Vital Signs Flashcards
when should you measure vital sings?
- If a registered nurse is not present, vital signs should be taken by the MRT when a patient is brought to the department for any invasive diagnostic procedure.
- Before and after the patient receives medication or as required by preprocedural screening (usually CT).
- Any time the patient’s general condition suddenly changes. (LOC)
- If the patient reports non-specific symptoms of distress. E.g. “I don’t feel so good”.
Is a physician’s order required to measure vital signs?
no
what are cardinal signs?
another name for vital signs
what is included in patient’s vital signs?
body temperature, pulse and respiration
Blood pressure as a vital sign
blood pressure is not a true vital sign category, but is often measured with the other three in the overall assessment of the patient
Pain as a vital sign
physiologic responses are indicators of adversity or response to therapy. One such response is pain and can be considered a vital sign
what fluctuations of temp are large enough to affect physiology?
2-3 C
What part of the brain controls thermoregulation?
hypothalamus
what is thermoregulation?
- Hypothalamus plays a role in preservation of heat through shivering and vasoconstriction.
- Regulation of heat loss through diaphoresis and peripheral vasodilation.
normal body temp and common daily variation
37 °C (98.6 °F)
daily variation 0.5 - 1 °C (1-2 °F)
Hypothermia
- Body temperature is below normal limits.
- May be induced medically or by trauma to hypothalamus
- Reduces patient’s need for O2 and therefore, cardiopulmonary system slows down (bradycardia)
Hyperthermia
- Elevated Body temperature
- Febrile
- Usually due to disease process
- As body temperature increases, body demands for O2 increase, CO2 production increases.
what is ferbile?
having or showing signs of having a fever
pyrexia meaning?
fever
measuring body temperature
- Site is chosen based on patient’s age, state of mind and ability to cooperate in the procedure.
- Because the reading varies depending where it is measured, site used must be included when recording or reporting.
Oral temperature
- mouth (under tongue)
- used in adults and cooperative children
- 37 °C O or 98.6 °F O
Axillary temp
- armpit
- particularly useful with infants
- time and precision of placement needed to obtain an accurate reading make this method somewhat unreliable
- 36.4-36.7 °C Ax or 97.6-98 °F Ax
Rectal temperature
- Anal opening to rectum
- Most reliable measurement – close to the “core”
- Should not be taken if the patient is restless or has rectal pathology.
- Normally only on infants
- Blunt & lubricated tip – probe cover is red
- 37.5 °C R or 99.6 °F R
Tympanic temperature
- Ear
- aka aural
- Thermometer is a small, hand-held device that measures the temperature of the blood vessels in the tympanic membrane of the ear.
- Core body temperature reading.
- Fast and easy method of obtaining reading in a clinical setting.
- 36.4 °C T or 97.5 °F T
temperature sensitive patches
- placed on abdomen/forehead.
- If abnormal temperature is indicated, a more accurate method can be used to verify reading.
temporal artery thermometers
- The temporal artery runs superficial in the temporal region of the skull.
- “Scanning” of the forehead or back of ear with a probe.
- Non-invasive swipe using along the forehead and temporal region provides immediate, accurate measurement.
- X °C TAT
- measurements approx. 1 °F higher than oral readings
Pulse
- Reflects rapidity of heart contractions.
- As the heart beats, the left ventricle contracts and blood is pumped into the aorta and arteries.
- Result: throbbing or pulsating of the artery that is felt superficially by locating arteries through the skin.
- Don’t press too hard, may obliterate.
normal pulse rate of an adult?
60-90 BPM
pulse of child
4-10 years
90-100 BPM
Infant pulse
0-3 years
120 BPM
Apical pulse
- listening to heart directly
- counting heartbeat
- if there is any doubt about the rhythm or rate of heart, take an apical pulse
- An apical pulse will never be lower than the radial pulse.
- 5th intercostal space, 3 – 4 inches lateral to left sternal margin .
- Count beats for 1 min.
Radial pulse
- At wrist (at base of thumb)
- Count for one minute
- When taking pulse, use pads of the middle of fingers
- Radial pulse is usually the most accessible and can be taken most conveniently on an adult
Brachial pulse
- Located in antecubital fossa above the elbow.
- To find a pulse, locate the brachial artery in the upper arm.
