Vital Signs Flashcards
What do we measure vital signs?
- provide info about effectiveness of circulatory, respiratory, neural and endocrine body functions
- monitor condition, identify problems and evaluate responses
- evaluated in terms of norms and client’s baseline; trends
When are vital signs indicated?
- medical order
- before/after surgery or procedure
- before/after medication administration
- before/after nursing intervention
- non-specific symptoms present
- change in condition of client
What affects temperature?
- age
- stress
- hormone levels
- environment
- circadian rhythm
- exercise
Dysrhythmia
interval interrupted by an early or late beat, or a missed beat
(regularly irregular)
Arrhythmia
irregularly irregular heartbeat or cardiac dysrhythmia
Sinus arrhythmia
variation with respiratory cycle
- increased HR when inhaling, decreased HR when exhaling
Bradycardia
slow heart rate less than 60 bpm
Tachycardia
abnormally fast heart rate of more than 100 bpm
Pulse deficit
difference between radial and apical HR
- indicates inefficient blood flow
Pulse Assessment includes..
- Rhythm
- Rate
- Strength/force
- Equality for radial pulse
Gas exchange between atmosphere and blood
Ventilation
Gas exchange between blood and cells
Diffusion
Factors that affect respiration
- exercise
- anxiety/stress
- medications
- acute pain
- smoking
- neurological injury
- hemoglobin function
Respiration Assessment includes..
- Rate
- Depth (deep, normal, shallow)
- Rhythm (regular or irregular)
- Sound (effortful, normal)
Bradypnea
less than 12 breaths per minute
Tachypnea
more than 20 breaths per minute
Hyperpnea
laboured, increased depth and rate
Apnea
pauses in breathing
Dyspnea
Difficulty breathing or breathlessness
What physiological factors effects blood pressure?
- cardiac output
- peripheral vascular resistance
- volume of circulating blood
- viscosity/thickness of blood
- elasticity of vessel walls
What is considered hypotension?
<90 / ___
What is considered hypertension?
> 140 / 90
Three ways to measure blood pressure
- Arterial lines (invasive)
- Automatic BP devices
- Auscultation with stethoscope and sphygmomanometer
Auscultatory Gap
period when sounds disappear during auscultation of BP – not inflating cuff enough
- can cause underestimation of systolic BP or overestimation of diastolic BP
pulse site: over temporal bone of head, above and lateral to eye
temporal
pulse site: along medial edge of sternocleiodmastoid muscle
carotid
Which pulse site should be used in emergencies?
carotid
pulse site: fourth or fifth intercostal space at left midclavicular line
apical
pulse site: groove between biceps and triceps muscles at antecubital fossa
brachial
pulse site: thumb side of forearm at wrist
radial
pulse site: pinky side of forearm at wrist
ulnar
pulse site: below inguinal ligament, midway between symphysis pubis and anterir superior iliac spine
femoral
pulse site: behind knee
popliteal
pulse site: inner side of ankle
posterior tibial
pulse site: along top of foot
dorsalis pedis
