Vital Signs Flashcards
Facility Standards for Monitoring in:
- Hospital
- Home Health Setting
- Clinic
- Skilled Nursing Facilities (SNF)
- Hospital: every 4-8 hours
- Home Health Setting: each visit
- Clinic: each visit
- Skilled Nursing Facilities: weekly to monthly
When to assess Vital Signs?
- admission to any healthcare agency
- institutional policy and procedure
- per orders of healthcare provider
- anytime a change in patient’s condition
- before and after surgical or invasive procedures
- before and after activity that may increase risk
- medications
What are the main Vital Signs?
Temperature Pulse Respirations Blood Pressure Pain Pulse Oximetry * always ask for allergies!!!
Define Body Temperature
Degree of heat maintained by the body.
- thermoregulatory center is located in the hypothalamus
- center initiates responses to produce or conserve body heat or increase heat loss
Sites to measure Body Temperature are…
Oral Tympanic Membrane Rectal Urinary Catheter Axillary or Groin Temporal Artery
Variables that Affect Body Temperature
- Circadian Rhythms
- Hormones
- Age
- Exercise
- Stress
- Food/Beverage Consumption
What is Hyperthermia?
An increase in body temp above normal
Ex: an extreme form = heat stroke
What is Hypothermia?
A decrease in body temp below normal
What is the Average Oral Temp and the Range? Advantages and Disadvantages?
-average: 37C or 98.6F
-range: 36-38C or 96.8-100.4F
Advantages: convenient, easily assessable, minimally invasive
Disadvantages: safety, physical abilities, accuracy
Contraindications to Oral Temp
- Infant or child under 6 years
- Unconscious, confused or disoriented person
- Someone who had surgery or injury to the face, neck, nose or mouth
- Receiving oxygen (>6 L/min)
- Paralysis on one side of body
- Seizure disorder
What is the Average Rectal Temp and Range? Advantages and Disadvantages?
-average: 37.5C or 99.5F
-range: 36.7-38.5C or 98.0-101.6F
Advantages: most accurate
Disadvantages: safety, invasive, uncomfortable
When should you take a Rectal Temperature?
Taken when oral or other routes cannot be used.
Contraindications to Rectal Temp
- Diarrhea
- Rectal disorder or injury
- Hemorrhoids
- Heart disease
- Rectal surgery
- Patient who is confused or agitated
What is the Average Axillary Temperature and Range? Advantages and Disadvantages.
-average: 36.5C or 97.6F
-range: 35.4-37.4C or 95.6-99.4F
Advantages: safe, noninvasive
Disadvantages: questionable accuracy, length of time to obtain measurement
When should an Axillary Temperature be used?
Used one other sites cannot be used.
What is the Average Tympanic Membrane Temperature and Range? Advantages and disadvantages.
-average: same as oral and rectal
-range: same as oral and rectal
Advantages: convenient, fast, safe, reduced risk of spreading infection
Disadvantages: questionable accuracy, technique effects reading
Define Pulse
The beat of the heart felt as a wave as blood passes through an artery
What is the Average Pulse Rate and Normal Range for Adults?
- average: 70-80 bpm
- range: 60-100 bpm
Define Tachycardia
Pulse rate greater than 100 bpm
Define Bradycardia
Pulse rate less than 60 bpm
Determine Pulse Volume
0 = absent 1 = thready 2 = weak 3 = normal 4 = bounding
Where are the Pulse Sites?
Peripheral Sites
Apical Pulse- over apex of heart
Where is the Apical Pulse?
Over Apex of Heart
- 5th intercostal space, left midclavicular line
- most accurate
What are the Peripheral Pulse Sites?
Carotid Temporal Brachial Radial Femoral Popliteal Posterior Tibialis Dorsalis Pedis
What are some Factors affecting Heart Rate?
Age Gender Activity/Exercise Metabolism Fever Emotional Status Pain Stimulants Medications Sympathetic Stimulation- increases heart rate Parasympathetic Stimulation- decreases heart rate
What is a Pulse Deficit?
The difference between the Apical-Radial Pulse.
What is the Normal Respiration Rate for an adult?
-rate: 12-20 per min
Define Apnea
Not breathing
Define Tachypnea
Fast or rapid breathing
Define Bradypnea
Slow breathing
Define Dyspnea
Difficult or labored breathing
Define Orthopnea
Difficulty breathing when laying down
Factors Affecting Respirations
Exercise Respiratory and Cardiovascular Disease Alterations in fluid, electrolytes, and acid balances Medications Trauma Infection Pain Anxiety
What is the Normal Range for Oxygen Saturation (Pulse Ox, SpO2)?
- range: 90%-100%
- report
Define Blood Pressure
- The force of blood against arterial walls
- Pressure rises as ventricle contracts and falls as heart relaxes
What are Korotkoff Sounds?
The sounds you hear when measuring blood pressure.
- The 1st sound occurs during systole
- The 5th sound is silence corresponding with diastole
What is the typical Adult Blood Pressure reading? What is the range for BP?
Typical Adult BP- 118/78
-Range: 90-140/60-90
Pre-hypertension BP Reading
120-139/80-89
Hypertension BP Reading
> 140/90
Hypotension BP Reading
Define Orthostatic or Postural Hypotension
A sudden drop in BP on moving from a lying to a sitting or standing position.
Define Systole
The period of heart contraction
-force needed to pump blood out of heart into arterial circulation.
Define Diastole
Period of heart muscle relaxation
-pressure in the arteries when the heart is at rest
What is a Pulse Pressure?
Systolic pressure minus the Diastolic pressure
- around 40mmHg in healthy adults
What is BP Regulation influenced by?
Cardiac function
Peripheral vascular resistance
Blood volume
What are the Factors Affecting BP?
Age
Gender
Race
Diet
Circadian Rhythm
Exercise
Weight
Blood Volume
-hypovolemia -hypervolemiaWhy do we take Vital Signs?
To provide an understanding of how the body’s ‘big three’ organ systems are functioning:
- heart
- lungs
- brain
