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N1180 > Vital Signs > Flashcards

Vital Signs Flashcards

1
Q

What are the Vital Signs

A
  1. Temperature
  2. Pulse
  3. Respiratory Rate
  4. Blood pressure
  5. Oxygen Saturation
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2
Q

Temperature Key Terms

A

Febrile - Client has a fever

Afrebrile - fever is not present

Pyrogen - a substance that produces a fever when present in the blood stream
- Bacteria often acts as a pyrogen when it invades the body, causing infection

Diaphoresis - Sweating
- You can also use the word to describe a client’s state by using ‘diaphoretic‘

Antipyretic - substance that combats fever and is a medication (ie. acetaminophen or ibuprofen)

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3
Q

Heart Rate Key Terms

A

Bradycardia - heart rate below 60bpm

Tachycardia - heart rate 100 bpm

Asystole - absent pulse due to no contraction of the heart

Arrythmia - abnormal/irregular heartbeat

Pulse Deficit - abnormal difference in rate bw the radial site and the apical site
- Bradypnea - respiratory rate below normal range

Tachypnea - respiratory rate above normal range

Excursion - assessing excursion means placing hands on clients back to look for symmetrical expanding of chest with breathing

Apnea - periods of no breathing
- Normal in babies as long as period does not exceed 15 seconds
- Adults frequently have sleep apnea - periods

Capillary Refill
- To assess, firmly press with tip of finger on clients nail bed
- It should turn white
- Let go and assess how many seconds it takes for colour to return
- Normal cap refill = 1-3 seconds

Hemoglobin - protein in red blood cells that carries oxygen

Oxygen Saturation
- Measurement of % of hemoglobin molecules (on RBC) that are fully bound with oxygen
- Each hemoglobin carries 4 oxygen molecules
- Deep breathing and coughing - exercise done to expand lungs and maintain airway
- Breathe deeply in and out 2-3 times, then replace last exhale with deep cough
- Repeat until client is mobile

SaO2 - measures oxygen saturation in arterial blood directly
- Accessing arterial blood is invasive and accompanies risk to the client
- SpO2 - indirect measure of arterial blood wit

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4
Q

Blood Pressure Terms

A

Sphygmomanometer - proper term for cuff

Korotkoff sounds - there are 5 of these known as ‘phases’
- When assessing BP, you are concerned with phases 1 & 5 (systolic and diastolic BP)

Auscultatory Gap - clients with peripheral perfusion problems have gaps where sounds are present, disappear briefly, then return
- Inflate to ~30mmHG above typical systolic
- The gap appears during phases 2 and 3
- If there is a gap during auscultation, document it
- Phases 2 and 4 are distinct in sound
- Sounds you are most concerned with are the phases 1 & 5

Valve - the metal wheel at the top pf bulb that controls air going in and out of cuff

Bulb - the part of the cuff that you hold in dominant hand and squeeze to fill cuff with air

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5
Q

Factors influencing body temperature

A
  • Activity/exercise
  • Age
  • Environment/weather
  • Metabolism
  • Smoking
  • Time of day
  • Digestion
  • Evaporation/sweat
  • Ovulation
  • Stress
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6
Q

Normal Ranges for temp

A

Body temp - 35.9-38.1 C (36-38C)

Oral (under tongue) - 36.5-37.5

Axillary (under arm) - 35.9-37.2

Tympanic Core (in ear) - 36.5-37.5

Temporal (forehead) - 36.5-37.5

Rectal Core (in rectum) - 37.0-37.5

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7
Q

Routes for Temperature

A
  1. Oral
  2. Axillary
  3. Tympanic
  4. Temporal
  5. Rectal
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8
Q

Oral Route

A
  • default route for assessing temperature (ie. BUT this route is not appropriate for infants and small children, or older adults who live with confusion)

How to assess:
- a cover is placed over the probe which is then inserted under the tongue, toward the back of the mouth, and down between the tongue and the molars.
- This area is called the posterior sublingual pocket and placing the probe here puts it next to the sublingual artery.

