Vital Signs Flashcards
Factors that affect VS
Medications
Illness/infection
Exercise/stresw
Age
Hypovolemia/dehydration
PO intake
Hormones
Circadian rhythm
Medications
Antipyretic such as acetaminophen decrease temp
Opioids such as morphine decrease resp rate
Antihypertensives such as atenolol decrease blood pressure and many decrease pulse
Cardiac glycosides such as digoxin can decrease pulse
Illness/infection
Can cause increased pulse, resp rate, bp
Infection causes increased pulse
Sepsis causes increased pulse and decreased bp
Exercise/stress
Increased metabolism temporarily increased temp,pulse,resp,bp
Postural changes can increase P and decrease BP
Age
Older adults and infants temp regulation is less effective
Hypovolemia/dehydration
Hemorrhage caused decreased bp and increased pulse same with dehydration
Environment
Visit to health care provider can increase BP, hot/cold environment can impact T
PO intake
Hot/cold beverages, smoking, etc can alter Temp, smoking, caffeine, heavy drinking can increase BP
Hormones
Ovulation can change T
Thyroid hormones cause increase in metabolic rate thus increase T and P
Circadian rhythm
T and BP can slightly fluctuate based on time of day
Why is it important to note VS
Important to note both negative and positive changes:
Can tell if a health status is declining or improving
Can tell if an intervention is working
Interpret
Assess in relation to other VS, clinical manifestations S&S, medical history, lab values
Temp average
36-38
Temp sites
Oral, axillary, temporal, tympanic, rectal
Skin tape, non contact
Core temp: pulmonary artery
Oral
Avg: 37
Most frequently taken
Easily accessible and comfortable
Must wait 20 minutes or chose another site if client has taken hit or cold foods/fluids, chewed gum, or smoked
Do not use on patient who have had oral surgery, facial trauma, very young, unconscious, confused, or uncooperative
Axillary
Avg: 36.5
Second most used
Takes longer to obtain reading
Often used in newborns and children
Accuracy effected by recent bathing, sepsis, surgery and sweating
If client is sweating wipe axilla prior to taking
Temporal
Avg: 37
Uses scanner probe to obtain infrared readings of temporal artery blood flow
Non-invasive and fast
Avoid any scar tissue, open abrasions or sores
Readings affected by diaphoresis and air flow across face
Tympanic
Avg: 37
Detects heat radiation from tympanic membrane using infrared sensor
Used less=prone to error such as incorrect straightening of ear canal, gettting a good seal, dirty lens
Affected by patients different sized and shaped ear canals, amount of cerumen as well as if they talk or yawn
Pull pinna down and back for ages 3 or less
Rectal
Avg: 37.5
Rarely used
Considered accurate but not convenient and uncomfortable/may be damaging to rectal tissue
Vagus nerve stimulation can cause bradycardia and synscope fainting
Need to be sure probe is not placed in feces
Contraindicated in infants and children, rectal surgery, disease, diarrhea, hemorrhoid, bleeding disorders, cardiac conditions, spinal injury, uncooperative clients
Skin tape or chemical disposable
Rarely used
Not very reliable
Contain liquid crystals that change colour according to temp
Non-contact
Newest
Used for covid 19
True core
Measures T of deep tissues
More closely represents T of internal organs
Is most accurate
Invasive, inconvenient, often unavailable
Used only in critical care and intraoperatively
Optimal core temp 36.5-37.5
Pulmonary artery catheter is best
T sensing foley in bladder and probe in esophagus are other methods
Alterations in temp
Pyrexia
Hyperthermia
Fever
Hyperpyrexia
Febrile, afebrile
Hypothermia
Thermoregulation
Process that allows your body to maintain its internal core temp
Thermoreceptors
The body’s cold and warm temp receptors, send messages to hypothalamus
Hypothalamus
Part of brain responsible for thermoregulation, goal is to restore homeostasis
Homeostasis
Bringing internal T back to normal range
Too hot
Body increases capillary blood flow through vasodilation which allows blood closer to surface and results in sweating = decreased T
Sweating is body’s only mechanism to dissipate heat when environment warmer than core temp
Too cold
