Vital Signs Flashcards by Meghan Light

How do you locate the apical impulse? (point over the apex of the heart where the apical pulse can be most clearly heard)

Palpate the angle of Louis
Slide finger just left of the sternum, palpate 2nd intercostal space
Palpate downward until locate 5th intercostal space
Move finger laterally along 5th intercostal space to midclavicular line (MCL)

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Angle of Louis

The angle between the manubrium, the top of the sternum, and the body of the sternum. Palpated just below the suprasternal notch and is felt as a prominence

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Normal HR for newborns

100-170bpm

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Normal HR for Infants to 2 years

80-130bpm

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Normal HR for 2-6 years

70-120bpm

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Normal HR for 6-10 years

70-110bpm

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Normal HR for 10-16 years

60-100bpm

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Normal HR for 17 years to adult

60-100bpm

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What causes the S1 heart sound (lub)?

The atrioventricular valves closing after the ventricles have been sufficiently filled

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What causes the S2 heart sound (dub)?

The semilunar valves closing after the ventricles empty

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What is a normal rhythm and strength of a heartbeat?

Normal pulse has equal time periods between beats

Normal beats are equal in strength

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Periodic breathing in newborns

some newborns pause for a few seconds between respirations. This condition can be normal, but parents should be alert to prolonged or frequent pauses (apnea) that require medical attention

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Why would an infants’ respiratory rate and effort of breathing increase with respiratory infections?

Compared to adults, infants have fewer alveoli and their airways have a smaller diameter

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Normal respiratory rate for newborns

30-80 pm

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Normal respiratory rate for 1 year

20-40pm

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Normal respiratory rate for 3 years

20-30pm

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Normal respiratory rate for 6 years

16-22pm

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Normal respiratory rate for 10 years

16-20pm

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Normal respiratory rate for 17 and older

12-20pm

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Tachypnea (Rate)

quick, shallow breaths

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Bradypnea (Rate)

abnormally slow breathing

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Apnea (Rate)

cessation of breathing

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Hyperventilating (Volume)

overexpansion of the lungs characterized by rapid and deep breaths

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Hypoventilation (Volume)

Underexpansion of the lungs, characterized by shallow respirations.

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Cheyne-Stokes breathing (Rhythm)

Rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea

Dyspnea (Effort)

Difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed.

Orthopnea (Effort)

Ability to breathe only in upright sitting or standing positions

Stridor

A shrill, harsh sound heard during inspiration with laryngeal obstruction

Stertor

Snoring or sonorous respiration, usually due to a partial obstruction of the upper airway

Wheeze

Continuous, high-pitched musical squeak or whistling sound occurring on expiration and sometimes on inspiration when air moves through a narrowed or partially obstructed airway

Bubbling

gurgling sounds heard as air passes through moist secretions in the respiratory tract

Intercostal retraction (chest movements)

Indrawing between the ribs

Substernal retraction (chest movements)

Indrawing beneath the breastbone

Suprasternal retraction (chest movements)

Indrawing above the clavicles

Hemoptysis (Secretions & coughing)

The presence of blood in the sputum

Productive cough (Secretions & coughing)

A cough accompanied by expectorated secretions

Nonproductive cough (Secretions & coughing)

A dry, harsh cough without secretions

The patient sitting with legs crossed while taking BP can cause what?

Elevated systolic and diastolic blood pressures

Blood pressure is what kind of sound (Pitch)?

Low frequency, best heard with bell (or light pressure)

Errors in Blood Pressure Assessment and Effect | Bladder cuff too narrow

Erroneously high

Errors in Blood Pressure Assessment and Effect | Bladder cuff too wide

Erroneously low

Errors in Blood Pressure Assessment and Effect | Arm unsupported

Erroneously high

Errors in Blood Pressure Assessment and Effect | Insufficient rest before the assessment

Erroneously high

Errors in Blood Pressure Assessment and Effect | Repeating assessment too quickly

Erroneously high systolic or low diastolic readings

Errors in Blood Pressure Assessment and Effect | Cuff wrapped too loosely or unevenly

Erroneously high

Errors in Blood Pressure Assessment and Effect | Deflating cuff too quickly

Erroneously low systolic and high diastolic readings

Errors in Blood Pressure Assessment and Effect | Deflating cuff too slowly

Erroneously high diastolic reading

Errors in Blood Pressure Assessment and Effect | Failure to use the same arm consistently

Inconsistent measurements

Errors in Blood Pressure Assessment and Effect | Arm above level of the heart

Erroneously low

Errors in Blood Pressure Assessment and Effect | Arm below heart level

Erroneously high

Errors in Blood Pressure Assessment and Effect | Assessing immediately after a meal or while client smokes or has pain

Erroneously high

Errors in Blood Pressure Assessment and Effect | Failure to identify auscultatory gap

Erroneously low systolic pressure and erroneously low diastolic pressure

Secondary skin lesions | Atrophy

A translucent, dry, paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin

Secondary skin lesions | Erosion

Wearing away of the superficial epidermis causing a moist, shallow depression. Because erosions do not extend into the dermis, they heal without scarring

Secondary skin lesions | Ulcer

Deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. May bleed. May leave scar

Secondary skin lesions | Fissure

Linear crack with sharp edges, extending into the dermis

Secondary skin lesions | Lichenification

Rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing

Secondary skin lesions | Scales

Shedding flakes of greasy, keratinized skin tissue. Color may be white, gray, or silver. Texture may vary from fine to thick.

Secondary skin lesions | Crust

Dry blood, serum, or pus left on the skin surface when vesicles or pustules burst. Can be red-brown, orange, or yellow. Large crusts that adhere to the skin surface are called scabs.

Secondary skin lesions | Scar

Flat, irregular area of connective tissue left after a lesion or wound has healed. New scars may be red or purple; older scars may be silvery or white.

Secondary skin lesions | Keloid

Elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. Extends beyond the site of the original injury. Higher incidence in people of African descent

Secondary skin lesions | Excoriation

Linear erosion | i.e. Scratches, some chemical burns