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9
Q

Axillary Route

A
  • produces temperatures at the lowest end of the normal range
  • It is useful for patients who cannot have their temperature taken orally
  • same piece of equipment used in oral temperature is used for axillary
  • probe must be placed horizontally and the tip must remain under the arm.
  • This route is only effective if the probe is tucked snugly under the client’s arm and is against bare skin.
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10
Q

Tympanic Route

A
  • Not used much with adults in acute care, but sometimes in long term care
  • most often used with children
  • this route measures core temperature
  • not favoured because faulty technique produces inaccurate results

How to assess:
- The ear must be positioned by pulling the pinea slightly out, back, and up.
- With children, the pinea is pulled slight out, back, and down
- This technique straightens out the ear canal so the light source on the thermometer can reach the tympanic membrane

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11
Q

Temporal Route

A
  • measure of surface temperature and
  • less common route
  • A light source is aimed at the forehead which measures the temperature of the temporal artery
  • often used in primary care because it is simple, quick, and non-invasive.
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12
Q

Rectal Route

A
  • used less often than all the others because it is invasive, and there are alternative ways of assessing core temperature.
  • common in the pediatric population but it increases risk of bowel preformation when used with infants and very young children
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13
Q

What is a Pulse?

A
  • When the heart contracts, a pulse wave travels from the aorta to the distal-most points of the arteries creating a palpable vibration under the fingers (nurses use to count how many times the heart beats in one minute)
  • default location used when assessing vital signs is the radial site
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14
Q

How to assess pulse:

A
  • To count the radial heart rate, place 2 fingers (not your thumb) on the radial artery (thumb side of the client’s wrist) lightly and count for 30 seconds.
  • Multiply the number by 2 and document.
    • Values are always documented per minute, not per 30 seconds.
    • If the pulse at the radial site is irregular, count for 1 full minute then go to the apical site and auscultate/ count for 1 full minute. Then compare the two values + Document
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15
Q

Heart Rate Ranges

A

New born - 1month: 30-65
1 month -1 year: 26-60
1-10 years: 14-50
11-18 years: 12-22
Adult: 12-20

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16
Q

Factors Affecting Heart Rate

A

Age
- Babies and children have lower heart rates
- Resting heart rate does not change much with age

Sex
- Female heart rates are slightly higher than male heart rates due to smaller size of female heart

Exercise
- Heart rate increases with physical activity
- Regularly active people have lower resting heart rate

Fever
- Heart rate increases to circulate more blood to cope with the challenges/illness

Medication
Hemorrhage/fluid loss
- Increases; body attempts to circulate what little remains around the body to tissues

Stress
- Increases HR
Pain
Respiratory conditions
- Heart rate increases due to poor oxygenation and lung expansion

Heart conditions
- can increases/decrease HR

Hydration
- Increases; body attempts to circulate what little remains around the body to tissues

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17
Q

Apical heart rate

A
  • If the pulse at the radial site is abnormal/irregular, the apical heart rate is assessed and compared to the radial.
  • Auscultation of the apical heart rate is the primary method for measuring heart rate with babies and children (as opposed to palpation).
  • The apex of the heart is found at the 5th intercostal space, left mid-clavicular line.
  • It can sometimes be palpated in very slim individuals lying on their backs, and small children, but is most often auscultated with a stethoscope.
  • This is the same landmark for auscultating heart sounds (mitral) and breath sounds during respiratory assessment.
  • Counting the heart rate here and comparing to the radial site may reveal a pulse deficit which is abnormal.
    Sometimes breast tissue, well-developed pectoral muscles, or excessive adipose (fat) tissue needs to be displaced in order to auscultate
18
Q

Characteristics of a Pulse

A
  • strength, rhythm, regular

Grading of Pulses
0 - absent pulse
+ - feeble
++ - palpable but diminished compared to the other side
+++ - normal
++++ - bounding pulse

19
Q

What is a Pulse Deficit?

A
  • the difference in rate per minute between the heart beat and the peripheral pulses.
  • the heart contracts, but the pulse waves do not always reach the periphery.
  • Normally, there is no deficit as long as the heart is able to perfuse to the rest of the body.
20
Q

Conditions that can cause pulse deficit are:

A
  • Atrial fibrillation
  • Heart failure
  • Large volume blood loss
  • Extreme pain
21
Q

If there is a pulse deficit present:

A
  • The #’s will be different bw the 2 sites
  • The count at the apical site must be higher than the radial site
  • If you count a higher # radially than you do apically, repeat the assessment bc you have made an error
  • ** It is more likely that a difference of 1 or 2 beats is not actually a pulse deficit but instead nothing more than technique related
22
Q

How to Count Respirations:

