Vital Signs Flashcards
When to measure vitals
Upon admission to any healthcare agency
Based on agency policy and procedure
Anytime there’s a change in the patient’s condition
Anytime there’s a loss of consciousness
Before and after surgical procedures
Before and after activity that may increase risk
Before administering medication that affects cardiovascular or respiratory function
Guidelines
Ensure equipment is working properly and select appropriate equipment
Know patience usual range
Know patient’s history
Body temp
Normal range 97-99.5 Core temp: - rectal - tympanic Surface temp: - oral - axillary - skin surface
Normal temps
Oral: 98.6
Rectal: 99.5
Axillary: 97.5
Temporal artery: 98.6
Rectal temp
Adult: 1.5 in
Child: 1 in
Primary source of heat in body
Metabolism with heat produced as a byproduct of metabolic activities that generate energy for cellular function
Temp regulation
Neural and vascular control
- hypothalamus = thermoregulatory center
- vasodilation
- vasoconstriction
Afebrile
Normal body temperature
Heat production
Metabolism
Hormones
Skeletal muscle activity
Vasoconstriction
Heat loss
Skin is primary source
Sweat
Elimination
Hypothermia
Shivering
Constriction of blood vessels
Radiation
Heat transfer via infrared radiation
Diffusion of heat by electromagnetic waves
Convection
Air / water
Heat by motion between areas of unequal density
Evaporation
Transfer heat as water
Conversion of liquid to a vapor
Conduction
Transfer heat from one object to another through physical contact
Pyrexia
Fever
Heat loss mechanism unable to keep pace with excess heat production
Function of fever
Inhibit bacteria growth
Increase WBC production
Stimulates interferons (virus fighting substances)
Constant / sustained fever
Remain above normal
Intermittent fever
Returns to normal at least once per 24 hours
Remittent fever
Does not return to normal, fluctuates up or down
Relapsing
Returns to normal for 1 or more days; episodes of fever lasting several days
Syncopal
Fainting or sudden temporary loss of consciousness
Pulse
Normal: 60-100
Bradycardia: < 60
Tachycardia: > 100
Pulse deficit
Difference in apocalyptic and radial rates
Pulse amplitude
0= absent not palpable \+1= diminished, weaker than expected \+2= brisk, expected (normal) \+3= bounding
Pulse rhythm
Pattern of the beats and phases between them
Regular= beasts and pauses occur at regular intervals
Irregular= beats and pauses occur at unequal intervals
Pulse pressure
Systolic - diastolic
Cardiac output
Volumes of blood pumped by heart
- heart rate x stroke volume
Stroke volume
Amount of blood pumped by the left ventricle
Respiration rate
12-20
Eupnea
Normal, unlabored breathing
Apnea
Periods there is no breathing
Orthopnea
Breathing better upright
Normal pulse oximeter
> 93% (95 % for class)
Blood pressure
Force exerted on the walls of the artery created by the pulsing blood under pressure from the heart
Peripheral resistance
Elasticity of the arteries
Lumen size
Smaller lumen= higher BP
Larger lumen= lower BP
Orthostatic hypotension
Form of low BP that happens when standing up from sitting down
Orthostatic hypotension signs
Dizziness Fainting Weakness Lightheadedness Pillar Syncope- temporary loss of consciousness cause by fall in BP
Blood volume
Increased volume = increase BP
- iv fluid overload
Decreased volume = decreased BP
- hemorrhage
Blood viscosity
Increased viscosity = increase BP
- heart has to work harder
Decreased viscosity = decreased BP
Auscultatory gap
Where sound completely disappears then return at a lower level
The true systolic BP is the higher reading the 4th diastolic sound is the distinct muffling sound
Hypotension
< 100 systolic
< 60 diastolic
Prehypertension
Systolic 120-139
Diastolic 80-89
Hypertension
> 140/90 on several readings
Guidelines for measuring orthostatic hypotension
Measure BP lying, sitting and standing
