Vital Signs ppt Flashcards
What is included in vital signs?
Temperature
Pulse
Respiration
Blood Pressure
Pain
Pulse oximetry
When do you assess vital signs?
- On admission to any health care facility or institution
- Based on facility or institutional policy and procedures
- Any time there is a change in patient’s condition
- Any time there is a loss of consciousness
- Before and after any surgical or invasive procedure
- Before or after activity that may increase risk, like ambulation after surgery
- Before administering meds that affect cardiovascular and respiratory function
Normal Oral Temp Range for Health Adults (Celsius and Farenheit)
35.8-37.5 C
96.4-99.5 F
Normal Pulse Rate Range for Healthy Adult
60-100
Average is 80
Normal Respiration Rate Range for Healthy Adult
12 to 20 breaths per minute
Normal Blood Pressure Range for Healthy Adult
Less than 120/80
What is the primary source of heat production
metabolism
What increases metabolism
Hormones, muscle movements, and exercise increase metabolism
What occurs to increase heat production
Epinephrine and norepinephrine are released when additional heat is required and alter metabolism
Thyroid hormone and shivering also increase heat production
What happens to energy production when heat production increases?
Energy production decreases
Sources of Heat Loss
- Skin (primary source)
- Evaporation of sweat
- Warming and humidifying inspired air
- Eliminating urine and feces
Transfer of Body Heat to External Environment occurs by:
- Radiation
- Convection
- Evaporation
- Conduction
Factors affecting temperature
- Circadian rhythms
- Age and gender
- Physical activity
- State of health
- Environmental temperature
Afebrile
without fever
Pyrexia
with fever (febrile)
Intermittent fever
temperature returns to normal at least once every 24 hours
Remittent fever:
temperature does not return to normal and fluctuates a few degrees up and down
Sustained or continuous fever:
Temperature remains above normal with minimal variations
Relapsing or recurrent fever:
Temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days
Equipment for Assessing Temperature
- Electronic and digital thermometers
- Tympanic membrane
thermometers - Disposable single-use
thermometers - Temporal artery
thermometers - Automated monitoring
devices
Normal oral temp adult
35.9–37.5°C;
96.6–99.5°F
Normal Rectal Temp adult
36.3–38.1°C;
97.4–100.5°F
Normal Axillary Temp Adult
35.4–36.9°C;
95.6–98.5°F
Normal Tympanic Temp Adult
36.8–38.3ºC;
98.2–100.9°F
Normal Forehead Temp (Temporal artery) for Adults
36.3–38.1°C;
98.7–100.5°F
What is pulse regulated by
Regulated by the autonomic nervous system through cardiac sinoatrial node
What does sympathetic stimulation do to heart rate?
Increases heart rate
What does parasympathetic stimulation do to heart rate?
decreases heart rate
What is pulse rate?
The number of contractions over a peripheral artery over 1 minute
What are characteristics of Peripheral Pulse?
Rate
Amplitude and quality (strong or weak)
Volume of Blood ejected with each heart beat
Rhythm
Sites for detecting pulse by light palpations
- Temporal
- Carotid
- Brachial
- Radial
- Femoral
- Popliteal
- Doralis pedis
- Posterior tibial
How to grade pulse strength (Amplitude)
Grade 0
Grade +1
Grade +2
Grade +3
What is Grade 0 pulse strength
absent, unable to palpate
What is Grade +1 pulse strength
diminished, weaker than expected
What is Grade +2 pulse strength
normal; brisk, expected
What is Grade +3 pulse strength
bounding
How to find Apical pulse
fifth intercostal midclavicular line
Ventilation
movement of air in and out of lungs
What makes up ventilation?
Inhalation
Exhalation
Inhalation
breathing in
Exhalation
breathing out
Diffusion
Exchange of oxygen and CO2 between the aveoli of lungs and circulating blood
Perfusion
Exchange of oxygen and CO2 between circulating blood and tissue cells
Rate and depth change in response to what?
Changes in response to tissue demands
Rate and depth are controlled by what?
Controlled by respiratory centers in the medulla and pons
Rate and Depth are activated by what
Activated by impulses from chemoreceptors
What is the most powerful respiratory stimulant?
Increase in carbon dioxide is the most powerful respiratory stimulant
Eupnea
normal, unlabored respiration
one respiration to every four heartbeats
Bradypnea
Decreased respiratory rate; occurs in some pathologic conditions
Tachypnea
Increased respiratory rate; may occur in response to an increased metabolic rate
Apnea
Periods when no breathing occurs
Dyspnea
Difficult or labored breathing
Dyspnea
Difficult or labored breathing
Orthopnea
Changes in breathing when sitting or standing
Blood pressure
Force of the moving blood against arterial walls
Systole/Systolic Pressure
Maximum pressure when left ventricle contracts and pushes blood through aortic valve into the aorta
Diastole/Diastolic pressure
Lowest pressure when the heart rests between beats
Pulse Pressure
Difference between systolic and diastolic pressure
Factors affecting Blood Pressure
Age, Race
Exercise
Weight
Circadian Rhythm
Emotional state
Food intake
Body position
Drugs/Meds
Biologic sex
Two forms of Decreased Hypotension
Hypotension
Orthostatic Hypotension
Hypotension
less than 90/60mmHg
result of disease processes
side effect of medications
inability of the body to maintain or return back to normal
Orthostatic hypotension (postural hypotension)
Results from an inadequate physiologic response to position changes
Occurs when rising to an erect position
What is orthostatic hypotension caused by?
Caused by dehydration, blood loss, or problems of the neurologic, cardiovascular or endocrine systems
Equipment for Assessing BP
Stethoscope and sphygmomanometer
Doppler ultrasound
Electronic or automated devices
Assessing BP what are you listening for
Listening for Korotkoff sounds with stethoscope
First sound- systolic
Change or cessation of sounds occurs- diastolic pressure
What arteries are commonly used for bp?
Brachial
Popliteal
