Vital Signs Flashcards
Vital Signs Definition
Baseline Measurements of cardio-pulmonary
Vital Signs Include (4)
- Temperature
- Heart Rate (measured as pulse)
- Respiration
- Blood Pressure
Pt. Who Need Baseline Vital Signs (5)
- Elderly
- Very Young
- Debilitated pts.
- History of disease, trauma, or condition affecting cardiovascular disease (SCI, CVA, HTN, PVD, COPD, and any cardiac disease)
- According to facilities policy & procedure
Factors Affecting Vital Signs (8)
- Recent physical activity or physical conditioning.
- Environmental temp.
- Age, Gender
- Emotional Status
- Illness
- Medications
- Blood Volume
- Size, condition of arteries.
Adverse Responses to Physical Activity (11)
- Mental confusion
- Severe fatigue
- Decreased response/lethargy
- Nausea
- Syncope
- Shortness of Breath
- Chest Pain
- Vertigo
- Diaphoresis
- Change in appearance
- Pupil constriction/dilation
Factors Affecting Temperature
Normal Body temp. is 98.6
Some peoples normal is much lower (i.e. 97.2) ask the pt. so you dont mistakenly think they are hypothermic.
Lower: In the AM and as you age.
Higher: during physical activity, illness, and in response to stress, & during ovulation.
Auto Temp. Reading in Special Care Unit
Notice baseline:
If low: monitor closer and give more rest.
Temp drops during activity= abnormal response.
Hear Rate is Measured By
Heart Rate (beats per minute)
Measure by pulse of by listening to a stehtoscope.
Weak pulse may require a stethoscope to hear.
Normal Resting HR for an adult
60-100 bpm
Normal Resting HR for a child (1-7 years)
80-120 bpm
Normal Resting HR for a newborn
100-130 bpm
In an acute hospital a HR never wants to raise over ____ w/ therapy activity
Never raise more than 10-20 bpm
HR Documentation
Strong & Regular Weak & Regular Irregular Thready Trachycardia Bradycardia
Pulse response to Activity: Begin or Increase Intensity
Normal Pulse Response: Increase then stabilize
Abnormal Pulse Response: Increase is very slow or does not increase
Pulse Response to Activity: Intensity Plateaus
Normal Pulse Response: Stable
Abnormal Pulse Response: Continues to increase or decrease
Pulse Response to Activity: Decrease Intensity or Stop
Normal Pulse Response: Slows & returns to resting rate within 5 min. of stopping.
Abnormal Pulse Response: Does not decline or return to resting rate.
Steps to Measuring Pulse
- Wash Hands
- Place two fingers over artery (not thumb) : radial artery at wrist, or carotid artery at neck, femoral artery on infant.
- Count beats per minute felt for 30 seconds.
- Multiply X2
- Count for longer periods to prevent error
- Need more time to check for irregular heart rhythm.
Blood Pressure
In direct measure of pressure inside an artery
-Use a sphygmomanometer
Normal BP for an Adult
120/80 = systolic/diastolic
Systalic Normal
Between 90 & 135 mmhg
-Measurement during left ventricle contraction
Diastolic Normal
between 60 & 80 mmhg
-Measurement between contractions during period of rest
Hypertension
140/90 or greater
Measuring BP (6 Steps)
- Ask normal BP (must know)
- Position so arm is relaxed (support or prop)
- Apply deflated cuff w/ center of bladder over medial aspect of arm (proximal to antecubital space)
- Pump to 180 mmHg unless known HP
- Known high BP or hospital pt. pump to 200mmHG
- Deflate cuff slowly at rate of 2-3 mmHG per second listen for Korotkoff’s sound.
- note when sound begins and when it stops.
Respiration
Measurement of breathing rate per minute.
One cycle = on inspiration and one expiration