A
  • Counting respirations is done at the same time as counting the radial pulse.
  • Position yourself next to the client so that you can see their chest rise and fall.
  • Tell the client you will be counting their pulse for about a minute.
  • count the radial pulse for 30 seconds, remember that number, and switch to watching the client’s chest rise and fall for the last 30 seconds.
  • Don’t change anything about where you are standing, keep your hands on the client’s wrist, but count the number of times the client’s chest rises and falls.
  • Then you will multiply each of those numbers by 2
23
Q

Normal Respiratory Ranges

A

Newborn -30-40
Infant: 26-40
1-10 Years: 14-50
11-18 Years: 12-22
Adult: 12-20

24
Q

Characteristics of Respiration Assessment

A
  • Depth
  • Rate
  • Rhythm
  • Not relevant: quality, strength, symmetry
25
Q

Normal Ranges Across the Lifespan

A

Shallow breathing
- Even if you are positioned well, it can still be difficult to see the client’s breathing pattern.
- put a hand on the client’s shoulder to feel the up and down movements with breathing, OR place their stethoscope on the chest and listen to the breathing that way

Tachypnea - breathing rate higher than expected range

Dyspnea - difficulty breathing

Client lying down
- Position matters for counting respirations.
- Position yourself beside the bed to watch the client’s chest rise and fall.

Irregular Rhythm
- count respirations for a full minute if the rhythm is irregular
- if regular, count for 30 seconds and multiplying by 2

Bradypnea - breathing rate is below normal range

Apnea - apneic episode is a pause in normal respirations for 10 or more seconds when sleeping

Combine PP & HR
- Staring at the client’s chest while you look at your watch causes the client to breathe unnaturally because they are so aware of being watched.
- combine RR with radial pulse assessment to create a seamless evaluation of both at the same time

  • smaller the body, the higher the respiratory rate
26
Q

What is Oxygen Saturation:

A

Oxygen saturation - an indirect measurement of the oxygen circulating in the blood.

  • A clip is placed on the finger and an infrared light source reads through the skin and tells us what percentage of the client’s hemoglobin (on the red blood cell) is fully saturated with oxygen.
  • Each hemoglobin can carry 4 oxygen molecules.
  • It is normal to have some red blood cells that have fewer than 4 oxygen molecules attached, and that is why the reading sometimes comes up as 98% or 97% instead of 100% even in healthy people.
  • The normal range is somewhere between 92-100% with a preference of over 95% for most clients.
  • Clients who have health conditions that prevent them from binding oxygen to their red blood cells, advanced respiratory diseases like COPD, clients who do not have enough red blood cells circulating around their bodies due to blood loss, will likely have low oxygen saturation readings.
  • An oxygen saturation of greater than 95% is actual NOT preferred, such as with clients with certain lung conditions like emphysema.
  • Giving a patient oxygen through their nose or a mask will not help them if they can’t bind it to hemoglobin or they don’t have enough hemoglobin for it to bind to.
27
Q

What happens if clients are less mobile than usual?

A
  • clients are less mobile when ill
  • can cause the alveoli in the lungs to shrivel, especially in the bases of the lobes.
  • Result = less surface area for gas exchange and clients’ oxygen saturation levels may decrease.
  • If the client’s SpO2 is =/< 95%, you can increase it by repositioning them to a seated/upright position and asking them to deep breathe and cough.

To do this:
- breathe in deeply through the nose and out the mouth
- repeat 2 more times
- on the 3rd exhale, ask the client to cough deeply (from way down deep, not a throat clear)

28
Q

Factors that interfere with reading SpO2

A
  • Tremor
  • Dark nail polish
  • Cold hands/fingers
  • Artificial nails
  • poor perfusion to the finger
29
Q

Blood Pressure

A

Blood pressure - the measurement of the pressure exerted on the walls of the arteries when the heart contracts and relaxes.

  • The pressure is high when the heart contracts to pump blood out to the body, and the pressure is low when the heart relaxes to allow the chambers to fill up with blood for the next contraction.
  • Stiff, plaque-filled, and occluded (blocked) arteries will all affect the client’s blood pressure.
  • Measuring blood pressure and comparing #’s over time can establish patterns and tell us, for example, if a treatment is having the desired effect or if a health condition is getting worse
30
Q

Blood Pressure Ranges

A

Low: <100/<60
Normal: 120/80
Elevated: 121-139/81-89
Hypertension (High BP): >140/>90

31
Q

Factors Affecting BP:

