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
Pulse oximetry
percentage of hemoglobin in the arterial blood that is saturated
Under normal circumstances hemoglobin is saturated (carrying) O2
Carbon monoxide (co) will bind more readily with hemoglobin, which may give a false “normal” reading
Remember, measures % of saturated hemoglobin….if a patient is profusely bleeding it may still give “normal” value despite decreased levels of hemoglobin
how pulse oximetry works
Works by having sensor probe with LED clipped to the patient to monitor blood flow and hemoglobin saturation through a vascular bed
Designed to measure pulsating blood vessels, therefore also give a pulse reading
Pulse oximetry readings
Normally oxygenated and perfused person should have value between 95-100%
A reading <95% may indicate some sort of respiratory compromise
< 90% may indicate need for aggressive O2 therapy
what may cause erroneous Pulse oximetry readings
Bright ambient light
Pt movement
Poor perfusion (circulation)
Nail polish
Abnormal hemoglobin ie. Carbon monoxide
Always treat the pt, not the monitor!!!
End tidal carbon dioxide
ETCO2
Measures the amount of CO2 at the end of exhalation
Capnometry Is the numerical value of the amount of CO2 that is expired
Normal values are 35-45 mmHg
BLS-PCS pg 98 – cerebral herniation
capnography
Capnography is a monitoring of the concentration of CO2 in the expired gasses
It is represented by a waveform graph
Etco2 common wave forms
slide 41 vital signs ppt
temperature average normal low
Average internal temp 37.0 °C (98.6 °F)
Normal range 36.5–37.5 °C (97.7–99.5 °F)
> 38 C or 100 F = febrile
Hypothermia < 35 C
Skin color, temperature, condition1
May indicate disease/illness
Pale, cool, diaphoretic may signal shock state/SNS response
Red, hot, clammy may signal infection
Cyanosis may signal respiratory distress
Mottled skin may indicate shock
Flush, hot, dry may signal anticholinergic OD
Skin color, temperature,condition2
Skin is the major organ governing the bodies thermoregulation
Cold causes vasoconstriction resulting in blood shunting
Hot environments cause dilation resulting in flushed/red skin
pupils
Pupil size is regulated by continuous motor commands (cranial nerve iii-oculomotor nerve)
Check for sizeshape, symmetry and reactivity of pupils
The diameter and reactivity of pupils to light reflect the status of the brains perfusion, oxygenation and condition
drugs/toxins, head injury, stroke, hypoxia, sns response, ambient light are just some examples of what might effect pupillary response
Blood glucose determination
Glucose is the fuel that runs the brain
The brain uses glucose just about faster than anywhere else in the body but has no way to store it (unlike in muscles and the liver)
Any pt with a change in mental status must have BG levels checked
Normal levels typically range from 4.0 mmol/l – 7.0 mmol/l (non-diabetic fasted)
High considered >7.0 mmol/l (fasted) >11 mmol/l >2hrs after eating
