Vital Signs and the Assessment of Pain Flashcards
Vital Signs
Temperature, Pulse, BP, Respiratory Rate, Height (m^2)/weight(kg) = BMI, Pain objective)
Temperature
Balance of heat production an heat loss, controlled by hypothalamus
97.3-99.5 F (oral, adult)
Factors Affecting Body Temp
metabolic (sleep, digestion, exercise)
Infectious process (fever)
Environment (hypo- hyperthermia)
Exogenous substances (cold/hot beverage, drugs)
5 methods of temperature measurement
Oral - 98.6
Rectal - 99.6 (most accurate)
Axillary - 97.6
Tympanic - 99.6
What constitutes a fever?
Adults: oral > 98.9 @6 am or >99.9 @ 4pm
Child: rectal > 100.4
Respiratory Rate
one breathing cycling, inspiration and exhalation. measured by viewing chest rise. normal is 12-20 in adults
Primary Muscles of Respiration
Diaphragm (contracts down) and intercostals
4 parameters to asses in respiration
rate, pattern, depth, signs of distress
6 patterns of respiration
apnea, tachypnea, bradypnea, dspnea, hypopnea, hyperpnea
Cheyne Stokes respirations
periodic breathing, increased and decreased rate and depth, periods of apnea
Kussmaul respirations
deep and labored. type of hyperpnea. metabolic acidosis (ex DKA)
Signs of Resp. Distress
tachypnea, bradypnea, accessory muscle use, nasal flaring, cyanosis, difficulty speaking, audible breathing, coughing, diaphoresis
Signs of REsp. Distress in Infants
flared nostrils, anxious face, cyanosis, intercostal retractions
Pulse
Movement of blood in arteries.
Typical adult 50-90 bpm
Characteristics of Pulse
Rate (bpm)
Rhythm (regular or irregular)
Regularity (regular or irregular)
Amplitude (strong, bounding, weak,0-4+)
Factors Affecting Pulse
Heart health, exercise level, neurologic status, emotions, drugs
Documenting Heart Rate
0-4+
Tachy is > 100 bpm
Brady is
Normal BP
Adult SBP
3 Factors that Affect BP
Stroke volume - amount of blood pumped by LV in 1 conraction
HR - bpm
Peripheral Vascular Resistance
Cardiac Output
stroke volume x heart rate
Korotkoff Sounds
low pitched sounds produced by turbulence of blood flow in the artery
Auscultatory Gap
gap of 10-15 mmHg where korotkoff sounds can be heard, disappear, and reappear
Pulse Pressure
systolic bp - diastolic bp. normal range is 30-50 mmHg
Ideal conditions for measuring BP
no nicotine or caffeine
Rest
warm
no constricting clothing
BP measurement step by step
1) place bell @ AC fossa, arm at heart level
2) center bladder over bracheal artery
3) inflate cuff 30mmHg above palpable radial pulse
4) deflate cuff
5) wait 30 sec, repeat steps 2-3
6) deflate slowly
Factors affecting BP
hyper or hypo tension white coat syndrome vascular resistance from atherosclerosis pain fever weight sedentary lifestyle use of caffeine alcohol or drugs
Medical Conditions that Affect BP readings
cardiac dysrhythmias
aortic regurgitation
venous congestion
valve replacement
Orthostatic BP
change in BP and pulse when pt. moves from supine to upright early detection of volume depletion 1) supine for 5 min, determine BP and HR 2) stand up 3) wait 1 minute, then take BP and HR
- drop in SBP > 10 mmHg or increase in HR > 20 bpm suggests volume depletion
Height and Weight
under reported, self reporting is not adequate.
body habitus is closely linked to many chronic diseases
BMI
weight (kg) / ht (m^2)
Acute Pain
short duration, sudden onset, injury, surgery, acute illness
Persistent / Chronic Pain
several months or longer. sustained by pathophysiologic process
Neuropathic Pain
long term associated with damage or dysfunction of CNS or PNS
How to document pain
value from 0-10
specify location
quality, character, severity, frequency, duration, OPQRST
