Vital Signs Flashcards
Acceptable Ranges for Adults
(Temperature, Pulse, Blood Pressure, Respiration, O2 Saturation)
Temp: 36C - 38C (96.8F - 100.4F)
Pulse: 60 - 100 Beats/min
BP - Systolic: less than 120
- Diastolic: less than 80 mmhg
Pulse Pressure: 30-50 mmhg
Respiration: 12-20 breaths/min
O2 Sat: SPO2 95-100
When to Measure Vital Signs (BASSH)
Before during after
- blood products transfusion
- medication administration
- nursing intervention
Admission
Status Changes
Symptoms that are non-specific
Hospital Routine Schedule
General Preparation WIPE
- Wash hands before and after procedure
- Identify Information patient abt procedure
- Provide privacy and position patient accordingly
- Explain procedure and evaluate
detects signals from receptors and sends signals to effectors to regulate body temperature.
Hypothalamus
Low body Temperature preserves heat by limiting blood flow to surface
Vasoconstriction
High body temperature increase blood flow to surface to promote
Heat loss
4 types of heat loss
- Radiation - transfer of heat from an object to another without direct contact
- Conduction – transfer of heat from one object to another with direct contact.
- Convection – heat loss through air movement.
- Evaporation – transfer of heat via evaporation
Factors Affecting Body Temperature
- Age
- Exercise
- Hormone level
- Circadian rhythm
- Stress
- Environment
Fever vs Hyperthermia
Fever: pyrexia; infection
Hyperthermia: Nausea and vomiting
- Fainting
- Moderately increased temperature
When the temperature drops the usual range of body temperature
Hypothermia
How to measure body temperature
- Oral 37C or 98.6F
- Axillary 36.5 or 97.7F (armpit)
- Tympanic 37C or 98.6F (ear)
- Rectal 37.5C or 99.5 F(Butt but recommended for babies)
1.5 inches for adults
0.5 inches for babies
Celsius to fahrenheit
(C x 1.8) + 32
Fahrenheit to celsius
(F - 32) x 5/9
Nursing Intervention for Hyperthermia AILMENT
Antipyretics
Limit physical activites
Increase rest
Monitor skin color and temp
Monitor blood count
Excess blankets when patient feels warm
Nutrition and fluids
Tepid sponge bath
Nursing intervention for hypothermia CCAKES
Cover patient scalp with cap
Clothes are dry
Apply warming pads
Keep limbs close to body
Environment warm
Supply warm oral and IV fluids
Amount of blood ejected per heartbeat
Stroke Volume
Amount of blood ejected within 1 minute
Cardiac output
Sites of Pulses
Radial - circulation of hand (near thumb)
Apical - 5th ICS at left clavicular line (for infants)
Brachial - for blood pressure
Irregular rhythm of pulse
Dysrhythmias
Phases of Fever (Pyrexia)
- Cold/Chill Phase
- Plateau Phase (warm skin)
- Fever Abatement/Flush Phase (Sweating)
Types of Fever SIRR
- Sustained - elevated temp above 38C
- Intermittent - temp spiked and returned to acceptable range after 24 hrs
- Remittent - temp spiked and fluctuated but with no return to normal temp
- Relapsing - returns to normal but recus
Chracteristics of pulse
Infant - 120-160 bpm
Toddler - 90-140
Preschooler - 80-110 bpm
School aged - 74-100 bpm
Adolescent 60-90 bpm
Adult - 60-100
Less than 60 beats/min
Bradycardia
Greater than 100 beats/min
Tachycardia
Tachypnea
RR over 20
Bradypnea
RR below 12
Absence of Breathing
Apnea
Overexpansion of lungs
Hyperventilation
Underexpansion of lungs
Hypoventilation
alternating periods of
apnea and hyperventilation; cardiac failure, increased
ICP, or brain damage.
Cheyne-Stokes breathing
shallow respiration of the same depth
followed by a period of apnea.
Biot’s
abnormally deep, regular, increased
rate; hyperventilation commonly seen in patients with KDA.
Kussmaul’s
Blood Pressure
Systole - Peak of maximum heart ejection
Diastole - Ventricular relaxation
Millimeters of mercury - mmhg
Difference between systole and diastole
Pulse pressure
Cardiac output
Stroke volume x heart rate
Loses elasticity; cannot compensate for the increased vascular resistance.
Arteriosclerosis
Ranges of BP
Normal - lower than 120 systolic and lower than 80 diastolic
Prehypertension - systolic: 120-139 ; diastolic: 80-89
Stage 1 Hypertension - systolic: higher than 140 ; diastolic: higher than 90
Stage 2 Hypertension - systolic: higher than 160 ; diastolic: higher than 90
Hypotension
Lower than 90mmhg or below
- Also known as postural hypotension, occurs when a normotensive person develops symptoms.
- Drop in blood pressure at least 20 mmHg for either systolic or diastolic pressure due to sudden movement or change in position.
Orthostatic Hypotension
Korotkoff’s sound Phases
Phase 1: First sound: Onset of Systolic Pressure. (Tapping)
Phase 2: Blowing or swishing sound occurs.
Phase 3: Blood flows freely through open artery, more intense. (Crisp)
Phase 4: Sounds become muffled and low pitched.
Phase 5: The last sound is heard: Diastolic pressure.
an unpleasant sensory and emotional experience, which we primarily associate with tissue damage or describe in terms of such damage, or both (IASP).
Pain
Types of Pain
- Referred pain - arising in different areas or other parts of body
- Visceral Pain - arisings from organs
- Acute Pain - lasts through recovery period
- Chronic Pain - prolonged over 6 months
Concepts associated with pain
- Hyperalgesia/Hyperpathia – increased sensation of pain in response to a normally painful stimulus.
- Allodynia – sensation of pain from a stimulus that normally does not produce pain (e.g., light touch).
- Dysesthesia – unpleasant abnormal sensation that can either be spontaneous or evoked.
Pain Assessment PQRST COLDSPA
Provocation (what)
Quality (how does it feel)
Radiation (where pain)
Severity (pain scale)
Time (when)
Character
Onset
Location
Duration
Severity
Pattern
Associated factors
