Vital Signs

Question 1

Vital Signs

Answer 1

Measurements of the body’s most basic functions-provide initial info of a patient’s health status (acute and chronic)

Question 2

What are the 4 vital signs?

Answer 2

1) Blood pressure
2) Pulse
3) respiration
4) Temperature

Question 3

What is blood pressure?

Answer 3

Measurement of force applied to artery walls (measured in mmHg)

Question 4

Why is an adequate blood pressure required for?

Answer 4

Organ perfusion

Question 5

What are the factors affecting blood pressure? (4)

Answer 5

1) Left ventricular stroke volume
2) Distensibility of the aorta and large arteries
3) Peripheral vascular resistance (esp. at arteriolar level)
4) Volume of blood in the arterial system

Question 6

How does blood pressure change and when does it reach maximum and minimum?

Answer 6

• Reaches maximum during systole (contraction and ejection)

- Minimum during diastole (relaxation and filling)

Question 7

What is systolic pressure?

Answer 7

Maximum pressure in the aorta when the left ventricle ejects blood into aorta

Question 8

What is diastolic pressure?

Answer 8

Lowest pressure in aorta just before next contraction

Question 9

What is pulse pressure?

Answer 9

Difference between systolic and diastolic pressure (of both arms)

Question 10

What is MAP and what is the lowest acceptable value?

Answer 10

Mean arterial pressure
P diastolic + 1/3 (P sys-P dias)
-Lowest acceptable MAP is 50mmHg to sustain function/perfusion of organs

Question 11

accurate measurement include: (4)

Answer 11

1) Patient prep
2) Proper size cuff
3) Proper placement of cuff
4) Proper positioning of patient’s arm

Question 12

Patient Prep includes: (7)

Answer 12

1) Ideally no smoking or caffeinated drinks 30 min prior
2) rest for 5 minutes
3) Do not use arm that has a fistula, lymphedema, or severe scarring
4) arm is free of cloth
5) Position arm-brachial artery should be at level of the heart
6) patient should be seated comfortably with arm rested on table
7) palpate brachial artery to confirm viable pulse

Question 13

Proper cuff size includes: (4)

Answer 13

1) width of inflatable bladder should be 40% of arm circumference
2) length should be 80% of arm circumference
3) cuff too small (narrow) ->high blood pressure
4) cuff too large (wide) -> high/low pressure

Question 14

Placement of cuff: (3)

Answer 14

1) Center inflatable bladder over the brachial artery
2) lower border of cuff should be 2.5cm above antecubital crease
3) Secure cuff snugly

Question 15

Measuring pressure: (10)

Answer 15

1) determine how high to raise cuff pressure by:
a) palpating radial artery
b) inflate the cuff
c) note pressure at which pulse disappears
d) add 30 mmHg to this
e) Deflate and wait 15-30 sec.
f) Place bell of stethoscope over artery (pitch low)
g) inflate cuff
h) deflate at 2-3 mmHg/sec
i) listen for 2 consecutive beats = P systole
j) disappearance of pulse = P diastolic

Question 16

Position: (blood pressure) (2)

Answer 16

1) take pressure in supine, sitting and standing position (done if orthostatic hypotension suspected)
2) Normally on standing-there is a slight drop in systolic and slight rise in diastolic pressure

Question 17

Special situations (blood pressure) (3)

Answer 17

1) anxious patient: diastolic higher
2) Weak or inaudible Korotkoff sounds: shock, technical problem
3) Arrhythmias: take several readings to confirm

Question 18

What is systolic and diastolic ranges for:

1) normal
2) prehypertension
3) hypertension stage 1
4) hypertension stage 2

Answer 18

1) normal: (Systolic BP: (or equal to 160), (Dias: > (or equal to 100)

Question 19

Hypotension

-Orthostatic

Answer 19

< 80 mmHg

-Orthostatic = fall of 20 mmHg systolic and 10 mmHg diastolic on standing from a recumbent (lying down) position

Question 20

What is an arterial pulsation?

Answer 20

The pressure wave felt with the ejection of blood into the aorta and on into the arterial tree by the left ventricular contraction

Question 21

Name the 9 points of palpation.

