Vital Signs Flashcards
Vital Signs general
A measurement of a group of the most important signs that may indicate the status of the body’s functions
canv ary due to age, drug use etc
help determine pt stability
Vital signs may change without significant external changes in pt presentation. they may also be the first indication of pt deterioration or improvement
Type Vital Signs
Blood pressure
Respiratory rate, rhythm, and quality
Pulse rate, rhythm, and quality
Glasgow coma scale
Pulse oximetry
temperature
Blood glucometry
Pupils
Skin colour, temperature and condition
Capnography- we monitor whenever BVM is being utilized
Age and Vital signs (als-pcs)
wide range of “normal” for vital signs in adults and especially pediatrics.
generally same for adult/child, some exceptions
Bp- ALS normotension and hypotension
Adults Normotension
SBP ≥100 mmHg
Hypotension
SBP <90 mmHg
Blood pressure (bP)
Measurement of the force exerted against the vessel walls
Device used to measure bp is a sphygmomanometer
Typically measured in a peripheral artery
BP = cardiac output (co) x peripheral vascular resistance (pvr)
CO = heart rate (HR) x stroke volume (SV)
Includes 2 components
systolic and diastolic pressure
BP systolic/diastolic pressure
SYSTOLIC pressure- created during systole or contraction of the left ventricle
DIASTOLIC pressure- created during the relaxation of the ventricles. This allows the passive filling of the chambers of the heart with blood (also perfusion of coronary arteries)
Diastolic pressure should not “zero” due to vasomotor tone (PVR)
bp measuring size
Must be measured using a cuff appropriate to the pt size (1/2 - 2/3) of upper arm
Too small/tight may produce an artificially high reading
Too big/loose may produce an artificially low reading
BP by auscultation
Kortokoff sounds
blood flow sounds heard while taking a BP by auscultation with a sphygmomanometer over the brachial artery in the antecubital fossa
First sound represents the systolic pressure
Last sound heard represents the diastolic pressure
BP by auscultation measuring and placements
Cuff should cover 1/2 - 2/3 of the pt’s upper arm
Confirm stethoscope is working and place over brachial artery
Inflate to 30 mmhg above point where Kortokoff sound vanish
Deflate at rate of approx 2-3 mmhg/second
Note the systolic pressure at initial Kortokoff sound and diastolic at the last
Most accurate way to determine blood pressure in the field
Bp by palpation
Useful in loud environments after proper BP has been determined either by auscultation or automated bp device (cardiac monitor)
method
Inflate the cuff with your fingers palpating the radial pulse
Note the pressure on the gauge where pulse can no longer be palpated
Increase 20-30 mmhg above this point then deflate slowly and note where pulse is palpated again…..this is the systolic pressure
Heart rate/pulse brachy/tachycardia
Bradycardia (ALS-PCS)
HR <50 BPM
Tachycardia
HR ≥100 BPM
Normal for adult is in between
Heart rate (pulse)
Should assess its presence, rate, location, quality, and rhythm of the pulses
To palpate gently compress an artery against a bony prominence. This allows you to feel the pressure wave generated by the hearts contraction
Basic way to evaluate perfusion and cardiac output
Compare proximal and distal pulses during patient evaluations
where to locate Heart rate/pulse
Can be obtained at several points in the body
Radial, ulnar, brachial, femoral, dorsalis pedis, posterior tibial and carotid arteries
Pulse points
carotid
radial
ulnar
brachial
femoral
dorsalis pedis
posterior tibial
Respirations
Typically measured by inspection of the patient’s chest movement
Normal respiratory rate for adults is 12-20 bpm
Can also be assessed by visualizing the abdomen, neck, face, mask (if applied- look for misting), and accessory muscle use
Must evaluate the rate, rhythm and quality of respirations
Auscultation must be performed
tidal volume
Tidal volume- amount of air that is breathed in and out during one normal respiratory cycle
Average is 6-8 ml/kg of ideal body weight….approx 500 ml
respirations rate tachypnea bradypnea
Tachypnea
RR ≥28 breaths/min
Bradypnea
RR <10 breaths/min
Is the pt breathing adequately?? (ie. Fast, slow, reg, irreg, adv sounds, accessory muscle use, positioning)
* Be vigilant, assess and monitor mental status
Tripod positioning
mouth open, trunk leaning forward, neck and chin extended
Glascow coma scale
The Glasgow Coma Scale (GCS) was initially developed and used to describe the general level of consciousness in patients withtraumatic brain injury(TBI)
The GCS is divided into 3 categories
eye opening (E)
motor response (M)
verbal response (V)
The score is determined by the sum of the score in each of the 3 categories, with a maximum score of 15 and a minimum score of 3
GCS SCORES
Mild head injuries are generally defined as those associated with a GCS score of 13-15
moderate head injuries are those associated with a GCS score of 9-12
A GCS score of 8 or less defines a severe head injury
These definitions are not rigid and should be considered as a general guide to the level of injury
GCS eye opening response
1.NO RESPONSE
2.TO PAIN
3.TO SPEECH
4.SPONTANEOUSLY
GCS VERBAL response
1NO RESPONSE
2.INCHOMPREHNSIBLE SOUNDS
3.INNAPROPRIATE WORDS
4.CONFUSED
5.ORIENTED TO TIME PLACE AND PERSON
GCS motor response
1.NO RESPONSE
2.ABNORMAL EXTENSION
3.ABNORMAL FLEXION
4.FLEX TO WITHDRAW FROM PAIN
5.MOVES TO LOCALISED PAIN
6.OBEYS COMMANDS
GCS altered level of awareness LOA
The word ‘altered’ refers to a GCS that is less than normal for the patient.The word ‘unaltered’ refers to a GCS that is normal for the patient. This may be a GCS <15.
Ie. Patient with dementia
