that you can feel their breaths
can match their breathing to make it easier to count
can set patient sitting up, can be hard if they’re laying down bc not breathing as deeply
- rate: how many breaths/minute
- rhythm: regular/irregular
- depth: deep, normal, shallow
- eupnea: ventilation of normal rate and depth (eu = normal, pnea = lungs)
factors influencing respirations
- exercise
- acute pain
- anxiety
- smoking
- body position: not breathing as deeply if curled up, laying down
- medications
- neurological injury - c-spine injuries
- hemoglobin function
alterations in breathing patterns
- eupnea: normal
- bradypnea: slower than normal rate with normal depth and regular rhythm
- tachypnea: rapid shallow breathing
- apnea: period of stopped breathing (ex: sleep apnea)
- dyspnea: difficulty breathing, shortness of breath
- Cheyne-Stokes respiration: rate of breathing increases, then decreases then apnea
- orthopnea: shortness of breath while laying down, normal when sitting up and standing
- Biot’s respiration: period of normal breathing followed by a varying period of apnea
eupnea
normal, breathing at 12-18 breaths/minute
bradypnea
slower than normal breathing (less than 10 breaths/minute), with normal depth and regular rhythm
tachypnea
rapid shallow breathing less than 24 breaths/minute
apnea
period of cessation of breathing. time duration varies; apnea may occur briefly during other breathing disorders, such as with sleep apnea. life threatening if sustained.
Cheyne-Stokes respiration
regular cycle where the rate and depth of breathing increase, then decrease until apnea (usually about 20 seconds) occurs.
Dyspnea
difficulty breathing, shortness of breath
orthopnea
shortness of breath while laying down, normal when sitting up and standing
Biot’s respiration
periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 seconds to 1 minute)
pulse oximetry
placed on any finger, recommend pointer finger
light source on nail bed, when number stops moving for 10-15 seconds, record the number
- indirect measurement of oxygen saturation
- light absorption with photo detector
- pulse saturation (SpO2) estimates arterial saturation (SaO2)
- acceptable range 95% - 100%
factors affecting pulse ox reading
- too loose / too tight
- polish, artificial nails
- temperature of extremity: cold is going to get lower reading, can warm the hands
- movement
- lighting
- skin pigmentation
- edema
- peripheral vascular disease: any disease that decreases blood flow in arms and legs, meaning colder
sample documentation for respirations and pulse ox
normal: respirations 18, regular. Deep, and unlabored, pulse ox reading 98%
abnormal: respirations 32, shallow and labored, pulse ox reading 86%
your postoperative patient is breathing rapidly. what is the first thing you should do?
c. assess the oxygen saturation, (you already know they are breathing fast, don’t need to count respirations)
you measure the O2 saturation and it shows 77%. what is the first thing you should do?
b. check the probe
blood pressure definition
- force exerted against the blood vessels by the blood
- measured in millimeters of mercury (mmHg)
- systolic pressure: max force exerted against blood vessels by blood
- diastolic pressure: minimum force exerted against blood vessels by blood
- pulse pressure = systolic minus diastolic
factors affecting arterial blood pressure
- cardiac output: more cardiac output = higher BP
- peripheral resistance: BP is going to work harder to get past it
- blood volume
- viscosity: thickness of blood,
more RBC = greater thickness = higher BP
less particles = easier to get through = less thick - elasticity
getting a blood pressure reading
equipment: cuff, sphygmomanometer, stethoscope
korotkoff sounds:
- 1st sound, sharp thump = systolic
- last sound before silence = diastolic
- some ppl have all sounds, some only have 1st and last
upper arm is most accurate, lower arm and thigh can work
palpate for brachial artery, put artery index marker in middle of inner arm
if can’t find brachial artery, put marker in middle of inner arm
towards you = closes it, away = releases it
ideal environment for taking B/P
- quiet room, comfortable temperature
- sitting is preferred position
- record in both arms initially
- same arm every reading if possible
- avoid sites with IV fluids
- rest at least 5 minutes before assessing
- ask patient not to speak
factors influencing blood pressure
- age
- stress
- ethnicity: european descent have lower B/P, african ancestors have genetic disposition for higher B/P
- gender: men have higher B/P beginning at puberty, but women have higher once they hit menopause
- daily variation
- medications
- activity, weight
- smoking
hypertension facts
increased blood pressure (above 140 or above 90)
- major factor underlying stroke
- contributing factor to heart attacks
- frequently no symptoms
- - - - -
- more common than hypotension
- thickening of walls
- loss of elasticity
- family history
- risk factors
hypotension facts
diastolic less than 90 and symptomatic
- skin mottling, clamminess, confusion, increased heart rate, or decreased urine output
- - - -
- SBP less than 90 mmHg
- dilation of arteries
- loss of blood volume
- decrease of blood flow to vital organs
- orthostatic / postural
orthostatic aka postural hypotension
B/P goes down when patient stands up after sitting or laying down and can faint - doctor may order check B/P when laying down, sitting and standing up
automatic blood pressure machines
- used when frequent assessment needed
- baseline BP manually first
- more susceptible to error
- unable to accurately detect low BP
- do not talk with patient during reading: can cause increase in BP by 10%-40%
alternate blood pressure sites
thigh
- supine position (not ideal), have patient bend knee
- systolic pressure usually higher by 10-40 mmHg
- diastolic also usually higher by 10-40 mmHg
arterial line
- catheter inserted in an artery
- reading monitored electronically
which blood pressure readings indicate the patient needs a hypertension evaluation?
a. 120/80, 118/78, 124/82
b. 112/80, 140/78, 118/72
c. 148/82, 148/78, 134/88
d. 158/86, 118/76, 126/84
c. 148/82, 148/78, 134/88
PQRST mnemonic
P - provokes/palliates (what makes it worse or better)
q - quality
r - region/radiation (is it radiating)
s - severity/setting (where is it)
t - timing
measure pain using what two things
- PQRST mnemonic
- pain intensity scale: 0 (no pain), 10 (worst pain)
assessing pain
- assess pain often
- always assess pain before procedures, activity and medicate if available
- always reassess pain at least 30 minutes after pain medication has been given
- do not assume to know what your patient’s pain level is: it is what your patient says it is
always reassess someone 30 minutes after medication given to ensure it is effective
trust what someone says their pain is
sample pain documentation
- 1000 patient complains of constant dull achy pain to right foot. pain level is “9” on 1-10 scale. medicated with morphine 5 mg IM in right hip per orders.
- 1030 patient reports pain to right foot has decreased to “3” on 1-10 scale, and is tolerable
how to document pain
- record values in EMR
- record any accompanying symptoms in nurses notes
- document interventions initiated
- document follow up assessment
things to remember about vital signs
- nurse is responsible for measurement
- know baseline
- assure equipment is functional
- know history, therapies and medications
- obtain vital signs in a systematic, organized way (keep same order so that you don’t forget anything)
- vital signs should be taken at same time every day