Body cells increase metabolic rate to increase heat production and blood vessels constrict to keep blood away from surface and core warm to conserve energy
Shivering (an involuntary contraction of muscles) occur to generate additional heat
Pyrexia
Fever
Occurs when the heat-loss mechanisms are unable to keep pace with excess heat production
Hyperthermia
T is elevated but it is a result of the body’s inability to promote heat loss or reduce heat production (an overload of the thermoregulatory mechanisms)
Febrile
If a client has elevated T they are febrile (above average temp is not called febrile, the client is called febrile
Increase T by heat exhaustion, heat stroke, virus, bacterial infection, sunburn
Treatment depends on cause and may include fluids, tepid bath, cooling blanket, anti-pyretics
Hypothermia
Occurs when core T is 36 or less
Can be mild or severe
Can be unintentional or medically induced (eg cooling protocol post MI)
Treatment can include warm IV, blanket warmer
Alterations In temp can indicate
Infection
Inflammatory response
Deteriorating client
Thermoregulatory disorders
Pulse
Radial
Apical
Brachial
Radial
Assessed by palpation
30 secs if normal, 60 if abnormal
Normal 60-100 per minute, regular rhythm, 2+ equal bilaterally
Pulse scale
0 (absent)
1+ (weak/thready)
2+ (strong)
3+ (full/increased)
4+ (bounding, difficult to obliterate)
If unequal bilaterally = impaired circulation to one side
Apical
Assessed by auscultation
Always needs to be assessed for full 60 secs
Needs to be assessed at PMI (Erbs points 3rd intercostal space L stern also boarder)
Brachial
Assessed by palpation but not usually counted for rate
Apical-radial pulse deficit
Difference between apical and radial pulse rates
Occurs when the pulse wave is not transmitted such as when someone has an arrhythmia
Respiration’s
Act of breathing addition of O2 and removal of CO2
Resp centre in brain stem driven primarily by CO2 levels
Ventilation, perfusion, diffusion
Mechanical ventilation sometimes used to assist
Perfusion involves cardio system ability to pump oxygenated blood to the body’s tissues and return unoxygenated blood to lungs
Diffusion responsible for the movement of molecules back and fourth
Inspiration
Active process with signals from brain causing diaphragm to contract and ribs to retract upward
Main muscles used are diaphragm and intercostal muscles
Exhalation
Passive
Expelling CO2
Diaphragm, lungs, chest wall return to their relaxed positions
Cardio output
HR x SV
Average pulse
60-100
Alterations in pulse
Tachycardia
Bradycardia
Arrhythmia/dysrhythmia
Pulse deficit
What causes pulse
When blood is pumped out of left ventricle that forceful contraction produces a pulse wave that is transmitted through the arteries to the periphery of the body
May be palpated where an artery is close to the surface of the skin, and over a bone or firm surface that supports the artery
CO
Volume of blood pumped in one minute
Approx 5L of blood a minute is pumped
HR
Number of beats per minute
Stroke volume
Amount of blood that enters the aorta with each ventricular contraction
Avg: 60-70ml
If pulse significantly increases, decreases or becomes irregular
Alters cardiac output
Increasing HR or pulse is the first compensatory mechanism the body used to maintain adequate CO
Body can increase SV by pumping more forcefully or increasing amount of blood that fills the left ventricle before it pumps
Tachycardia
Abnormally fast HR
Greater than 100 bpm
Increased pulse can be caused by exercise, fever and heat, anxiety, stress, acute pain, meds such as epinephrine, hemorrhage, postural changes, diseases such as asthma, COPD, CHF
Bradycardia
Slow HR less than 60bpm
Can be caused by long term exercise, hypothermia, relaxation, medications such as digoxin, lying down , hypothyroidism, cardiac conduction block
Arrhythmia/dysrhythmia
Irregular heart rhythm
Places individuals at risk as it may cause an inadequate cardiac output
Pulse deficit can be caused by
Cardiovascular disease
Atrial fibrillation
Aflutter
Heart block
Premature ventricular contractions
Assessment of resps include
Rate: if regular count 30 secs 12-20
Depth: normal deep or shallow
Rhythm: regular or irregular
Quality: effortless/silent, or dyspnea/orthopnea
