Vital Signs Checklist Flashcards
What are the clinical signs of cardiovascular alterations?
cyanosis, chest pain, jaw pain
What are factors that can alter pulse rate?
pain, drugs, vigorous activity
What are factors that might alter respiratory rate?
drugs, pain, smoking
What are factors that affect blood pressure?
ethnicity, smoking, drugs
What is the normal value for blood pressure?
120/80
What is the normal range for pulse?
60-100 bpm
Where is the temporal pulse site located?
sides of head
Where are the carotid pulse sites located?
sides of neck (only palpate one side then another side)
Where is the brachial pulse site located?
medial arm
Where is the radial pulse site located?
wrist thumb side
Where is the apical pulse site located?
5th intercostal space midclavicular line
Where is the femoral pulse site located?
groin area
Where is the popliteal pulse site located?
behind the knee
Where is the posterior tibial pulse site located?
inner part of foot tibia side behind the ankle
Where is the dorsalis pedis pulse site located?
on top of the foot
What is the procedure for taking the radial pulse?
Radial Pulse: Palpates radial pulse by placing first 2 fingers of dominant hand over groove along radial artery. Lightly compresses against radius. Begins counting the first beat after the second hand hits the number. Begin with 1. Count for 30 seconds, multiply by 2 to determine pulse rate for one minute.
How is the pulse rhythm described?
regular/irregular
-normal is regular
How is the pulse strength described?
(0,1+,2+,3+,4+) and absent,weak/therady, normal, strong, bounding
-normal is 2+
How is the condition of the arterial wall described?
smooth,elastic,ropelike
-normal is smooth elastic
What do you do if the rhythm is irregular or not baseline?
Check the apical pulse for a minute for any abnormality
What is the procedure for taking an apical pulse?
Correctly places stethoscope on left side of chest at the apex of the heart – 5th intercostal space left side, mid clavicular line.
Begin counting with number 0 when second hand hits 12 on dial
Obtains an apical pulse for one full minute.
Obtains pulse rate within 2 beats of instructor reading.
What is the procedure for counting respirations?
Observes complete respiratory cycle (one inspiration and one expiration). After cycle is observed, looks at second hand and begins counting at 1 with first full respiratory cycle.
Counts the respiratory rate for 30 seconds and multiplies by 2 to determine respiratory rate.
Evaluates the respiratory rate in relation to the baseline data or normal range for age, relationship to other vital signs, respiratory depth, rhythm and character in relation to baseline data and health status.
Adult – 12-20
What is normal when observing the depth, rhythm, and character of respirations?
-unlabored, easy, regular, steady, no use of accessory muscles
What is the range for a normal amount of respirations?
12-20 per minute
How is the blood pressure cuff measured to fit patient accurately?
- width = at least 40% of the bladder
- length = at least 80% of the bladder
- demonstrate on the arm the sizes to make sure
- if tight then there is a false high
- if loose then there is a false low
What is the procedure for taking a blood pressure?
Demonstrates competency with aneroid blood pressure sphygmomanometer.
Selects appropriate sized cuff – width of cuff encircles at least 40% of the arm. The length of the bladder encircles at least 80% the circumference of the arm. Verbalize how to measure cuff size.
Prepares and positions the client appropriately with forearm supported at heart level.
Wraps deflated cuff evenly and snuggly around the upper arm.
Measure Blood Pressure using Two-Step method.
Palpates brachial or radial artery while inflating cuff, note point at which pulse disappears and continue to inflate cuff to a pressure of 30mm Hg above that point.
Slowly deflate cuff and note where pulse reappears. This is the client’s estimated systolic BP. Wait 30 seconds.
Places diaphragm of stethoscope over brachial artery. Inflates BP cuff 30mm Hg above client’s estimated systolic pressure. Slowly releases pressure bulb valve on the cuff so that the pressure decreases at a rate of 2-3mm Hg per second. Notes point on manometer when first clear sound is heard and continues to deflate cuff gradually noting point at which sound disappears in adult.
Evaluates the blood pressure in relation to baseline data, normal range for age and health status; relationship to pulse and respiration
What is important when documenting the vitals?
- comparison to baseline
- is in line with what is expected of ethnicity, gender, age, condition, etc.
