Vital Signs Flashcards
General Symptoms
fatigue
generalized weakness
fever
chills
night sweats
weight change
pain
Fatigue is associated with
depression/anxiety
low blood count
stress
endocrine DX
viral
cancer
autoimmune
heart failure
liver or respiratory disease
electrolyte
Fever and chills
ask: Associated symptoms? Travel? sick contacts? medication use?
Fever maskers
NSAIDS
immunocompromised
older pts
Causes of Night Sweats
menopause
TB
Malignancy
Medications
drug addiction
thyroid disease
Weight Gain considerations
-excessive Kcal
-fluid retention
-medications (birth control, corticoid steroids, antidepressants, diabetetic meds)
Weight Loss
loss of 5%s over a 6-month period
-intentional vs unintentional
-malignancy, stress, older age, medications, GI disease, endocrine disorder, smoking, dentistry, social factors)
Acute pain
lasting hours, days or weeks
gradually resolves as injury heals
-surgery, trauma, acute illness
Chronic Pain
-not associated with cancer or other medical condition persisting>3-6mths
-Acute pain that lasts longer than a month
-Pain recurring at intervals
Nociceptive (somatic) pain
linked to tissue damage to the body
-acute or chronic
-dull, pressing, pulling, throbbing, boring, spasmodic, colicky
Neuropathic pain
-direct consequence of lesion or disease affecting the somatosensory system
-persists after healing from injury
-“electric shock, pins and needles, stabbing, burning)
OLDCARTSS
Onset, location, duration, character, aggravating and alleviating, radiation, timing, severity, symptoms
General Survey
Apparent state of health
level of consciousness
discomfort or distress (explain)
skin color or lesion
hygiene or grooming
facial expression
odors
posture/gait
height/weight
Nevi
Birthmark
Stadiometers
height measurment
BMI calculation
(Weight (lbs)/(Height in.)^2) x703
Underweight
<18.5 kg/m2
Normal BMI
18.5-24.5 kg/m2
Overweight BMI
25-29.9 kg/m2
Obesity class 1 bmi
30.0-34.9 kg/m2
Obesity class 2
35-39.9 kg/m2
Obesity class 3
> 40 kg/m2
if BP cuff is too small Bp is
High
If BP cuff is too large Bp is
low
Palpated Radial Pulse Obliteration Pressure
Inflate cuff and feel when you stop feeling radial pulse
-add 30 mmHg to determine target level for BP cuff
-avoids error from auscultatory gap
Auscultatory gap
silent interval between systolic and diastolic
-record the auscultatory gap in your documentation
Korotkoff sounds
heart beatNO
Normal difference between arms BP
5-10mmHg
Causes for abnormal BP pressure difference between arms
subclavian steal syndrome
supravalvular aortic stenosis
aortic dissection
Normal BP
120/80
Elevated BP
systolic= 120-129 AND
Diastolic=<80
Stage 1 hypertension
systolic=130-139
OR
diastolic= 80-90
Stage 2 hypertension
systolic= >140
OR
diastolic= >90
Between two BP categories?
Use higher category
Orthostatic BP measurment
Measure BP with pt lying supine
repeat with pt standing
Orthostatic Hypotension
Drop in SBP>20mmHg
Drop in DBP >10mmHG
Causes of orthostatic hypotension
Blood loss
older age
anemia
medications
POTS
White coat hypertension
isolated clinic hypertension
clinic bp >140/90 but normal at home
-does not need treatment
Masked Hypertension
Clinic BP <140/90 but elevated BP >135/85 at home
-untreated= risk of CVD, end organ damage
Tachycardia
> 100 bpm
Bradycardia
<60bpm
If irregular HR rhythm
OBTAIN EKG to identify rhythm
Apnea
cessation of breathing longer than 10 seconds
Tachypnea
RR>20brpm
Bradypnea
RR <12brpm
Signs of labored breathing
nasal flaring
accessory muscle use
intercostal retractions
position of breathing
Normal body temp
98.6 F
37 C
Pyrexia
> 100.4 F
Hyperpyrexia
extreme elevation
>106 F
Hypothermia
95 F
Worse way to measure temperature
axillary
Best way to measure temperature
Rectally
avoid oral temp on
unconscious patients
Restless pts
pts unable to close their mouth
pts who cant follow directions
Rectal Temperature
lubricate the tip
1.5 inches insertion
preferred in pediatric pts with fever
Rapid shallow breathing
Quick inspiration and expiration
-consider salicylate intoxication, lung disease, chest pain, elevated diaphragm
Rapid deep breathing
Hyperpnea (in response to metabolic demand)
Hyperventilation (rapid breathing independent of metabolic demand)
Kussmaul breathing
Kussmaul breathing
compensatory over breathing due to systemic acidosis
-common in diabetic ketoacidosis (DKA)
Bradypnea
Slow breathing
long periods of no inhalation and expiration
-consider uremia, drug induced, increased ICP
Cheyne stokes Breathing
Periods of increased inspiration and expiration/increased rate followed by apnea
-normal in children and adults while sleeping
-consider: heart failure, drug induced respiratory depression, TBI
Ataxic (Biot) breathing
irregular rate, inspiration and expiration
-consider: meningitis, respiratory depression, and brain injury (medulla level)
Sighing respiration
Eupnea with periods of increased inspirations
hyperventilation syndrome- suggested by frequent signs (causes dyspnea and dizziness)
Obstructive breathing
Prolong expiration
-narrow airways that increase the resistance of airflow
-consider: asthma, Chronic bronchitis, COPD
Vital Signs
Ht (feet, inches)
Wt (lbs)
BMI (kg/m2)
BP (mmHg), which limb, standing or sitting
Pulse (bpm), regular or irregular
Respirations (brpm), labored?
Temperature (F or C), how it was taken?
Pulse Ox (%), RA or Supplement O2
