VITAL SIGNS Flashcards
- Are measurements of the body’s most basic functions.
- Are the body’s indicators of health.
- Common, noninvasive physical assessment procedure that most clients are accustomed to.
*First step in physical assessment.
VITAL SIGNS
VITAL SIGNS also called
“Cardinal Signs”
the four main vital signs routinely monitored by medical professionals and health care providers including the following:
- body temperature
- pulse rate
- respiratory rate
- blood pressure
*is a measurement of our body’s ability to make or expel heat.
- THERMOREGULATION CENTER: Hypothalamus
BODY TEMPERATURE
— number of calories you burn as your body performs basic life-sustaining function
BMR
Types of Body Temperature
-Core
- Surface
— deep tissues of the body
— constant
Core
— transfer of heat from one molecule to a molecule of lower temperature through physical contact.
Conduction
— skin, subcutaneous tissue
— rises and falls in response to the environment
Surface
— transfer of heat without contact between the two objects (infrared rays).
Radiation
Types of Heat Transfer
- Radiation
- Conduction
- Convection
- Evaporation
— continuous vaporization of moisture from the respiratory tract and from the mucosa of the mouth and from the skin.
Evaporation
formula:
C= ?
F= ?
C= (Fahrenheit temperature - 32) * 5/9
F= (Celsius temperature * 9/5) + 32
— dispersion of heat by air currents.
Convection
Assessing Body Temperature
Oral
Rectal
Axillary
Tympanic
Temporal Artery
Normal Range: 35.9’C- 37.5’C
Client type: Older children and adults who are awake, cooperative, alert, and oriented.
*Do not use if client has just consumed very cold or very warm food or drink.
Advantage: Easy and accurate
Disadvantage: Cannot be used if client has had oral surgery, if the client is a smoker, or if the client is mouth breather.
ORAL
Normal Range: 36.3’C- 37.9’C
Client type: Adults who require a very accurate core temperature
*Use with caution because there is a higher risk of exposure to body fluids.
Advantage: Most indicative of core body temperature (when compared to other routes)
Disadvantage: Cannot be used with clients who have had rectal surgery, abscesses, diarrhea, low WBC, or cardiac disease
RECTAL
Normal Range: 35.4’C- 37’C
Client type: Infants, young children , and anyone with an altered immune system, because this technique is noninvasive.
Advantage: Easy to take
Disadvantage: Takes a very long time while nurse holds thermometer under client’s arm. Not as accurate as oral or rectal
AXILLARY
Normal Range: 36.7’C- 38.3’C
Client type: All clients, except with ear infection or ear pain
Advantage: Easy and quick to obtain
Disadvantage: There is no research to support the accuracy of this method (Mayo Clinic, 2018). Only one size of thermometer is available, and it is very difficult to use in children under 3 years of age
TYMPANIC
Normal Range: 36.3’C- 37.9’C
Client type: All clients, unless sweating profusely
Advantage: Easy and quick to obtain
Disadvantage: Sweating can interfere with accurate reading
TEMPORAL
FACTORS AFFECTING BODY TEMPERATURE
AGE
EXERCISE
HOMONAL LEVEL
CIRCADIAN RHYTHM
ENVIRONMENT
ILLNESS OR INFECTION
Types of Fevers
- Intermittent
- Remittent
- Relapsing
- Constant
alternates at regular intervals between periods of fever and periods of normal/subnormal temperatures.
- Intermittent
wide range of temperature fluctuations all of which are above normal
Remittent
fluctuates minimally but always remain above normal
Constant
short febrile periods of a few days are interspersed with periods of 1 or 2 days of normal temperature
Relapsing
Nursing Interventions During Fever
- Monitor vital signs and skin color
- Encourage fluid intake
- Tepid sponge bath
- Dry clothing and linens
- Antipyretics
- Monitor lab values
Nursing Interventions During Fever
- Monitor vital signs and skin color
- Encourage fluid intake
- Tepid sponge bath
- Dry clothing and linens
- Antipyretics
- Monitor lab values
PROCEDURE: Count the rate for a full minute, noting the regularity (rhythm).
