Vital Signs Flashcards
Types of vital signs
temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain
when to measure vital signs
on admission
per physicians order
any change in patients condition
before and after any major procedure
during blood transfusion
after medications or interventions that affect vital signs
temperature ranges
96.8-100.4
oral/tympanic/temporal
97.6-99.6
rectal
98.6-100.4
axilla
96.6-98.6
pulse: average adults
60-100 beats per minute
respirations
12-20 breaths per minute
blood pressure: normal adults
less that 120/80 mmHg
pre-hypertensive
systolic: 120-139
diastolic: 80-89
hypertensive
systolic: > (greater than) 140
diastolic: > (greater than) 90
hypotensive
systolic: < (less than) 90 and symptomatic
body temperature
heat produced
heat lost
help balance body temperature
no single temperature is normal for every individual
temperature sites
oral, rectal, tympanic membrane (ear), temporal artery, esophageal, pulmonary artery (arterial line), and urinary bladder
temperature regulation
anterior and posterior hypothalamus: internal thermostat
posterior hypothalamus
heat production
BMR: basal metabolic rate
shivering
anterior hypothalamus
heat loss
- radiation
-conduction
-convection
-evaporation
-diaphoresis: sweating
skin regulates body temperature through
skin: only for a few minutes
vasoconstriction: goose bumps
sensation: body sensing hot and cold
radiation
transfer of heat from surface of one object to surface of another without direct contact between the 2
conduction
transfer of heat from one object to another with direct contact
convection
transfer of heat away by air movement
evaporation
transfer of heat energy when a liquid is exchanged to a gas
ex. sweat evaporating to cool down body
diaphoresis
visible perspiration
med term for sweating
factors affecting body temperature
age: very young- hypothalamus is not fully developed; very old: loose skin layering
hormonal level: women can tell ovulation based on body temperature
environment: skin eventually cannot keep the body warm/cool
exercise: metabolic process creates heat
circadian rhythm: body resting itself; middle of sleep= lowest body temperature
temperature alterations: fever, virus, bacteria, etc. ; taking a antipyretic to lower body temperature
fever (pyrexia)
usually not harmful if below 102.2 F
important defense mechanism
temp should be taken several times throughout day: when the body is the most active, its temp will be the highest
results from an alteration in the hypothalamic set point: set point can get raised and body does not adjust quick enough
causes increase in metabolism and oxygen consumption
increased heart rate and respiratory rate
hyperthermia
inability to promote heat loss or reduce production
heat stroke
long exposure to heat, body has expelled all fluids
dangerous heat emergency/high mortality rate
body temp 104 F or more
signs and symptoms:
-most important: dry, hot skin
-confusion, excess thirst, muscle cramps
-vital signs: increased HR, decreased BP
-no sweating
heat exhaustion
right before heat stroke
diaphoresis (sweating) results in excess water and electrolyte loss
need to replace
want to SLOWLY bring temp down
hypothermia
extremely slows down the body
prolonged exposure to cold decrease’s body’s ability to produce heat
can be accidental or intentional (typically done in hospital setting)
temps <86-96.8
below 86 F is not suitable for life
oral temperature
probe under tongue ~1 degree lower than core temp
temperature easily influenced by hot or cold foods
one of the most frequently used methods of attaining temperature
may be glass (mercury) or electronic
rectal temperature
typically done in children or someone with hypothermia
placement of thermometer:
-adult: insert 1.5 inches
-child: insert 1 inch
-infant: insert .5 inch
placement of thermometer into feces may give inaccurate readings
axillary temperature
arm pit: least accurate
considered the safest
must be left in place for 5-10 minutes
moisture in axillary area may reduce temp reading
tympanic
ear canal, must get into ear canal or will not be accurate
one of the most rapid means of measurement
unaffected by PO intake
must remember to remove hearing aids before using
temporal temperature
most accurate compared to core temp
head of scanner must always be touching skin
fast read: 2-3 seconds
easy to use
fewer errors than tympanic
what do you do for a fever?
