Vital Signs Flashcards
Times to take vital signs
- on admission
- before, during and after surgery or invasive procedures
- before, during and after administering medications that may affect vitals
- before and after nursing interventions (eg, ambulating) that may affect vitals
- after incidents such as falls
- if patient reports feeling unwell, or symptoms such as chest pain or shortness of breath
- if patient experiences a change in health status
What are the different types of breathing rates?
Eupnoea - regular breathing rate and depth
Tachypnoea - quick, shallow breaths
Bradyphnoea - abnormally slow breathing
Apnoea - no breathing
What are the different types of breathing volume?
Hyperventilation - quick, deep breaths, overexpansion of the lungs
Hypoventilation - shallow breathing, under expansion of the lungs
What is Cheyne-Stokes?
a breathing pattern that alternates between deep and shallow breathing, with periods of no breathing.
What are dyspnoea and orthopnoea?
dyspnoea - difficult, laboured breathing
orthopnoea - only able to breathe when sitting or standing
What are the different types of breath sounds?
Stridor - shrill, harsh sound on respiration with laryngeal obstruction
Stertor - snoring, partial obstruction of upper airway
Wheezing - continuous, high pitched sound on expiration and sometimes inspiration - air moving through a narrowed or partially obstructed airway
Bubbling or gurgling - air moving through mucous or moist secretions
Factors affecting oxygen saturation readings?
- Haemoglobin - the oximeter reads haemoglobin saturation. If there is good haemoglobin saturation, but low levels of haemoglobin, the reading will be normal while the person is anaemic and lacking oxygen
- Circulation
- Shivering or excessive movement
- dark coloured nail polish
- carbon monoxide poisoning - the oximeter doesn’t differentiate between CO and O2
Determinants of blood pressure
- pumping action of the heart - the higher the cardiac output, the higher the blood pressure
- peripheral vascular resistance - increased blood pressure, especially diastolic blood pressure.
- blood volume - a lowering of blood volume, such as when dehydrated or haemorrhaging, lowers blood pressure
- blood viscosity - if the blood is viscous (increased percentage of red blood cells to plasma), blood pressure increases
Factors affecting blood pressure
- age
- gender
- ethnicity
- exercise
- stress
- medications
- disease processes
- obesity
- diurnal variations
- hyper or hypovolaemia
Factors affecting pulse
- age
- gender
- exercise
- pyrexia
- medications
- hypovolaemia
- stress
- position changes
- pathology
Pulse sites
- temporal
- carotid
- apical
- brachial
- radial
- femoral
- popliteal
- posterior tibial
- pedal / dorsalis pedis
Pulse averages (and ranges)
Newborn - 130 (80 - 180) 1 year - 120 (80 - 140) 5 - 8 years - 100 (75 - 120) 10 years - 70 (50 - 90) Teen - 75 (50 - 90) Adult - 80 (60 - 100) Older Adult - 70 (60 - 100)
Respiration averages (and ranges)
Newborn - 35 (30 - 80) 1 year - 30 (20 - 40) 5 - 8 years - 20 (15 - 25) 10 years - 19 (15 - 25) Teen - 18 (15 - 20) Adult - 16 (12 - 20) Older Adult - 16 (15 - 20)
Factors affecting bodily heat production
- Basal Metabolic Rate (BMR)
- muscle activity
- Thyroxine output
- Adrenaline / noradrenaline
- fever
Heat loss processes
- Radiation - heat transfer without contact
- conduction - heat transfer from warmer to cooler with contact
- convection - heat dispersion by air currents
- vaporisation - evaporation from respiratory tract, mouth mucosa and skin
Factors affecting body temperature
- age
- hormones
- exercise
- stress
- diurnal variations
- environment
Locations to measure body temperature
- oral
- rectum
- ear
- axilla
- forehead
Types of fever
- intermittent - regular alterations between fever and non-fever (eg Malaria)
- remittent - wide fluctuations of fever temperatures (eg colds, flu)
- relapsing - febrile periods of days interspersed with days of normal temperatures
- constant - little variation, always febrile
Temperature ranges
<34 = death 34 - 36 = hypothermia 36 - 37.5 = normal / average 37.5 - 41 = pyrexia (fever) 41 - 43 = hyperpyrexia >43 = death
Fever phases
Chill phase (onset of fever) Plateau phase (course of fever) Defervescence phase (fever abatement)
Clinical manifestation of chill phase of fever?
- tachycardia
- tachypnoea
- shivering
- pale, cold skin
- patient feels cold
- cyanotic nail beds
- goosebumps
- cessation of sweating
Clinical manifestation of plateau phase of fever?
- tachycardia
- tachypnoea
- no chills
- skin feels warm
- photosensitivity
- glassy-eyed look
- polydipsia
- dehydration
- drowsiness
- lesions in mouth
- anorexia
- muscle aches
Clinical manifestation of defervescence phase of fever?
- skin flushed and warm
- diaphoresis
- decreased shivering
- possible dehydration
Symptoms of heat stroke
- very high body temperature
- red, hot, dry skin
- dry, swollen tongue
- throbbing headache
- tachycardia
- tachypnoea
- confusion
- nausea
- possible loss of consciousness
