Vital Signs Flashcards
Elder speak?
Communication that conveys message of incompetence: “sweetie, honey, dear, etc.”
Evidence says: In older adults with dementia, Resistance To Care (RTC) increases with elder speak, disrupts nursing care, and increases costs of care by 30%
Why do VS need to be accurate?
Therapeutic action can be taken from VS
When to assess vital signs?
Admission, institutional policy, change in condition, before/after: surgical or invasive procedure, certain meds, certain activities
*know textbook norms and patient range norms (some abnorms may be normal for specific patient)
Order to report VS?
temp
pulse
respiration
BP + MAP
pain
02
Temperature physiology?
Regulated by hypothalamus
Heat production: metabolism is primary source- hormones, muscle movement, exercise increase metabolism
Heat loss: Skin (primary source), sweat evaporation, warming/humidifying inspired air, eliminating urine and feces
Mechanisms of heat transfer?
Radiation: diffusion of heat by electromagnetic waves, ex. body gives off waves of heat from uncovered surfaces
Convection: heat dissemination by motion between areas of unequal density, ex. fan blows cool air across surface of warm body
Evaporation: conversion of liquid to vapor, ex. perspiration
Conduction: heat transfer to another object during direct contact, ex. body transfers heat to ice pack causing it to melt
Temperature factors?
Circadian rhythms- lower morning, higher afternon
Age- elderly will be less
Gender- men lower
Physical activity- increase
Environmental temperature
Fever types?
Intermittent: body temp returns to normal once every 24 hrs
Remittent: body temp does not return to normal, fluctuates degrees
Sustained/continuous: body temp remains above normal w/ minimal variations
Relapsing/recurrent: body temp returns to normal for 1+ days with 1+ episodes of fever, each lasting several days
Terms
Afebrile: no fever
Febrile: temp/fever
Pyrexia: fever/temp
Fever effects?
Decreased appetite
Headache
Hot skin
Flushed face
Thirst
Muscle aches
Fatigue
Fever blisters
Elderly- periods of confusion
Fever interventions?
Maximize heat loss:
remove heavy blankets
keep clothing/linens dry
cool compress
ice packs
cooling blanket
Minimize heat production:
limit physical activity
*oral care
Pulse physiology?
Palpable bounding of blood flow in peripheral artery
Regulated by cardiac sinoatrial node
Pulse characteristics?
Rate, rhythm,
Amplitude 4 point scale-
0: Absent
1+: Weak
2+: Moderate
3+: Strong
4+: Bounding
Pulse palpation detection sites?
Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
Where is the only place you can hear the heart?
apical
Pulse assessment methods?
Palpate peripherals (cannot hear them)
Auscultate apical- 5th intercostal space
Doppler peripherals
Pulse factors?
Age- aging affects metabolic rate, decreases
Sex- women slightly higher
Physical activity- increases w exercise, athletes may have decreased
Body temperature- elevated=increased, low=decreased
Stress- increase
Meds
Disease/health condition
Tachycardia?
Rapid heart rate, 100+
Contributing factors:
decreased BP (blood loss, shock, trauma)
increased body temp
poor oxygenation of blood (COPD, anemia)
exercise
hyperthyroidism
pain
strong emotions
meds (epinephrine)
Bradycardia?
Slow heart rate, less than 60
Contributing factors:
CAD, MI
decreased body temp
hypoxemia, sleep apnea
altered mental status (delirium)
hypothyroidism
increased intracranial pressure or nervous system conditions (CVA/stroke)
vagal stimulation (ocular pressure, vomiting)
meds (antiarrhythmics)
Pulse deficit?