*When an irregular peripheral pulse is present, the nurse needs to assess for a pulse deficit.
PROCEDURE: Count the rate for a full minute, noting the regularity (rhythm).
*When an irregular peripheral pulse is present, the nurse needs to assess for a pulse deficit.
- A shock wave produced by the contraction of the heart and forceful pumping of blood out of the ventricles into the
aorta - Is an indirect measurement of cardiac output obtained by counting the number of apical or peripheral pulse waves over a pulse point.
- A normal pulse rate for adults is between 60 and 100 beats per minute
PULSE
PULSE commonly called
arterial or peripheral pulse
- Condition in which the apical pulse rate is greater than the radial pulse rate
- A ____________ results from the ejection of a volume of blood that is too small to initiate a peripheral pulse wave.
Pulse Deficit
assessment of pulse
*assessed using a stethoscope
temporal
carotid
brachial
femoral
dorsalis
pedis
apical
ulnar
radial
popliteal
posterior tibial
Amplitude can be quantified as follows:
3+ Bounding (requires firm pressure)
2+ Normal (obliterate with moderate pressure)
1+ Weak, diminished (easy to obliterate)
0 Absent
Amplitude can be quantified as follows:
3+ Bounding (requires firm pressure)
2+ Normal (obliterate with moderate pressure)
1+ Weak, diminished (easy to obliterate)
0 Absent
characteristic of pulse
rate
rhythm
strength
equality
-is the regularity of the heartbeat
-there are regular intervals between beats
- Pulse Rhythm
-irregular heart beat
- Dysrhythmia
-Artery feels straight, resilient, and springy
- Arterial Elasticity
-is a measurement of the strength or amplitude of force exerted by the ejected blood against the arterial wall with each contraction
- Pulse Volume
normal respiratory rate
12-20 breaths/min
normal respiratory rate ranges
AGE:
- NEWBORN TO 6 WEEKS
- INFANT (6 WEEKS TO 6 MONTHS)
- TODDLER (1-3 YEARS)
- YOUNG CHILDREN (3-6 YEARS)
- OLDER CHILDREN (10-14 YEARS)
- ADULTS
normal respiratory rate ranges
BREATHS/MIN:
- 30-60
- 25-40
- 20-30
- 20-25
- 15-20
- 12-20
is a heart rate less than 60 beats per minute in an adult may be normal in well – conditioned clients
- Bradycardia
- The act of breathing
- Rate and character are additional clues to the client’s overall health status
Respirations
-is a heart rate in excess of 100 beats per minute in an adult
-may be normal in clients who have just finished strenuous exercise
- Tachycardia
movement of breathing
- normal amount od inhaled air (tidal volume) =500 mL
- inspiration
- expiration
- breath/minute
- can be influenced by activity and age, as well as by illness, injury, or disease
respiratory rate
- deep, normal, shallow
ventilatory depth
- regular / irregular
ventilatory rhythm
factors influencing character of respirations
- exercise
- acute pain
- anxiety
- smoking
- body position
- medication
- neurological injury
- hemoglobin function
< 12 breaths/minute
bradypnea
> 20 breaths/minute
tachypnea
> 20 breaths/minute; labored breath, increased rate and depth
hyperpnea
no respiration for several seconds
apnea
increased rate and depth of respiration
hyperventilation
decreased rate and depth of respiration
hypoventilation
2-3 abnormally shallow breaths followed by an irregular period of apnea
bio’t respiration
alternating patterns of depth separated by periods of apnea and hyperventilation
cheyne-strokes
deep and labored, increased rate
kussmaul’s
normal blood pressure
120/80 mm Hg
is the force exerted on the walls of an artery by the pulsing blood under pressure when pumped by the heart.
