Vital Signs (Pt Care Ch. 3, Big Red Ch. 2) Flashcards
6 vital signs
- Temperature
- Heat rate
- Blood pressure
- SPO2
- Respiration Rate
- Pain
Why do we need to take vitals?
Baseline measurement of vitals at rest helps us determine changes in tolerance to exercise.
Normal oral temp
96.8°F - 99.5°F
Locations to assess body temp
- Oral
- Ear
- Rectal
- Inguinal
- Axillary
Factors affecting body temp
- Time of day (lower in morning, higher in afternoon)
- Age (decreases as you get older)
- Environmental temperature
- Infection
- Physical activity
- Emotional stress
- Site of measurement (rectal higher than oral, axillary lower than oral)
- Menstrual cycle
- Oral cavity temperature
Pulse
Indirect measure of the contraction of the left ventricle of the heart; indicates the rate at which the heart is beating.
Normal pulse rates
- Newborn
- Children
- Adults
- Newborns: 100 - 150 bpm
- Children: 70 - 130 bpm
- Adults: 60 - 100 bpm
Pulse margin of error
+/- 6 when measuring for 10 sec
+/- 4 when measuring for 15 sec
+/- 2 when measuring for 30 sec
Factors affecting pulse
- Age
- Sex
- Anxiety/stress
- Environmental temperature
- Exercise
- Infection
- Medications
- Disease process
What should you document for pulse?
- Rate (bpm)
- Rhythm: pattern of pulsations and intervals between
- Quality: amount of force created by ejected blood volume against arterial walls during ventricular contraction
* Graded 0-4 - Descriptions of heart rate: strong and regular, weak and regular, irregular, thready, tachycardia, bradycardia
Normal blood oxygen saturation
95% - 100% at or near sea level
*Hypoxemia >90%
Factors affecting pulse ox readings
- Altitude
- Temperature
- Lighting
What does systolic BP mean?
What does diastolic BP mean?
- Systolic: BP when the left ventricle contracts (systole)
- Diastolic: BP when heart is relaxed (diastole)
Phases of Korotkoff sounds
I) First, clear, faint, rhythmic, tapping sound that gradually increases in intensity
- Systolic BP
II) Murmur or swishing sound as artery widens to let more blood to flow through
III) Sounds become crisp, intense, and loud
IV) Sound is distinct but abruptly becomes muffled
V) Last sound is heard
- Diastolic BP
Normal BP values
- Infants
- Children
- Adolescents
- Adults
- Elderly
Infants:
- Birth-3mo: 85-90/35-65
- 3mo-1yr: 90-100/60-67
Children:
- 1-4yr: 100-108/60
- 4-12yr: +2 per yr from 100/60-70
Adolescents:
- 100-120/65-75
Adults:
- Normal: <120/<80
- High normal: 130-139/85-89
Elderly (over 65):
- 120-140/80-90
BP values
- Pre HTN
- Stage 1 HTN
- Stage 2 HTN
- Hypertensive crisis
Pre HTN: 120-139/80-89
Stage 1: 140-159/90-99
Stage 2: 160-179/100-109
Hypertensive crisis: >180/>110
How fast should a BP cuff be deflated?
2-3 mmHg/sec
Factors affecting BP
- Age
- Physical activity
- Emotional status
- Medications
- Size and condition of arteries
- Arm position
- Muscle contraction
- Blood volume
- Dehydration
- Cardiac output
- Site of measurement
Normal respiration rate
- Infants
- Adults
Infants: 30-50 breaths/min
Adults: 12-18 breaths/min
What should you document for respiration?
- Rate: number of breaths/min
- Rhythm: regularity of pattern
- Depth: amount of air exchanged with each respiration
- Deviations from normal, resting, quiet respiration
Wheezing
- Respiration through narrowed airways
- Continuous and musical
- COPD, asthma, CHF, pulmonary edema, chronic brochitis
Ronchi
- Snoring or gurgling sound with expiration
- Secretions in larger airways
Stridor
- Inspiratory
- Over trachea
- Obstruction of trachea or larynx
- Medical emergency
Crackles (rales)
- Sharp, discrete bursts of sound heard on inspiration
- Asthma, bronchitis, bronchiectasis, CHF