Eupnea
Normal breathing
12-20, effortless, automatic, quiet and regular
Resp rate strong predictor of adverse events
Newborn resp
30-60
RR gradually slows fill the normal adult rate
Factors affecting resp
Exercise, age, acute pain, anxiety, smoking, body position, meds, neurological injury, hemoglobin function, fever
Tachypnea
Fast rate of breathing over 20 breaths per minute
Bradypnea
Slow rate of breathing under 12 breaths per minute
Hyperventilation
Rapid and deep respiration’s which may result in hypocarbia (decreased CO2)
Hypoventilation
Slow and usually shallow breathing which may result in hypercarbia (increased CO2)
Dyspnea
Difficult/laboured breathing, breathlessness, an unsatisfied need for air. Clinical manifestation of hypoxia
Orthopnea
Ability to breath only upright, standing or in tripod position, need serval pillows to sleep at night or need head of bed to be elevated
Oxygen saturation
Avg adult 95-100%
Under 70% life threatening
Sensor placed on finger, toe, nose, earlobe
Pulse oximetry
Measures the ratio of oxygen in the blood combined with hemoglobin to the total amount of oxygen that the hemoglobin molecule can carry
Things that affect o2 measurement
Nail polish
Impaired circulation
Movement such as shivering
Severe anemia (may have good readings however as their amount of hgb is inadequate they are still hypoxia)
Carbon monoxide can trick into providing a good reading because co attached to Hgb in oxygens spots and the oximeter is unable to differentiate between the two molecules
Hypoxia
Inadequate tissue oxygenation at the cellular level
Can be caused by anemia
Hypoxemia
Below normal level of oxygen in your blood, specifically in your arteries
From COPD
What is bp
Pressure exerted on arterial walls by the force of the hearts contraction
Pressure rises and falls during the cardiac cycle
Where is pressure highest
In the ventricles and decreased as the distance from the heart increases
Why is adequate bp required
For perfusion of all the body tissues with oxygenated blood, transportation of essential nutrients, and removal of waste materials by the liver, kidneys, and lungs
Systole/systolic bp
Top or bigger number, highest pressure on the arterial walls and occurs during heart contraction
Diastole/diastolic
Lower or smaller of the two numbers, the lowest pressure in the arteries during the brief rest period
Pulse pressure
Difference between systole and diastole and is normally 30-50mmHg
Consistently high/wide pulse pressure
Can be a result of arteriosclerosis, increased ICP, fever, pregnancy, anxiety, endocarditis, heart block, anemia
Consistently low/narrow pulse pressure
Can result from blood loss, low stroke volume, heart failure, shock
Procedure of measuring BP
- Position client
- Find brachial artery
- Measure bp cuff and apply
- Preform palpatory
- Place stethoscope over brachial
- Obtain reading
- Document and inform client
Cuff is inflated
To a pressure greater than the arterial blood flow, blood returns to brachial artery and produces sounds
Bp sounds
Korotkoff sounds
Phase 5
Diastolic value
Absence of sound
Position
In order to determine future treatment in relation to BP important to compare values in a consistent position and on the same arm
Apply bp cuff
2.5-3cm above antecubital fossa 40/80 rule
Auscultatory gap
Temporary disappearance of sound often between first and second phase, can occur and may last up to 40mmHg may cause systolic reading to be underestimated
Why we do palpatory
Often occurs with hypertensive clients as a result of arteriosclerosis and can lead to a missed diagnosis of hypertension
Last sound
Take last sound heard and subtract 2mmHg
Why not use arm in bp
If client has had a mastectomy on same side may cause lymphedema leading to aching, discomfort
Also cannot use are that has a dialysis fistula or graft, an iv infusion, if arm is painful or swollen and if there is a cast or injury
Alternative sites for bp
Radial artery
Posterior tibial artery
Popliteal artery
Bladder length
Covers 80%-100%
Bladder width
40%
Cuff too small
False high
Cuff too big
False low
Optimal bp
120/80
Normal bp
Less than 130/85
Hypertension
135/85
Hypotension
Systolic less than 90
Bp value
