Vital Signs Flashcards
What are vital signs
- Are clinical measurements that include blood pressure, pulse, body temperature, respiration, and oxygen saturation.
- Provides a baseline of data to compare to future findings
- Identify trends, or patterns, that may indicate a change in a client’s condition.
- Guide treatment decisions and nursing interventions.
Blood pressure
A measurement of the force, or pressure, of the circulating
blood on the interior walls of the blood vessels.
Pulse
The rhythmic dilation of the arteries that occurs with the beating of the heart.
Body temperature
The balance of heat produced by the body and the heat
lost to the environment.
Respiration rate
The number of breaths taken per minute.
Oxygen saturation
The estimated amount of oxygen bound to the
hemoglobin molecule in red blood cells, indicating the amount of oxygen
being transported to body tissues.
Systolic and diastolic
Systolic BP: The maximum amount
of pressure exerted when the
heart contracts and forces blood
into the aorta.
Diastolic BP: The minimum amount
of pressure exerted when the heart
is relaxed.
Cardiac output (Exam)
BP is a direct reflection of cardiac output.
* Cardiac output = volume of blood pumped into the circulatory system in 1 minute
Cardiac Output = Stroke Volume x Heart Rate CO = SV x HR
* Stroke volume is amount of blood ejected by the
ventricle during one heart contraction.
Equation for cardiac output (Exam)
Cardiac Output = Stroke Volume x Heart Rate CO = SV x HR
hypertension (Exam)
- Hypertension is a blood pressure above the expected reference range.
- A client is diagnosed with stage I hypertension when the systolic pressure
is 130 to 139 mm Hg or the diastolic pressure is 80 to 89 mm Hg. - When a client’s systolic pressure is greater than 140 mm Hg or the
diastolic pressure is greater than 90 mm Hg, they have stage II
hypertension. - A hypertensive crisis occurs when the systolic pressure is greater than 180
mm Hg and/or the diastolic pressure is greater than 120 mm Hg. - Greatly increases risk for heart attack or stroke
hypertension can cause (Exam)
increase in: heart issues, drinking caffeine, pain, fever, exercise, Increase in sodium
decrease in: fever
nursing interventions for hypertension (Exam)
- Encourage lifestyle changes
- exercise, stress reduction techniques,
a low-sodium diet, and weight loss if
needed - Provide the client with information
about antihypertensive
medications, if prescribed by the
provider, including expected
adverse effects and when the
provider should be notified.
hypotension
- Hypotension = blood pressure below the expected reference range
- In the absence of baseline data, a systolic pressure less than 90 mm Hg or a diastolic pressure less than 60 mm Hg is typically considered hypotension for an adult.
- Manifestations of hypotension can
include dizziness, nausea, blurred vision, increased pulse, and fatigue
what is a common thing to cause hypotension
sepsis
extreme hypotension -> shock manifestations
- cold, pale skin
- rapid breathing (tachypnea)
- weak and rapid pulse
treatments for shock
- rapid IV fluid infusion or rapid administration of blood products
- medications that increase contractility of heart muscle and BP
orthostatic hypotension
- drop in blood pressure that occurs after standing up from sitting, or sitting up from a lying position.
- Causes include dehydration, general hypotension, heart failure, or disorder of CNS.
- To assess for orthostatic hypotension, check blood pressure while client is lying, sitting and standing with 1 minute between positions.
* These patients are fall risks
nursing interventions for hypotension
- Increase fluids.
- Place in a supine position unless medically contraindicated.
- Evaluate the medications the client is taking.
- Instruct the client about the risk for dizziness and falling.
- Encourage the client to change positions slowly.
- Avoid extremes in temperature.
- Stay well hydrated.
pulse
- The pulse is the rhythmic dilation of the arteries and pulsation of blood flow
that occurs with each contraction of the heart. - The expected reference range for an adult is 60 to 100 beats per minute.
pulse rate is a variable and influences by many factors including?
body position
age
activity level
health conditions
body temperature
auscultate and palpating at the apex
Apical pulse - auscultated and palpated at the apex of the heart
- Auscultation = should hear S1 and S2 (“lub dub”)
Apex of the heart heard (in adults and children over 7) at:
- left side of chest
- 5th intercostal space
- midclavicular line
Rhythm regular or irregular?
