Vital Signs Flashcards
What are the 5 vital signs
Temp
Pulse
Resp
Blood Pressure
Pain
Normal Blood Pressure
120/80
Normal Temp Range
96.4 - 99.5
Normal Respirations Range
12-20 breaths per minute
Normal Pluse Range
60-100 beats per minute
LOC
Level Of Consiousness
When to asses vitals
admission
change in condition
change in LOC
before and after an invasive prodcedure
before and after activites that may cause change
before meds
per facility policy
Factors affecting body temp
Age
menopause
pregnancy
time of day
physical activity
overall health
What temp is does a fever start at
100.5
What is hyperthermia
causes
benefits
increase above normal body temp
causes; illness, cancer, trauma, surgery
benefits; start immune system, inital something is wrong
S & SX (signs and symptoms) of Hyperthermia
confusion&delerium (older patient)
fatigue
flushed face
hot, dry skin
increased pulse and resp rate
loss of appetite
muscle aches
shivering
thirst
Hyperthermia treatment
priority
pharmacological
nonpharmacological
Priority; treat the cause
pharmacological; antipyretics(NSAIDS/Acetaminophen)
nonpharmacological; cool sponge baths, increase fluid intake
What is hypothermia
-causes
decrease in temperature below the lower limit of normal
causes; exposure to cold, chronic conditions, perioperative clients, new born babies
S & SX (signs and symptoms) of hypothermia
poor coordination
slurred speech
poor judgement
amnesia
hallucinations
vital sign decrease
Hypothermia treatment
rewarming
with a warming blanket, warm fluids, and/or additonal clothing/blankets
Temperature routes
sublingual
tympanic
temporal
rectal
axillary
Advantages and contraindications of sublingual temp
advantages;
most common
easily acessible
contraindications:
intake of hot/cold fluids or food
smoking
chewing gum
advantages and contraindications of tympanic temp
advantages;
easily accessible
contraindications;
drainage in ear
ear pain
ear infection
scars on tympanic membrane
advantages and contraindications of temporal temp
advantages;
more accurate than axillary
contraindications;
forehead coverings
affected by external temps
advantages and contraindications of rectal temp
advantages;
most accurate
contraindications;
special thermometer
heart disease or surgery (vagual stim. can cause heart rate to bottom)
neutropenic precautions
low platelet count
spinal cord injuries
advantages and contraindications for axillary temp
advantages;
use when sublingual and rectal sites are contraindicated or not acessible
contraindications;
least accurate of them all
unable to keep arm down until reading is complete
pulse characteristics
rate
rhythm (regualr or irregular)
amplitude (strength)
bradycardia (-60)
tachycardia (+100)
factors affecting pulse rates
age
biological sex
fever
medication use
physical activity
presence of disease
stress
athletes have a lower heart rate, stress/anxiety have higher heart rate
pulse location
temporal
carotid
apical (PMI pulse, between 4&5 rib)
brachial
radial
femoral
popliteal
post. tibia artery
pedal
tachycardia
rate
causes
fast heart rate
between 100-180 bpm
causes;
drugs
fever
hypotensive
low oxygen blood
pain
stress
bradycardia
rate
causes
below 60 bpm
causes;
decreased body temp
deleruim
heart attack
hypothyroidism
intracranial pressure
medications
sleep
sleep apnea
vagal stimulation
pulse amplitude
how its measured
the quality or fullness of the sound
meausured by grades
0-absent, unable to palpate
+1 - deminished, weaker than expected
+2 - brisk, expected
+3 - bounding
respiration characteristics
rhythm - reg or irreg
depth- force of inhalation/exhalation
factors affecting respiration
acid-base balance
acute pain
age
anemia
anxiety
brain lesions
exercise
increased altitude
medications
respiratory disease
respiration rhythms
apnea - without resporations
tachypnea - rate greater than 24 breaths per min
bradypnea - rates less than 10 breaths per min
respiration rates
normal - 12-20 breath/min
tachypnea - >24 bpm
bradypnea - <10 bpm
hyperventilation - increased rate and depth
hypoventilation - decreased rate and depth
cheyne-stokes - alternating periods of deep rapid breathing, followed by periods of apnea (regular)
Biots resp - varying depth and rate of breathing followed by periods of apnea (irregualr)
pulse oximetry
range
false reading causes
measures the % of oxygen saturation in the blood
range; 95% - 100%
false reading causes;
cold hands
wrong location
equipment malfunction
fingernail polish/acrylic
Blood pressure top number
name
systolic
Blood Pressure bottom number
name
diastolic
blood pressure ranges
normal; < 120/80
elevated; 120-129/80
hypotension; below 90/60
hypertensive stage 1; 130-139/80-89
hypertensive stage 2; >140/>90
hypertensive crisis; >180/>120
factors affecting blood pressure
age
biological sex
body position
circadian rhythm
drugs/medications
emotional state
exercise
food intake
race
weight
factors causing false low blood pressure readings
hearing deficit
noise in enviornment
applying cuff thats too wide
inserting stethoscope in ears incorrectly
releasing valve too fast
factors causing false high blood pressure readings
incorrectly calibrated manometer
applying cuff that is too narrow
releasing valve too slow
reinflating bladder during ausculatation
hypertension
at risk?
over 130/80
at risk?
family hx (history)
race
sleep apnea
diabetes
cholesterol
african american males
hypotension
less than 90/60
orthostatic hypotension
preventions
rapid movement of sitting to standing, gets dizzy
let patient dangle and get up slowly
oxygentation
amount of oxygen in the blood
perfusion
volume of blood