- Use two fingers to feel for the pulse
Carotid pulse
- At angle of mandible over carotid artery
- Typically, during CPR
- Push up with fingers slightly anterior and below the angle of the mandible.
femoral pulse
- over femoral artery in groin
- not routine
popliteal pulse
- behind knee
- trauma
temporal pulse
- over temporal artery - in front of ear
dorsalis pedis pulse
- at the top of the foot in line with the groove between 1st and 2nd toes
- between the extensor tendon of the great and second toe
- may be congenitally absent
posterior tibial pulse
medial aspect of ankles
what patients often have a low heart rate?
fit individuals and hypothermic patients
assessment of pulse
should be taken at rest
- apical most accurate for infants
- assess strength and regularity of pulse as well as number of beats per minute
- should be regular with equally timed intervals between beats
Tachycardia
abnormally rapid heart rate (>100 BPM)
Bradycardia
abnormally slow heart rate (<60 BPM)
Electrocardiography
- Process of producing an electrocardiogram (ECG/EKG).
- An ECG is a recording of the heart’s electric activity.
- Graph of voltage versus time of the electrical activity of the heart using electrodes placed on the skin.
ECG electrodes
These electrodes detect the small electrical changes that are a consequence of cardiac muscle depolarization followed by repolarization during each cardiac cycle (heartbeat).
what cardiac abnormalities can cause changes in the normal ECG pattern
cardiac rhythm disturbances (atrial fibrillation and ventricular tachycardia), inadequate coronary artery blood flow (such as myocardial ischemia and myocardial infarction), and electrolyte disturbances.
traditionally how is an ECG done?
painless
- traditionally usually means a 12 lead ECG taken while lying down
simplest and fastest way of evaluating the hearts activity
isoelectric line
The baseline of an ECG is called the isoelectric line and signifies resting membrane potentials.
deflections
Deflections are the positive or negative changes in the tracing relative to the isoelectric line over the time of the cycle.
p wave
- Represents depolarization of the atrial muscle cells.
- SA node fires at the start of the P wave.
- Atrial contraction begins at the peak of the P wave.
QRS complex
- Represents depolarization of the ventricular muscle cells.
- The Q portion is the initial downward deflection.
- The R portion is the initial upward deflection. Contraction commences at the peak of the R portion.
- The S portion is the return to baseline.
T wave
- After depolarization, ventricular muscles repolarize.
- This generates a T wave.
- Although not always seen, the U wave represents the repolarization of the papillary muscles and the Purkinje fibers.
PR interval
- Measured from the beginning of the P wave to the beginning of the QRS complex.
- The PR interval commences with atrial depolarization and ends with the start of ventricular depolarization, indicating electrical impulse passes through to the AV node during this interval.
determining regular or irregular rhythm
If the intervals between peak of QRS complexes (RR intervals) are consistent, ventricular rhythm is regular.
STEMI
Profoundly life threatening and associated with atherosclerosis (CAD)
- ED physician activated system STEMI notification system.
- The goal is to reduce door to balloon (angioplasty) time.
respiration
the action of inhaling oxygen and exhaling carbon dioxide while breathing
adult respiratory rate
12-20 breaths/min
child respiration rate
1-10 years
20-30 breaths/min
newborn/infant respiration rate
under 1 year
30-60 breaths/min
low respiration rate
respiration fewer than 10 breaths per minute for an adult may result in cyanosis, apprehension, restlessness and change in LOC
assess rate of respiration
- Count number of times the patient’s chest (abdomen) rises and falls for one full minute (inspiration and expiration).
- Patients who are aware that respirations are being counted may alter their normal pattern of breathing.
assessing respiration
- rate of respiration
- pattern of respiration (regular or irregular)
- depth of respiration (shallow, normal or deep) determines tidal volume
recording respiration
when recording respiration, use abbreviation “R”
R20 = 20 rises and falls of the chest wall
dyspnea
- common term used to describe difficulty breathing
- often presents as shortness of breath
tachypnea
- Respiratory rates greater than 20 breaths per minute in adults.
- Causes include exercise, fever, infection, pain, heart failure, chest trauma, decreased oxygen in blood, and central nervous system pathology.
Bradypnea
- Abnormal decrease in respiratory rate.
- Less frequent than tachypnea.