A
  • Age
  • Sex
  • Family history (genetics/hereditary)
  • Weight
  • Smoking
  • Circadian cycle
  • Stress
  • Emotional state
  • Medications
  • Position
  • Exercise
  • SDoH
  • Race/ethnicity
  • Diet (ie. Fat, sodium)
32
Q

Major Factors affecting BP:

A

Circulating volume
- Less blood circulating means less volume to exert force on the walls of the arteries
- HYPOTENSION - BP below normal
- High circulating volume, such as in pregnancy, can elevate the blood pressure
- HYPERTENSION - BP above normal

Peripheral vascular resistance
- Think about trying to push a large volume of fluid quickly through a straw. There is resistance there if the walls are thickened or stiff due to arterial disease, or if the vessels are narrowed due to build up of fatty plaques inside. This type of resistance raises blood pressure.

Elasticity (compliance) of vessels
- Stiffened/hardened arteries cause BP to rise.
- Vessels with elasticity can stretch to accommodate blood flow without encountering resistance, but stiff arteries do not stretch to accommodate increased volumes or flow.

Cardiac output
- Cardiac output - amount of blood the heart pumps out in 1 minute
- When things increase cardiac output, like exercise, this increases requirements of the vessels.
- Elastic vessels will accommodate that, stiff ones won’t.

Blood viscosity
- Viscosity refers to the thickness of
- Some conditions can cause blood to thicken which increases resistance

33
Q

Where to locate the Brachial Pulse:

A
  • find the pulse in the Antecubital Fossa
  • The brachial artery comes down and is most superficial here in the antecubital fossa (other side of your elbow).

Finding the pulse here has two purposes:
1. It helps you with cuff placement
2. It helps you with stethoscope
placement

  • Fingers are on the medial (inside) part of the arm
  • The pulse is less superficial than the radial so more pressure is usually needed to locate it.
  • You do not count this pulse, you are only locating it for the purposes of placing the cuff and your stethoscope
34
Q

Terminology

A

Mean arterial pressure (MAP)
- 1/3 of the SBP + 2/3 of the DBP
- It represents the average blood pressure during a single cardiac cycle.
- MAP of at least 60 mmHg is needed to perfuse the body’s organs.
- If the MAP is too low to perfuse organs, interventions to increase blood pressure include infusion of blood, fluid, and/or volume expanders

Pulse pressure
- The difference between the SBP and the DBP.
- Normal is ~40 mmHg.
- Wide pulse pressure - when the difference is large
- Narrow pulse pressure - when the difference is small

Orthostatic Hypotension
- A drop in blood pressure when moving from lying to sitting or sitting to standing.

Hypertension - High blood pressure

Diastolic BP
- The pressure is lower as the left ventricle relaxes and fills with blood.
- the beginning of diastole (di-AST-olee)

Systolic BP
- The force on the vessels when the left ventricle contracts.
- Indicates the beginning of systole (SIS-tol-ee)

35
Q

How to assess BP:

A

1) Position
- Lay client down in a bed that is raised to working height
- If the client is seated, ensure they are sitting up straight with their legs/ankles UNCROSSED and their back supported.
- If they are lying down in bed, the head of the bed can be at a comfortable height for the client. Lower the side rail. Uncross legs/ankles.

2) Locate brachial pulse
- If the client has sleeves, roll one up or remove the shirt if the sleeve is too tight when rolled. F
- Find the brachial pulse in the antecubital fossa.
- The arm should be straight and supported

3) Apply Cuff
- When you apply the cuff to the client’s arm, place the bottom edge of the cuff about 2.5cm/1” or so ABOVE the bend in the arm.
- LINE UP that artery marker with the spot you felt the brachial pulse.
- The artery marker should be pointing at the brachial pulse from it’s perch ~1 inch above the arm crease.
- Wrap the cuff around the arm and make sure it is snug enough
- When the cuff is on correctly, the artery marker will be lined up with the pulse, and the botttom of the cuff will be above the crease in the arm.

4) Place the stethoscope
- The diaphragm of the stethoscope can touch the cuff, but it should not be under it.
- Repalpate the brachial pulse and adjust the artery marker if needed. Put your stethoscope in your ears.

**NOTE: when you place your stethoscope in your ears and on the clients arm, YOU WILL NOT HEAR ANYTHING.
- The reason we hear anything at all is because we force the vessel to make noise by squeezing it shut and then gradually allowing it to open up again.
- Wherever you feel the brachial pulse the strongest is where you will place your stethoscope.
- Lay the diagphragm over the pulse and get firm contact there by pressing down on it.
- Hold it in place with your non-dominant hand. Make sure the client’s arm is still straight and supported.