One bp alone does not give enough data , needs to be several bp’s to diagnose something like hypertension
Factors that affect bp
Age
Sex
Stress
Ethnicity
Daily variations
Medications
Activity
Weight
Smoking
Pyrexia
Diabetes
White coat syndrome
Hypertension
Significant risk factor for CVA, CAD, CHF, PVD, renal failure
Clinical manifestations HTN
Often silent killer
May get headache, ringing in ears, flushed face, nosebleeds, fatigue
Hypotension
May occur due to hemorrhage, MI
Clinical manifestations hypotension
Pallor, mottling, clamminess, confusion, increase hr, decreased urine output
Orthostatic hypotension
Postural hypotension
Important to assess as it leads to falls
Drop of 20mmHg or more in systolic or 10mmHg or more in diastolic within 3 mins of the client rising
Direct vs indirect bp
Indirect = non invasive sphygmomanometer or automated bp machine
Direct = invasive obtained by using an arterial line needle or catheter into brachial, radial, or femoral artery and the reading is displayed on a monitor
Only in ICU
Shivering
Monitor when reducing heat not to cause shivering as it increased core temp
Hyperthermia symptoms
Decreased skin turgor
Dry mucous membranes
Tachycardia
Hypotension
Decreased venous filing
Concentrated urine
Heatstroke symptoms
Body temp of 40 or more
Hot
Dry skin
Tachycardia
Hypotension
Excessive thirst
Muscle cramps
Visual disturbances
Confusion
Delirium
Hypothermia symptoms
Pale skin
Skin cool or cold
Bradycardia
Dysrhythmias
Shallow respiration’s
Older person temp
At lower end 36
Temps considered within normal range often reflect fever in an older person
Pulse sites
Temporal (above and lateral to eyebrow)
Carotid ( along medial edge of sternocleidomastoid in neck)
Apical
Brachial
Radial
Ulnar
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
Risk factors for pulse alterations
History of heart disease
Cardiac dysrhythmia
Onset of sudden chest pain or acute pain
Invasive cardiovascular diagnostic tests
Surgery
Sudden infusion of a large volume of iv
Internal or external hemorrhage
Meds
Signs and symptoms of altered cardiac function
Dyspnea
Fatigue
Chest pain
Orthopnea
Syncope
Palpitations
Edema
Cyanosis
Pallor
Symptoms of peripheral vascular disease
Pale
Cool extremities
Thin shiny skin
Decreased hair growth
Thickened nails
If pulse count differs by more than 2
A deficit exists
S1 S2
S1 is sound of tricuspid and mitral valves closing at the end of ventricular filling S2 is sound of pulmonic and aortic valves closing at end of systolic contractions
Diffusion
Movement of o2 and CO2 between alveoli and rbc
Risk factors for resp alterations
Fever
Pain
Anxiety
Diseases of lungs or chest wall
Constructive dressings
Abdominal incisions
Gastric distension
Chronic pulmonary disease
Traumatic injury to chest
Presence of chest tube
Resp infection
Pulmonary edema and emboli
Head injury
Anemia
Symptoms of resp alterations
Cyanosis of skin nail beds lips mucous membrane
Restlessness
Irritability
Reduced levels of consciousness
Pain during inspiration
Laboured breathing
Orthopnea
Use of accessory muscles
Adventitious breath sounds
Inability to breath spontaneously
Thick frothy blood tinged or copious sputum
Apnea
Resps cease for several seconds, resistant cessation results in resp arrest
Biots respiration
Irregular resps varying in depth followed by periods of apnea (associated with CNS disorders)
Bradypnea
Rate of breathing is regular but abnormally slow (less than 12)
Cheyne-stokes resps
Rate and depth irregular characterized by alternating periods of apnea and hyperventilating
Hyperpnea
Resps increase in depth and rate over 20 (occurs during exercise)
Hyperventilation
Resp increase
Hypocarbia may occur
Hypoventilation
Rate is abnormally low
Hypercarbia may occur
Priority abc
Airway, breathing, circulation
Radiation
Transfer of heat from the surface of one object to the surface of another without direct contact
Conduction
Transfer of heat from one object to another through direct contact
Convection
Transfer of heat away from the body by air movement
Diaphoresis
Visible perspiration
Pyrogens
Such as bacteria and viruses can rise temp
Fever causes
Cellular metabolism to increase and oxygen consumption to rise
HR and resp rate increase