Answer 21

1) Temporal artery
2) Facial artery
3) Carotid artery
4) Brachial artery
5) Radial artery
6) Femoral artery
7) Popliteal artery
8) Posterior tibial artery
9) Dorsalis pedis artery

Question 22

Assessment of pulse includes: (4)

Answer 22

evaluate for:

1) Rate
2) Rhythm
3) Volume
4) Character

Question 23

What are the Pulse rate ranges for:

• Normal
• Tachycardia
• Bradycardia

Answer 23

Normal: 60-100/min
Tachycardia: >100/min
Bradycardia: <60/min

Question 24

Pulse rhythm-what constitues regular and irregular? (2)

Answer 24

Regular: normal
Irregular:
a) Regular irregular: premature atrial or ventricular contractions
b) Irregularly irregular: atrial fibrillation

Question 25

Pulse volume (scale 0-4)

Answer 25

4- bounding
3- full and increased
2- normal
1- diminished, barely palpable
0- absent

Question 26

Pulsus alternans

Answer 26

Alternating weak and strong beat (left ventricular failure)

Question 27

Pulsus bisferiens (biphasic pulse) (2)

Answer 27

• 2 main peaks

- 2 strong systolic beats seperated by mid-systolic dip (aortic stenosis and regurgitation)

Question 28

Pulsus Bigeminus (2)

Answer 28

1) 2 beats in rapid succession

2) Normal beat plus premature beat (pre-ventricular contraction)

Question 29

Pulsus paradoxus (2)

Answer 29

1) exaggeration of normal fall in amplitude during inspiration
2) Systolic BP drop = >12-15 mmHg (severe airway obstruction)

Question 30

Water hammer (collapsing) pulse (3)

Answer 30

1) greater amplitude
2) rapid rise
3) sudden descent (backflow through aortic valve, AR, PDA)

Question 31

Pulse:

• Symmetry
• Asymmetry

Answer 31

Symmetry: both sides normal
Asymmetry: (pulsus differens) may indicate stenosis

Question 32

Respiration Prep and technique (3):

Answer 32

Prep: Rest for at least 3 minutes, divert attention
Technique:
1) Observe chest movement
2) Try not to make patient conscious of actions (Do respiration after measuring pulse with hand still on pulse)
3) Count number of breaths in one minute

Question 33

Respiration assessment includes: (4)

Answer 33

1) Pattern of respiratory cycle
2) Symmetry of thoracic movement
3) Change in configuration of thorax
4) Labored breathing

Question 34

Pattern of respiratory cycle (4)

Answer 34

1) rate
2) rhythm
3) depth
4) effort of breathing

Question 35

Normal respiration characteristics include (2):

Answer 35

1) normal respiration is 14-20/min

2) regular, quiet, barely visible

Question 36

Respiration rate-Bradypnea (slow breathing) arises from (2):

Answer 36

1) disease of CNS (ex: drug induced coma, intracranial pressure can be causes)
2) metabolic disorders

Question 37

Respiration rate-Tachypnea (rapid, shallow) arises from (2):

Answer 37

> 24 bpm

1) restrictive lung disease
2) pleuritic chest pain

Question 38

Respiration rate-Hyperpnea (rapid and deep) arises from: (2)

Answer 38

1) Exercise

2) anxiety

Question 39

Respiration rhythm: (2)

Answer 39

1) Regular or irregular

2) respiratory depression and mid brain damage

Question 40

Respiration depth: (2)

Answer 40

1) shallow or deep

2) Deep alternating with periods of apnea (Cheyne-stokes)

Question 41

Respiration- effort of breathing: (2)

Answer 41

1) labored

2) use of accessory muscles

Question 42

What is temperature?

Answer 42

Measurement of a balance between heat produced and heat lost to environment

• normal variations:
  a) time of day
  b) level of physical activity

Question 43

Temperature routes include: (3)

Answer 43

1) oral
2) rectal
3) axillary

Question 44

Temperature- oral route: (3)

Answer 44

common route

• must place under tongue
• not to be used in semi-conscious patient or unconscious
• universal precautions w/ body fluids

Question 45

Temperature- Axillary route (2)

Answer 45

• 0.3 to 0.4 degrees cooler than mouth

- less accurate

Question 46

Temperature- Rectal route (5):

Answer 46

1) 0.5-0.7 degrees higher than mouth
2) needs more time
3) more accurate
4) contraindicated in diarrhea, bleeding
5) Needs lubrication