Vitals Flashcards
Whats considered a normal ABI?
1.0-1.4
Whats does an ABI OF 0.9 - 1.0 mean?
Acceptable calcification/vessel hardening
Whats does an ABI OF 8 - 0.9 mean?
Some arterial disease - treat risk factors
Whats does an ABI OF 0.5 - 0.8 mean?
Moderate arterial disease - refer to vascular specialist
Whats does an ABI OF less than 0.5 mean?
Severe arterial disease - refer to vascular specialist
Apical pulse
*Most central pulse
Supine, index finger of your right hand on the Angle of Louis (The angle formed at the junction of the manubrium and the body of the sternum.)
Move the index finger of your right hand to the left to locate patient’s 2nd intercostal space.
Walk index finger down from 2nd ICS to 5th ICS.
Place the diaphragm of stethoscope firmly over apex of heart. (The apex is normally located in the fifth intercostals space left of the sternum in the midclavicular line)
Pulse deficit
*Possible poor perfusion
Count the apical and radial pulse at the same time
Apical pulse is typically more accurate by about 10 bpm and gives an assessment of rhythm. Both measurements underestimate the true rate
Be aware – pts. w/ dysrhythmias
Describe amplitude of a pulse score 0-3+ :
+ 3 = BOUNDING - readily palpable, forceful, not easily obliterated by finger-pressure
+ 2 = NORMAL
+ 1= WEAK
0 = ABSENT
What could an amplitude of 0 indicate?
Absent =
Cardiac arrest
Arterial insufficiency
Peripheral arterial thrombus/embolus
Gross edema
What could an amplitude of +1 indicate?
Diminished pulse = heart failure, arterial insufficiency, edema, altered vascular tone
What could an amplitude of +3 indicate?
Bounding =
Heart failure
Renal failure
Altered vascular tone
Regularly Irregular
Regular overall rhythm with evenly skipped beats
Irregularly Irregular
Chaos! No real pattern, very difficult to measure rate accurately
Carotid artery landmarks
b/w trachea and SCM
Caution!! Don’t want to record both at the same time because you do not want to occlude blood to the brain
Femoral a. landmarks
b/w ASIS and pubic symphysis, below inguinal ligament
Dorsalis pedis
Medial ankle, POST/inferior to medial malleoli b/w it and achilles tendon
POST tibial a landmarks
Dorsum of foot, “ext big toe”
What is a normal respiration rate?
12-20
How should you take respiration rate?
Pretend taking radial pulse
Place over chest, every rise + fall = 1
Count for 60 seconds
Describe depth - shallow, moderate, deep
Note if they’re a “chest or belly - breather”
What are contraindications to taking BP in L arm?
Emphydema
Fistula
Dialysis port
Lymph node involvement
What does ABI tell you?
Detects PAD
How do you take someones ABI?
Take at brachial artery first
Then foot
Cuff above malleoli
Gel on post tibial a and dorsalis pedis a. (use the higher pressure)
ABI = ANKLE / ARM
Blow up BP cuff while listening w/ doppler till don’t hear anymore, record when you hear it again