obtain blood culture
monitor VS, assess skin color, temperature, turgor and lab work
reduce frequency of activities to low O2 demand
maximize heat loss: take blanket off, cool to the point that they are not shivering
extra fluids: as they start to lose heat they might sweat
tepid water bath: not to shock the body with freezing ice pack
oral hygiene: mouth is filled with bacteria
dry bed linens: as they sweat bed gets wet and cold and could induce shivering
antipyretic meds as ordered: fever reducer medications ex. Tylenol or Motrin
pulse
palpable or audible bounding of blood flow noted at various points on the body
an indirect measure of circulatory status
radial pulse
wrist
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 (to ensure adequate blood flow to both hands)
apical pulse
listening with stethoscope
if pulse is abnormal
if taking meds that affect HR
if radial pulse is inaccessible (ex. cast)
5th intercostal space, mid clavicular, on left side
corotid
only in case of emergency and NEVER at the same time
if patient condition suddenly worsens
need pulse quickly
do not measure bilateral at the same time (reduces blood flow to the brain)
dorsalis pedis
top of foot
assesses status of circulation to foot
via doppler if unable to palpate
assess bilaterally
rate: assessment of pulse
baseline is 60-100
if abnormal, obtain apical
rhythm: assessment of pulse
regular
irregular
dysrhythmia
strength
4+ (bounding), 3+, 2+ (normal), 1+ (faint), 0 (cannot palpate
gas exchange
the process of transporting oxygen into cells
transport of carbon dioxide out of cells
ventilation
movement of gasses into and out of the lungs
respirations
inspiration and expiration
the exchange of gas in alveoli
ischemia
insufficient oxygen supply to tissue, which can lead to the death of cells
hypoxia
not enough oxygen reaching the cell
hypoxemia
not enough oxygen to the red blood cells
respiratory acidosis
build up of CO2
impaired gas exchange
ineffective ventilation: not able to ventilate in and out
reduced capacity for gas transportation (reduced hemoglobin and/or red blood cells)
inadequate perfusion: not creating enough RBC
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
rate: assessment of respirations
how many breaths per minute
rhythm
regular/irregular
depth
deep, normal, shallow
eupnea
ventilation of normal rate and depth
factors influencing respirations
exercise
acute pain
anxiety
smoking
body position: sitting up= expanding chest= better breathing
medications
neurological injury
hemoglobin function: part of RBC responsible for transporting oxygen in blood
bradypnea
slower than normal respirations
apnea
absence of breathing
cheyne-stokes respirations
increase of rate and depth, then decrease, then apnea
dyspnea
difficulty breathing
orthopnea
breathing that changes with body position
tachypnea
rapid or above normal rate
assessment of diffusion and perfusion
indirect measurement of oxygen saturation
-pulse oximetry
light absorption with photo detector
pulse saturation (SpO2) estimates arterial saturation (SaO2)
acceptable range 95%-100%
factor affecting pulse ox reading
too tight/too loose
polish, artificial nails: darker the polish the harder to read
temperature of extremity: if the extremity is cold, O2 might read low
movement
lighting
skin pigmentation: darker skin can read low
edema: low due to swelling
peripheral vascular disease
blood pressure
force exerted against the blood vessels by the blood
measured in millimeters of mercury (mmHg)
systolic pressure
top number
max amount of pressure
diastolic pressure
bottom number
lowest amount of pressure
pulse pressure
systolic-diastolic
factors that affect arterial blood pressure
cardiac output: amount of blood heart is pumping through
peripheral resistance
blood volume: high blood volume= high blood pressure
viscosity: thickness of the blood (high viscosity= thick blood)
elasticity: ability for vessels to contract and expand
ideal environment for BP
quiet room, comfortable temp
sitting is preferred position
record both arms initially
same arm every reading
avoid sites with IV fluids
rest at least 5 minutes before assessing
ask patient not to speak: can raise your BP up to 40%
factors that influence blood pressure
age, stress, ethnicity, gender, daily variation, medications, activity, weight (high BMI might= high BP), and smoking
hypertension
major factor underlying stroke
contributing factor to heart attacks
frequently no symptoms
thickening of walls
loss of elasticity
family history
risk factors: smoking, obesity, diet, etc.
hypotension
do not consider till patient is symptomatic
-symptoms include: skin mottling, clamminess, confusion, increased heart rate, or decreased urine output
SBP <90mmHg
dilation of arteries
loss of blood volume
decrease of blood flow to vital organs
orthostatic/postural: blood pressure decreases as patient changes position
automatic blood pressure machines
much more susceptible to error
used when frequent assessment is needed
baseline BP manually first
unable to accurately detect low BP
do not talk with patient during reading
- can increase BP by 10%-40%
alternate BP sites: thigh
supine position (not ideal) have pt bend knee
systolic pressure usually higher by 10-40 mmHg
diastolic the sane
alternate BP sites: arterial line
typically done in ICU
catheter inserted in an artery
reading monitored electronically
Pain mnemonic: P
provokes/palliates: what makes it worse/better
Pain mnemonic: Q
quality: type of pain
Pain mnemonic: R
region/radiation: where is pain and where does it radiate to?
Pain mnemonic: S
severity and setting: how severe and when does pain happen?
Pain mnemonic: T
timing: does it happen at a particular time of day
pain assessment
assess pain often
always assess pain before procedures, activity, and medicate if available
always re assess pain at least 30 minutes after pain medication has been given
do not assume to know what your patients pain level is
documentation
record values in EMR (electronic medical record)
record any accompanying symptoms in nurses notes
document interventions initiated
document follow up assessment
korotkoff sounds
5 stages
phase 1: a sharp thump
phase 2: a blowing or whooshing sound
phase 3: a crisp intense tapping
phase 4: a softer blowing sound that fades
phase 5: silence