5) Inflate cuff
- Prior to the assessment you should look at records to see what the usual BP is.
- If you are in primary care, a clinic setting, and certainly the hospital, there will be bedside records to tell you what the client’s blood pressure usually is. It is the top number you are interested in for this.
- Knowing the client’s approximate top number is what will help you determine how high to inflate the cuff.
- Overinflation of the cuff is painful and can skew the values. Look at the records and inflate the cuff 30 mmHg higher than the client’s average systolic BP (top number).
- Use you dominant hand to hold the bulb and your thumb and index finger to manipulate the valve.

6) Auscultate
○ Because you inflated 30 mmHg higher than the client’s likely systolic value, you should hear silence before the first sound comes in.
- If you inflate the cuff then begin deflating and hear sounds immediately, stop, open the value all the way to let the air out, and start over inflating another 30 mmHg higher next time.
- You want a good amount of silence at the beginning of auscultation.
- The goal is to deflate the cuff so that the needle on the dial falls at a steady rate.
- The sounds you hear each have their significance and are called Karotkoff sounds (there’s five). The only two sounds you need to listen up for are the FIRST and the LAST.
- 1st sound - SYSTOLIC BLOOD PRESSURE
- last sound - DIASTOLIC BLOOD PRESSURE
- After you have heard the last sound (you know it’s the last one because there is only silence after it) listen for 10 mmHg more.
- Some people have a ‘gap’ at the end and their sounds can disappear and then return. In that case, take that last sound after the sounds return
- After you have listened for any gaps, DEFLATE THE ENTIRE CUFF BY OPENING THE VALVE ALL THE WAY.

7) Communicate findings
- Being collaborative with clients is working WITH them, not working ON them.
- Communicate your findings. If the clients have questions, answer them.
- If you don’t know the answer, or don’t know what the findings mean, tell them that too. Then go find the answers.

8) Document
- Document the client’s blood pressure
- Look at the other values there–are they consistent with your values? Different? Do you need to reassess? Report the findings to someone else?

36
Q

Temperature Considerations for Babies and young children

A
  • There is no separate range of temperature depending on the age of the individual.
  • a temperature outside normal range for babies/small children is a bigger problem than with other age groups.
  • babies cannot regulate their own body temperature.
  • When babies and young kids have a fever, it is important to monitor the temperature.
  • High fevers can cause febrile seizures in babies and kids but they’re usually not serious
37
Q

Temperature Considerations for Older People

A
  • Normal body temperature does not change with aging,
  • it can become more difficult to control/maintain body temperature.
  • Loss of subcutaneous fat with aging often means older clients feel colder
38
Q

Normal Pulse Ranges

A
  • Newborn - 70-190
  • Infant - 10-160
  • Toddler - 80-130
  • Child - 70-115
  • Preteen - 65-110
  • Teen - 55-105
  • Adult 60-100
  • Elite athlete -50-100
39
Q

Normal Respiration Ranges

A
  • Newborn - 30-40
  • Infant - 20-40
  • Toddler - 25-32
  • Child - 20-26
  • Preteen - 18-26
  • Teen - 12-22
  • Adult 12-20
  • Over 65 - 16-24
  • Elite athlete - 10-20
40
Q

Blood Pressure

A
  • These values do not represent a range
  • this is why vital signs values must be interpreted by a nurse who understands the client’s health condition, including deviations from the ‘norm.’
  • Newborn - 73-55
  • Infant - 85/37
  • Toddler - 89/46
  • Child - 95/57
  • Preteen - 102/61
  • Teen - 112/64
  • Adult <120/80
  • Elite athlete - <120/80
41
Q

Oxygen Saturation Considers

A
  • the normal range for SpO2 does not fluctuate much with age
  • It fluctuates with health conditions.
  • A normal range of 92-100% applies to most clients, and then individual differences will exist depending on the client’s health.
  • Oxygen saturation measurement can be intermittent or it can be measured on a continuous monitor.
42
Q

Probe Styles for SpO2

A
  • There are different probes styles and sizes for clients
  • Finger probe - can be used on a toe
  • Forehead probe - useful for continuous monitoring bc it stays in place
  • Earlobe probe - there are lots of capillaries in the earlobe which makes it a good site for assessment of oxygen saturation
  • Toe probe - used for continuous monitoring and for clients who move around a lot (kids)

N1180 (13 decks)

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