- Results from depression of the respiratory centers of the brain – common with drug overdoses, head trauma and hypothermia.
orthopnea
difficulty breathing unless sitting up or standing erect
apnea
absence of spontaneous ventilation
stridor
- Latin derivative: “stridulus” means creaking, whistling, or grating
- Caused by narrowing or obstruction of airway
- May also be the first sign of a serious and even, life-threatening disorder.
- Therefore, patient should not be left unattended
Blood pressure
- Pressure is product of flow and resistance.
- BP is the reflection of resistance the blood meets in the systemic vasculature when it is ejected from the left ventricle of the heart during systole.
PVR
Peripheral Vascular Resistance
- Resistance of the circulatory system (arterioles) that is used to create BP.
- Vasoconstriction: ↑ PVR
- Vasodilation: ↓ PVR (shock)
- PVR is mediated on a neuro-hormonal level.
cardiac output
- the amount of blood your heart pumps each minute
- cardiac output = stroke volume x HR
Pumping action of the heart
- slowing down the heart rate, reduces how hard the heart must work
- beat blockers
blood volume
- Dehydration/hemorrhage – IV fluids/blood products as Rx
- Diuretics to reduce BP. E.g., hydrochlorothiazide (HCTZ), Lasix
Blood viscosity
- The number of red blood cells in the blood plasma determines the viscosity of the blood.
- With an increased number, the blood becomes more viscous and subsequently, increases the blood pressure.
- Rx: blood thinners e.g. aspirin, coumadin, heparin
Elasticity of the arterial vessel wall
- Vasoconstriction can result in increased blood pressure.
- Rx: ACE inhibitors – blocks the production of angiotensin (vasoconstrictor), causing the blood vessels to relax, resulting in drop in BP.
Factors that affect BP
- BP normally varies with age, sex, physical development, body position, time of day and health status.
- BP increases with age due to deterioration in systems that regulate it.
- Males usually have higher blood pressure than females.
- Lower in the morning after a night of sleep.
- Increases after a large intake of food.
- Emotions and strenuous activity cause systolic pressure to increase.
highest point of blood pressure
The highest point reached during contraction of the left ventricle of the heart as it pumps blood into the aorta (Systolic Pressure, numerator)
lowest point of blood pressure
The lowest point to which the pressure drops during relaxation of the ventricles (Diastolic Pressure, denominator)
normal blood pressure range of an adult?
95-120 mmHg: Systolic
60-80 mmHg: Diastolic
normal blood pressure range of an child?
104 - 120 mm Hg: Systolic
60 - 80 mm Hg: Diastolic
normal blood pressure range of an adolescent?
85 -130 mm Hg: Systolic
45 - 85 mm Hg: Diastolic
Hypertensive BP
A patient is considered hypertensive if systolic BP is consistently higher than 140mm Hg and if diastolic pressure is consistently greater than 90mm Hg.
- can be classified into mild, moderate or severe
Hypotensive BP
A patient is considered hypotensive blood pressure is consistently lower than 95/60 mm Hg.
Sphygmomanometer types
- Mercury manometer (most accurate)
- Aneroid manometer
sphygmomanometer
- Each has a cuff that comes in a variety of sizes.
- The cuff contains an inflatable bladder
using a stethoscope
When using the diaphragm (aka bladder), place your fingers around the base of the bell, rather than holding the bell with your thumb (allows even pressure on the diaphragm)
measuring blood pressure prep
- Have patient sitting upright or lying down with arm reclined and supported. At rest for 3-5 min.
- Sleeves should be rolled up, no tight clothing around arm.
- Room should be quiet to facilitate hearing the pulse.
- The diaphragm, bell and earpieces should be cleaned with alcohol before and after each use.
- cuff typically measured over brachial artery
steps on measuring the blood pressure
- Inflate cuff to exceed systolic pressure in artery by 30 – 40 mm Hg
- Release air in cuff until pressure in cuff matches systolic pressure
- When no sounds are heard anymore, diastolic pressure value has been reached
cyanosis
- Bluish tinge due to lack O2 in tissues, build up of deoxyhemoglobin.
- Mucous membranes; tongue, lips or the lining of mouth (core cyanosis)
- Nail beds (peripheral cyanosis)
pallor
- Absence of color
- Unhealthy pale appearance
- Most evident in face and palms.
diaphoretic
excessive sweating
fever
hot and dry skin
syncope
cold and clammy
