vital signs Flashcards
vital signs
provide critical info about pt physiological status
4 internationally recognized vial signs and 3 other measure
HR
BP
RR
Temp
pain
Pulse OX
perceived exertion rating
basal HR
pulse rate measured after an extended period of rest
Resting HR
without imposed stress
periactivity HR
HR during intervention
Recovery pulse rate
1-3 min following intervention
Patency
the openness of the peripheral portion of the CV system
presence or absence of pulse at.a given site
red flag for patency
patent with lack of patency without known pathology immediate referral to MD
max HR
target HR
220-age
max HR*desired intensity
0-4 assessing pulse
0 - absent 1 - theady (barely) 2 - weak 3 - normal 4 - bounding
Heart rate norms
Newborn 120-160
infant 100-120
children 80 - 100
adult 60-100
manual palpation
pads of index and middle finger over x site
don’t use thumb
Auscultation
Hr with stethoscope
common HR spots
brachial carotid radial popliteal femoral dorsal pedis ant tib
systole vs diastole
systolic/diastolic
systole - ventricles
diastolic - ventricles relaxed
BP where
left arm except if stroke lymphedema or otherwise noted
Normal resting BP
Neonates 1-28 days systolic below 60 diastolic HV
infants 1-12 months systolic 70-95 diastolic HV
children 1-8 yrs old systolic 80-110 diastolic HV
Adults systolic 90-120 diastolic 60-80
Ankle Brachial Index ABI
systolic BP is measure both in tibial or dorsal and divided by brachial
.9 or less = peripheral arterial disease
> 1.5 abnormal finding
pulse pressure
difference between systolic and diastolic
Respiration Norms
Newborn (1-28days) 40-60
Infant (2month-1yr) 25-50
Children (1-8) 15-30
Adults 12-20
elderly may increase due to decreased elasticity/ efficiency of gas exchange
RR rating scales
Borg scale
ATS dyspnea scale
temp norms
infants and children 95.9-99.5
.5 higher on tympanic
adults 95.9-98.6
Pulse ox
measures oxygen in the blood
Perceived exertion rating
6-20 how hard are you working
Edema scale
1+ = Barely detectable impression when finger is pressed into skin 2+ = Slight indentation; 15 sec to rebound 3+ = Deeper indentation; 30 sec to rebound 4+ = > 30 sec to rebound
Integ
color, scar formation, moisture, texture, temp, firmness, elasticity, shape , symmetry
provides info about CV and pulm
cyanosis
blue-gray discoloration
ecchymosis
bruising
erythema
redness
jaundice
yellow hue
pallor
pale
clubbing
bulbous swelling of the fingertip
beaus lines
deep indented transverse lines across the nail
meees lines
transverse white lines across entire nail
balance questions
fallen last 12 months
are you concerned about balance
neurological impairments
over 65