- listen and count for 1 full minute if irregular
grading pulses via palpation
- 0 = pulse that is absent/nonpalpable (none)
- +1 = pulse that is weak/diminished (weak)
- +2 = pulse that is normal
- +3 = pulse that is increased/strong (fast)
- +4 = pulse that is bounding (racing)
tachycardia
pulse greater than 100, some clients may experience no symptoms.
some may feel a “racing” feeling in the chest
possible causes of tachycardia
exercise
anxiety
certain medications
caffeine and nicotine
abnormality in the electrical system of the heart
nursing interventions for tachycardia
- Educate on possible causes to prevent it (use of nicotine or caffeine)
- provide resources/pamphlets
- Encourage relaxation techniques
- meditation
- yoga
- guided imagery
- Valsalva maneuver
- Bearing down as if having a bowel movement
bradycardia
pulse less than 60 beats per minute
- there are often no symptoms in physically fit individuals. others may report, dizziness, fatigue, SOB, chest pain, or confusion
possible causes of bradycardia
expected in physically fit individuals
congenital cardiac abnormalities
heart failure
heart muscle damage
hypothyroidisim
nursing interventions for bradycardia
- Instruct client to change positions slowly
- Take all medications as prescribed
- Keep all scheduled medical appointments
- Notify provider of any changes in health status
body temp
- The measurement of the balance of heat produced by the body and the heat lost to the environment.
- Measured in degrees
- degree celsius (common for charting)
- degree fahrenheit
- Expected body temperature is between 36° C and 38° C (96.8° F and 100.4° F).
- Average temperature for most clients is 37° C (98.6° F).
ways of measuring body temp
oral
tympanic membrane
temporal artery
axillary
rectal
hyperthermia
- A fever is an increase in body temperature above the expected reference range of 38° C (100.4° F).
- Commonly caused by infection.
- Symptoms may include a flushed face, diaphoresis, skin that feels “hot,” tachycardia, and increased respiratory rate.
nursing interventions for hyperthermia
- Encourage sips of cool fluids.
- Remove excess clothing.
- Administer medications as ordered.
- Antipyretics to reduce or prevent fever
- Antibiotics or antivirals if an infection
is present - Place the client in a cooler environment.
- Give a tepid bath.
hypothermia
- Abnormally low body temperature
- Early symptoms include:
- shivering
- decreased motor skills
- impaired peripheral perfusion
- Later symptoms:
- confusion
- poor concentration
- dilated pupils
- loss of consciousness (LOC)
nursing interventions for hypothermia
- Warming mats/blankets
- Bair Hugger
- Increase room temperature
- Layers of clothing/blankets
- Warmed IV fluids
respiratory rate
- Respiration consists of inspiration and expiration.
- Inspiration is the intake of air by the
lungs in order to oxygenate body
tissues and support cellular function. - Expiration expels carbon dioxide from
the lungs.
- Inspiration is the intake of air by the
- Expected reference range is 12 to
20 breaths per minute for adults.
eupnea
normal breathing
tachypnea
faster than normal
bradypnea
slower than normal
cheyne-stokes
end of life
- rapid and shallow, deep breaths, apnea and repeat
kussmual
deep and rapid
apnea
absence of breathing
what is tachypnea
- Respiratory rate above the expected reference range (greater than
20 breaths per minute). - Possible causes
- Physical activity
- Anxiety
- Pain
- Health conditions (e.g., asthma)
- Common symptoms
- Dizziness
- Tingling in the hands
what is bradypnea
- Respiratory rate that is below the expected reference range (less than 12
breaths per minute). - Possible causes
- Health conditions
- Medications: opioids, sedatives
- Common symptoms
- Dizziness
- Fatigue
- Weakness
- Confusion
- Impaired coordination
oxygen saturation
- Oxygenation saturation is the
estimated amount of oxygen bound
to the hemoglobin.- Expressed as a percentage
- Direct reflection of a client’s
respiratory status
- Expected reference range is 95%
to 100%
alterations in oxygenation
- Decreased oxygen saturation is a
level below 95%. - Possible causes
- Health condition (e.g., pneumonia,
chronic lung disease, pulmonary
edema, poor cardiac output).
- Health condition (e.g., pneumonia,
- Common symptoms
- Decrease in mental alertness
- Confusion
nursing interventions for hypoxia
Depends on underlying cause or etiology. Some routine interventions to increase
oxygen saturation include:
* Sitting client in upright position
* Take deep breaths/cough
* Apply oxygen as prescribed
* Flow rate depends on severity of hypoxia
* Give medications as prescribed
Impending respiratory arrest = notify doctor and prepare for intubation.
