Vital Signs Flashcards
What are the five main vital signs and their normal ranges?
Temperature(96.8-100.4)
Pulse(60-100bpm)
Blood Pressure (120/80 mmHg)
Respiration(10-20 breaths per min)
Oxygenation (95%-100%)
Secret sixth: Pain
When should you measure vitals?
-On admission
-On order
-Routinely (4 Hours)
-Before During and After(B.D.A.) any major procedure
-B.D.A. Blood Transfusion
-After any form of intervention(Usually Meds) that could measure vital signs
-When the pt’s conditions changes or they report that they’re having physical pain/distress
What is Body temperature?
What organ controls it?
Heat Produced vs Heat Lost
Hypothalmus
How do we produce heat?
-Metabolism(BMR)
-Shivering
How do we lose heat?
-Radiation(No contact)
-Conduction(Direct Contact)
-Convection(Air movement)
-Evaporation
-Diaphoresis(Perspiration/sweating)
What’re factors that affect temperature?
-Age
-Hormones
-Environment
-Exercise
-Sleep(Circadian Rhythm)
-Meds
What is a fever and its facts?
- High Temperature
- Only harmful if over 102.2
- Take temperature multiple times a day
- Ups metabolism and O2 consumption and HR and respiratory rate
What’re Hyperthermia and Heat stroke?
-Hyperthermia: Inability to promote heat loss or reduce production, resulting in a high temperature
- Heatstroke: Very hight heat emergency with a very high mortality rate, body temp of 104 or more
What is the difference between hyperthermia and heatstroke.
-Heatstroke results in DRY AND HOT SKIN, as well as confusion excess thirst and muscle cramps, this increases HR and decreases BP, once again NO SWEATING
What is hypothermia?
-Prolonged exposure to cold decreases the body’s ability to produce heat, resulting in a cold body temp
-Can be accidental but also intentional
-Temps are 86F - 96.8
Whatre the conversion equations for Celsius to Fahrenheit?
C = (F-32) x 5/9
F = (9/5 x C) +32
Facts on Oral Temperature?
- It can be easily influenced by food and drinks
- One of the most common
- ~1 degree lower than the core body temperature
Facts on rectal temperature?
- In adults go 1-1.5in in the anus
- Feces could cause innacurate readings
Facts on axillary temperature?
- Armpit
- 5-10 minutes
- Moisture can reduce the temp
Facts on tympanic temp?
- One of the most rapid measurements
- PO intake does not matter
-Take off hearing aids
Temporal temp?
- Closest to core temp
- Fast reading
- Easy to use
- Very few errors
A patient has a fever, what can you do for them?
-Cool room
- Reduce the coverings on patient
- Keep cloths and linen dry
- Limit activities
- Give antipyretics
- Encourage patient to take fluids
- Take blood samples if ordered to
- Check pt’s VS, skin color, temp, and lab work and turgor?
What is pulse?
- Audible bounding of blood flow at certain body points
- Also indicates circulatory status indirectly
What are the sites of assessment for the pulse and noteworthy facts?
-Radial
Most common
Best used for patient teaching
Assess both hands at once for one pulse
- Apical
only use if pulse is abnormal or radial is inaccessible
could change if meds that affect HR are taken
-Carotid
If patient condition is worsened or if you need a pulse quickly
DO NOT DO BOTH SIDES AT ONCE
- Dorsalis Pedis
Top of foot
Assess both at the same time
How can you categorize pulse rhythm?
Regular, irregular, or dysrhythmia
How can you categorize the strength of pulse
4+, 3+(strong), 2+(Normal), 1+(Weak),0
What should you do if the pt has a rapid pulse?
- Ask pt to take slow and deep breaths
- Assess for pain, anxiety, or stress
What is gas exchange?
O2 in and CO2 out
Ventilation
Movement of gas into and out of the lungs
Diffusion
exchange of O2 and CO2 between alveoli and RBC’s
Perfusion
Distribution of RBC’s to and from the pulmonary capillaries
What causes impaired gas exchange?
- Poor ventilation
- Low capacity for gas(Usually from low hemoglobin or RBC’s)
- Poor perfusion
What are the assessments of respiration?
- Rate: Breaths/min
- Rhythm: Regular or Irregular
- Depth: Deep, normal, or shallow
What factors can affect respiration?
- Exercise
- Acute pain
- Anxiety
- Smoking
- BODY POSITION
- Meds
- Neurological injury
- Hemoglobin Function
What are the alterations in respiration?
- Bradypnea: Slow (<10 breaths/min
- Tachypnea: Fast (>24 breaths per min)
- Apnea: Moments with no breathing occurring (sleep apnea)
- Cheyenne Stroke: Regular cycle of fast breathing to slow then to apnea
- Biot’s Respiration: Normal breathing then apnea
What does pulse oximetry measure?
O2 saturation in the blood
What does Pulse saturation (SpO2) estimate?
arterial saturation (SaO2)
Normal Pulse oximetry range?
95%-100%
What can affect Pulse Ox?
-Positioning of device
- Polish or fake nails
- Temp of finger
- Movement
- Light
- Skin color
- Edema
- Peripheral vascular disease
What can you do if Pulse ox is low?
- CHECK POSITION OF PULSE OX
- Raise bed’s head
- Ask pt to take slow and deep breaths
- Give O2 if necessary and tell the physician after
What is BP and how is it measured?
-Blood Pressure: Force exerted against blood vessels
- mmHg with Systolic and Diastolic numbers
What are factors affecting BP?
- Cardiac output
- Peripheral Resistance(resistance of BV)
- Blood volume
- Viscosity
- Elasticity
Factors affecting BP?
- Age
- Stress
- Ethnicity
- Gender
- Changes daily
- Meds
- Activity and weight
- Smoking
What are hypertension usually factors of? And are there usually symptoms of Hypertension
- Stoke and Heart attack
- No
Symptoms of Hypotension?
- Skin mottling
- Clamminess
- Confusion
- ^ HR
- Low urine output
If taking BP in the thigh, what is usually off?
Systolic pressure is usually higher by about 10-40mmHg
What to do for low BP readings?
- Check O2 saturation
- Give fluids
- Tell pt to call when they need to get up
- Put pt in trendelburg position
What to do if High BP?
- Assess for pain, anxiety, or stress
- Reduce activity
- Rest
What is PQRST for pain assessment?
- Provokes/palliates:
- Quality: How bad is it
- Region/Radiation: Where and is it radiating?
- Severity and setting:
- Timing:
When should you assess for pain?
Often
- before procedures, activity and meds
-at least 30 mins after pain meds are given
- NEVER assume their pain, it is what they say it is
How to measure pain?
Ask for a scale of 1-10
What to do for pain?
- Give meds if ordered
- Lower activity
- Give any distraction possible if wanted
