Vital Signs Flashcards
Guidelines for taking vitals
- use appropriate equipment
- know pt’s usual ranges and values
- know reference ranges
- control environmental factors
- delegate tasks appropriately
- document accurately
Vital Signs Reference Ranges
- BP < 120/80
- Temperature 98.6°F - 100.4°F (36°C-38°C)
- Pulse: 60 - 100 bpm
- Respirations: 12 - 20 breaths per minute
- O2 Sat: 95% or higher
- Pain: Subjective, usually ranked 0 to 10
Factors affecting Temperature
- Age
- Exercise
- Hormonal Levels
- Circadian rhythm (drops during sleep)
- temperature alterartions
- environment
- stress
Factors affecting pulse
- age
- stress
- medications
- fever
factors affecting respirations
- exercise
- acute pain
- anxiety
- smoking
- body position
- medications (ie albuterol or narcotics)
- neurological injury
- hemoglobin function
Factors affecting O2 Sat
- nail polish
- carbon monoxide
- jaundice
- pt motion
- outisde light
factors affecting blood pressure
- age
- stress
- ethnicity
- gender
- daily variation
- medications
- activity
- weight
- smoking
Considerations for meauring BP
- Fistulas
- Mastectomy
- Dialysis
- Stroke
What is the max O2 for COPD patients?
2L. Anything higher may interfere with the patient’s hypoxic drive
Hypoxic Drive: mechanism that stimulates breathing response
Measures of core temperature
- tympanic membrane
- rectal
Rectal temperature is 0.9°F higher than oral
measures of surface temperature
- oral
- skin
- temporal artery
- axillary
Heat LOSS promotion
- remove excess clothing
- ice to groin and axilla
- cool wet towel
- cooling blanket
- IV fluids
Heat CONSERVATION promotion
- take off wet clothes
- heat pads
- hot liquids
- no alcohol or caffeine
changes during fever
- chills/shivers
- skin warm/flushed
- diaphoresis
- increased HR, RR, dehydration
Role of posterior hypothalamus
vasoconstriction to conserve heat
pulse sites
- carotid
- temporal
- apical
- brachial
- radial
- ulnar
- femoral
- popliteal
- posterior tibial
- dorsalis pedis
mean arterial pressure (MAP)
average pressure in the arteries in one cardiac cycle (70 - 105 mmHg)
Heart Sounds
- S1: Closing of AV valve
- S2: Closing of Semilunar valves
- S3: Ventricular Gallop (Systolic HF)
- S4: Atrial Gallop
Heart Sounds
APTM?
- Aortic Area
- Pulmonary Area
- Tricuspid Area
- Mitral Area
Ventillation
movement of gases in and out of lungs
Diffusion
movement of O2 and CO2 between the alveoli and RBCs
Perfusion
the distribution of RBCs to and from the pulmonary capillaries
Conditions not appropriate for electronic BP readings
- irregular HR
- shivering
- seizing
- excessive tremors
- inability to cooperate
- BP less than 90 mmHg systolic
characteristics of acute pain
- increased perspiration
- skin temperature decreases (cool and clammy skin)
characteristics of chronic pain
- fatigue
- withdrawal
pulse deficit
radial pulse < ventricular rate
systolic
ventricular contraction
diastolic
pressure when heart is relaxed/filling
