Vital Signs Flashcards
Definition
- Temperature, Pulse, Respiration, and Blood Pressure
- Indicates the state of health of individual
Define Temperature
Difference between heat produced and heat lost by the body
4 methods of checking temperature
- Oral Method
- Axillary Method
- Rectal Method
- Non-contact Method
Both of these methods have the following contradictions:
- Infants
- Unconscious and Irrational Patients
- Patients with Oral cavity and surgery in mouth
- Patients that recently taken cold or hot food or fluids
Oral Method and Axillary Method
This method has the following contradictions:
- With recent rectal surgery
- Patients with diarrhea
- Patiends having cardiovascular alternation
- Pateints with leukemia
Rectal Method
Define Pulse
Rythmical throbbing caused by wave of blood passing through and artery as heart contracts
What are the possible sites to checking for a person’s pulse?
- Temporal artery
- Carotid artery
- Brachial Artery
- Radial Artery
- Apical Artery
- Femoral Artery
- Popliteal Artery
- Posterior Tibialis
- Dorsalis Pedis
What should we be mindful of when taking a person’s pulse? R.R.T.V
Rate, Rythm, Tension, and Volume
Average Normal Pulse rate range for new borns?
80 to 180 bpm
Average Normal Pulse rate range for 1 year olds?
80 - 140 bpm
Average Normal Pulse rate range for 5 - 8 yrs old
75 - 120 bpm
Average Normal Pulse rate range for 10 yr olds
50 - 90 bpm
Average Normal Pulse rate range for Teens
50 - 90
Average Normal Pulse rate range for Adults
60 - 100 bpm
Average Normal Pulse rate range for elderly
60 - 100 bpm
Purpose for checking a person’s pulse
estimate quality of the heart’s action per minute
Where do we assess a new borne or infants pulse
Brachial, apical, or femoral aretery
Define Respiration
exchange of oxygene and CO2 between the atmoshpere and body cells initiated by breathing
Purpose for checking a person’s cpr
obtain patient’s respiratory status
Blood Pressure
lateral force exerted by the blood on arterial walls
Purpose for checking a persons blood pressure
- aids in diagnosis
- enables observation for any changes in patients condition
Contradictions for checking BP in brachial artery
- Pateints with surgery on arm, breast, axilla, shoulder, or hands
- Venous access device like AV shunt and IVF
- Injury or Disease to shoulder, arm or hands
Sites for taking BP
- antecubital space on arm
- Leg or popliteal space
- dorsal pedis
Classifications of Blood Pressure
Normal =
Prehypertension =
Hypertension Stage 1 =
Hypertension Stage 2 =
Normal = 120/80 mmhg
Prehypertension = 120-139/80-89 mmhg
Hypertension Stage 1 = 140 -159/ 90-99
Hypertension Stage 2 = 180/100
Normal Temperature
36 to 36.5 C
Heat loss can happen through
- radiation
- conduction
- convection
- vaporization
Normal O2SAT
95% to 100%
How to assess pain
WHATSUP ACRONYM:
W - where is the pain?
H - how does the pain feel?
A - aggravating & alleviating factors
T - timing
S - severity
U - useful other data
P - perception
Term For High Fever
Hyperlexia
Medical term for patient that has fever?
Fibril
- The 5th vital sign
- easiest to asses
- must not be invalidated
- highly subjective
- most common reason to seek medical advice
- protective mechanism or warning to prevent injury
Pain
Pain Transmissions
- pain receptors
- free nerve endings on skin
- respond to intense potentially damaging stimuli
- found in joints, skeletal muscle, fascia, and tendons
- not found in large organs
Nociceptors
These chemical increase the transmission of pain
HISTAMINE - stimulates allergic reactions
ACETYLCHOLINE - fight/flight response
SEROTONIN - happy hormone
BRADYKININ - inflammation
- A group of lipids made at sites of tissue damage or infection
- releases chemical substances that increases sensitivity to pain
- increases pain provoking effect of bradykinin
Prostaglandinds
2 main fibers that help with pain transmission
- Myelinated fibers - fast pain
- type C fibers - second wave of pain
Chemicals or hormones that reduce or inhibit pain
endorphins and enkephalins
Process of pain flow
- Transduction
- Transmission
- Perception
- Medulation
Process of pain flow
- injury releases chemicals that send pain message to sensory neuron
Transduction
Process of pain flow
- nociceptors to spinal cord then to the brain
Transmission
Process of pain flow
- pain received by the brain
Perception
Process of pain flow
- reduces or increase the pain by the brain stem neuron
Medulation
Types of Pain according to duration and Etiology
- Acute
- chronic
Types of pain according to location and perception
- visceral or internal pain
- somatic or pain in muscles, skin, and joints
- Cutaneous or superficial pain
- Radiating or pain travels from one part to another
- Referred or pain is experienced simultaneously on different parts of the body
- Phantom or pain felt only because of psychological factors
Pain assessment tools
- for people with chronic pain
- help identify patterns and factors
- records time or onset, activity before pain, pain related positions or behaviors, pain intensity, use of relief methods, duration of pain, time spent in relief activities
Daily Pain Diary
Pain assessment tools
- visual representation of pain scale
Visual Analog Scale
Pain assessment tools
- 0 to 10 rating
- best for adults with not cognitive problems
- common tool
Numerical Rating Scale
Pain assessment tools
- best for cognitively impaired
- nurse observes face of the client
Wong Bakers scale
Pain assessment tools
- document for detailed recording of pain
Mccaffrey Initial Pain Assessment Tool
Pain assessment tools
- FLACC Behavioral Scale
For kids