Difference between apical and peripheral
Need 2 people
Assessing respirations?
rate
depth
rhythm
work of breathing
symmetry
hypoventilation
low rate, shallow depth
hyperventilation
fast rate, deep depth
dyspnea
difficulty breathing
tachypnea
fast breathing
orthopnea
difficulty breathing when lying down
apnea
no breathing
What is blood pressure?
force of blood against arterial walls
systolic BP?
highest pressure on arterial walls, contraction of the ventricles (systole)
diastolic BP?
lowest pressure on arterial walls, ventricles at rest (diastole)
what is normal BP?
below 120/80
what is elevated BP?
systolic between 120-129
AND
diastolic between 80-89
what is stage 1 BP?
systolic 130-139
OR
diastolic 80-89
lifestyle changes start at 130/80 and meds if at risk for CV
what is stage 2 BP?
systolic at least 140
OR
diastolic at least 90
what is a hypertensive crisis?
systolic over 180
AND/OR
diastolic over 120
what is hypotension?
less than 90/60 WITH symptoms
what is the decrease in orthostatic hypotension?
20 systolic, 10 diastolic
how to assess orthostatic hypotension?
lay down for 5 mins, take BP and pulse
sit for 3-5 mins, retake
stand for 3-5 mins, retake
limitations to automatic BP?
vulnerable to error:
-arrhythmias
-older adults
-obese extremity
may not work with hypotension
Normal MAP? Need a MAP of ____ or more to perfuse vital organs? How to find MAP?
70-100, 60
diastolic x2 + systolic divided by 3
factors affecting BP?
age- older= vessel stiffness increase BP
race- AA increased chance hypertensive
circadian rhythm- lower in morning higher in afternoon
exercise
weight
emotional state- increase BP
body position- lowest=supine
meds
disease
smoking- vasoconstriction
if reduced salt intake by _____, this could reduce high BP by _____ million and save _____ billion health care dollars per year?
2300 mg per day, 11, $18
purpose of BP two step method?
to not miss the auscultatory gap
first Korotkoff sound?
systolic
fifth Korotkoff sound?
diastolic
how do you know you’ve found diastolic?
all sound disappears
most commonly used artery for BP?
brachial
when do you not take BP?
mastectomy, fistula, lymphedema, amputee, IV
what to do if BP reading indicates hyper or hypo tension?
retake BP in other arm
the pulse (feel) of a fistula is _____ and the sound of a fistula is _____
thrill, bruit (whooshing)
bruit normal in fistula, abnorm in heart
numerical pain scale- mild, moderate, severe?
mild: 1-3
moderate: 4-6
severe: 7-10
what is FLACC? when to use?
Face, Legs, Activity, Cry, Consolability
when patients cannot communicate
PAINAD use?
advanced dementia patients
what to ask if patient says they have pain?
onset
location
functional limitations
interventions
functional goals
reassess every 4 hrs or sooner
what does SPO2 measure?
amount of hemoglobin saturated with oxygen in arterial blood, measures oxygenation NOT ventilation
*rough measurement bc can have 100% SPO2 but 6 hemoglobin (male: 14-18, female: 12-16)
what is FIO2 and why is it important?
fraction of inspired air
important: 88% on oxygen more emergent than 88% on room air
*when low, raise head of bed to help lungs expand
what SPO2 is norms
healthy adult: around 95%
adult w disease: less than 92%
abnorm for everyone: less than 85%
hypoxemia ____?
kills
factors interfering with light transmission?
outside light sources
carbon monoxide
patient motion
jaundice
dark skin pigmentation (signal loss)
saturation estimation (false high)
factors interfering with arterial pulsations?
peripheral vascular disease
hypothermia
low cardiac output
hypotension
peripheral edema
tight probe
arrhythmias
edema
what are the VS criteria for rapid response team?
pulse: over 140, less than 40
resp: over 28, less than 8
BP: systolic greater than 180 or less than 90
SPO2: less than 90% despite supplementation
*also call RR for acute mental status change
taylor vs jarvis?
taylor:
T: 35.8-37.5
P: 60-100
R: 12-20
SpO2: 95-100
jarvis:
T: 35.8-37.3
P: 60-100, 50=brady
R: 10-20
SpO2: 97-99 on RA or 95 w normal Hgb