arterial blood pressure
maximum peak pressure during ventricular contraction
systolic pressure
minimum peak pressure during ventricular contraction
diastolic pressure
mm Hg in bp is
millimeter of mercury
The American College of Cardiology and the American Heart Association______________ define normal blood pressure as systolic less than 120 mmHg and diastolic less than 80 mmHg
(Cifu & Davis, 2017)
Arterial blood pressure is the result of several factors:
- Pumping action
- Peripheral vascular resistance
- Blood volume
- Blood viscosity
A ________________ (e.g., less than 25 mmHg) occurs in conditions such as severe heart failure.
low pulse pressure
systolic >160 mm Hg
diastolic >100 mm Hg
stage 2 hypertension
systolic stage of hypertension according to the american heart association
- stage 2 hypertension
- stage 1 hypertension
- prehypertension
- normal
systolic 120-139 mm Hg
diastolic 80-89 mm Hg
prehypertension
systolic <120 mm Hg
diastolic <80 mm Hg
normal
systolic 140-159 mm Hg
diastolic 90-99 mm Hg
stage 1 hypertension
When taking a blood pressure using a stethoscope, the nurse identifies phases in the series of sounds called
Korotko sounds.
An ________________ is the temporary disappearance of sounds normally heard over the brachial artery when the cu pressure is high followed by the reappearance of the sounds at a lower level.
auscultatory gap
A drop in BP of 20 mmHg systolic or 10 mmHg diastolic or increase in pulse of 20 bpm indicates
Orthostatis/Postural Hypertension
Factors Affecting Arterial Blood Pressure
Age
Stress
Ethnicity
Gender
Daily variation
Medications
Activity, weight
Smoking
Diet
High salt/sodium diet
Processed foods
High amounts of caffeine
Excessive alcohol intake
Peripheral vasculature tone decreases and lessens blood return to the heart. Central cardiac tone decreases, which lowers the force of contraction
Age
Genetic and environmental factors are often contributing factors
Ethnicity
Direct alteration: antihypertensives Indirect alteration: opioid analgesics (↓blood pressure and volume), vasoconstrictors († blood pressure)
Medications
Causes sympathetic stimulation, which increases heart rate, cardiac output, and vascular resistance
Stress
Higher blood pressure in men after puberty and in women after menopause
Gender
Blood pressure lowest between hours of sleep: ↑ blood pressure when waking up
Daily variation
Modifiable risk factors blood pressure:
Obesity
Smoking
Alcohol/caffeine consumption
High sall/sodium intake
Nonmodifiable risk factors blood pressure:
Age
Gender
Ethnicity
Family history
Exercise can reduce blood pressure for several hours: obesity can trigger hypertension
Activity, weight
Directly affects vessels and leads to vasoconstriction, which causes ↑ blood pressure
Smoking
detects the amount of oxygen bound to RBCs and calculates the oxygen saturation (SpO₂)
Photodetector:
What Can Affect Oxygen Saturation?
Infection
Disease
Peripheral perfusion
Activity
normal Oxygen saturation
95%-100%
The amount of oxygen that is in t the blood carried to the extremities of the body (fingers, ears, nose, toes)
Usually between 95% and 100%
oxygen saturation (SaO2)
Pulse Oximeter Levels
95%-100%
Normal blood oxygens levels
91%-95%
“Concerning” blood oxygen levels
<90%
Low blood oxygen levels
80%-85%
When low oxygen saturation affects the brain
< 67%
Cyanosis no oxygen perfusion to extremities
Pulse Oximeter Levels
95%-100%
Normal blood oxygens levels
91%-95%
“Concerning” blood oxygen levels
<90%
Low blood oxygen levels
80%-85%
When low oxygen saturation affects the brain
< 67%
Cyanosis no oxygen perfusion to extremities
Types of Oxygen Saturation Probes
Finger
Nose
Ear
Forehead
