Vitals Flashcards
Pulse/heart, blood pressure, respiration, temperature
Vital signs
Indirect measurement of heart rate , # of times the heart ventricularly contracts in a given period of time
Pulse
Beats per minute
Pulse
Manual palpation
Pulse
What is the most accurate way to asses resting
Pulse
Pulse is an indicator of
Peripheral circulation
2 ways to test manual heart rate
Radial and carotid pulse
Carotid pulse
- stand on same side you are assessing
- do not apply significant pressure
- never palpate both arteries at same time
Antebrachial fossa, medial to the biceps brachii tendon
Brachial artery location
placement of stethoscope for assessing BP
Brachial
60‐100bpm
Children over 10 and adults heart rate
40‐60bpm
Well conditioned athletes
Abnormal Responses Exhibited by the Pulse
Slowly ↑ or does not ↑ during active exercise
● Continues to ↑ or ↓ as intensity of exercise or activity plateaus
● Slowly ↓ as intensity of exercise or activity declines and terminates \
● Does not ↓ as intensity of exercise or activity declines
● ↓ during exercise before intensity of exercise or activity declines
● ↑ pulse rate or amount of increase exceeds level expected to occur during exercise period ● Rhythm of pulse becomes irregular during or after exercise or activit
Peripheral pulses can also be used to assess how well blood is moving through
distal vessels
use of sound waves to assess passage of blood through arterial and venous blood vessels
Doppler sonography
f no Doppler is available, manual assessments are a screening tool for
Blood circulation
Want to assess bilaterally, start distally
Peripheral pulse
Bounding pulse
4
Increased pulse
3
Normal pulse
2
Weak or thready
1
Absent or non palpable
0
Peripheral pulse
Femoral, popliteal, dorsalis pedis, posterior tibial pulse
Start with palpating radial pulse
Assessing respiration
Watch for the rise and fall of the thorax, try not to let the patient be aware you are
watching them breathe
Assessing respiration
Respiratory rate
RR
Normal resting respiratory rate
12-20
voluntary (breath holding) vs involuntary (obstruction or damage to respiration
control centers in the brain)
Apnea
Labored, difficult, and painful
Ease of breathing
Measurement of oxygen in the blood
Pulse oximetry
“Sp02”
- max 100%
Normal pulse ox
95-100%
HYPOXEMIA suspected if
<90%;<85%
severehypoxemia
The force exerted by the blood against any unit area of the vessel wall
Blood pressure
BP at the time of contraction of the left ventricle (systole)
Systolic pressure
the BP at the time of the rest period of the heart
Diastolic
Sensors placed directly into the arterial vessels (e.g. arterial lines)
Direct
Mostcommonsiteisbrachialartery,useleftarm unlessmedicallynotadvisabledueto
Indirect
Elevated blood pressure
120-129, less than 80
130-139 80 to 89
High blood pressure stage 1
Higher than 180
Hypertensive case
BP Changes during exercise that are serious warnings
Systolic reading >250 mm Hg
● Diastolic reading > 115 mm Hg
● ↓ systolic pressure > 10 mm Hg from baseline
● Failure of the systolic pressure to ↑ with ↑ workload
physiologic stress related to an upright posture (sitting or standing)
Orthostasis
once you stand up the gravitational changes on circulation are compensated by
the
Circulatory and autonomic nervous systems
Venous pooling in the lower limbs, along with decreased filling pressure of the heart and a
reduction in cardiac output lead t
fall in arterial BP
Decrease in BP of at least 20 mm Hg systolic OR > 10 mmHg diastolic within 3 min of
assuming an upright position
Orthostatic
Turgor (elasticity/tension) Hair growth Sensation
◦ Light touch/Pressure
◦ Sharp/dull (pain/temp) Pigmentation changes Bruising Odor
Integumentary integrity
◦ Look at skin
◦ Patient characteristics – e.g. bed ridden or post op?
◦ May need to drape/ undres
Visual assessment
(redness that does not disappear quickly once pressure is relieved is
Stage 1 pressure sore
A flat, small (1 centimeter or less) lesion with color change. Seen in rubeola, rubella, scarlet fever, roseola infantum.
Macule
An elevated, sharply
circumscribed, small (1
centimeter), colored lesion. May
be pink, tan, red, or any
variation. Seen in ringworm and
psoriasis.
Papule
A bulging, small (under 1 centimeter), sharply defined lesion filled with clear, free fluid. Seen as groups in herpes simplex, varicella, poison ivy, and herpes zoster.
Vesicle/blister
An elevated, sharply circumscribed lesion (less than 1 centimeter) filled with pus. Seen in impetigo, acne, and staphylococcus infections.
Pustule
An elevated, white to pink edematous
lesion that is unstable and associated
with pruritus. Wheals are evanescent –
they appear and disappear quickly.
Seen in mosquito bites and hives.]
Wheal
Tiny, reddish purple, sharply circumscribed spots of hemorrhage in the superficial layers of the skin or epidermis. Petechiae may indicate severe systemic disease such as meningococcemia, bacterial endocarditis, or non-thrombocytopenic purpura and must be reported immediately
Petechiae
Fresh blood that comes from a recent wound, bright red color, seen in partial thickness and full thickness wounds, bloody
Sanguineous drainage
Thin, clear and a little thicker than water, occurs during the healing process of the wound
Serous
Drainage is cloudier and can be slightly yellow or tan in appearance, means wound has infection and will need further treatment
Seropurulent drainage
Being “milky” in appearance , almost always a sure sign of infection, thick
Purulent
There is also a lack of smell when the dressing has been removed.
No odor
An odor is only detectable at close proximity to the patient and when the dressing is removed.
Slight odor
Similar to the above ranking, except that the dressing remains on the patient.
Moderate odor
This is when an odor is discernible within 6 to 10 feet of the patient and the dressing is removed.
Strong odor
An odor that’s also noticeable within 6 to 10 feet, but the patient’s dressings remain fully intact.
Very strong odor
Sweet smell =
pseudomonas
Pressure Injuries aka
Pressure ulcers
localized damage to the skin and/or underlying soft
tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.”
Pressure injury
Five classic locations
Pressure injuries
• Sacrum/coccyx
• Greater trochanter
• Ischial tuberosity
• Heel
• Lateral malleolus
Purple or maroon localized area of discolored, in tact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear
Deep tissue pressure injury
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Area may be painful, soft, warmer or cooler as compared to adjacent tissue.
May be difficult to detect in individuals with dark skin tones
Stage 1
Partial thickness loss of dermis Presents as a shallow, open ulcer with a red/pink wound bed without slough
Can also present as an intact or open/ruptured serum-filled blister Should not be used to describe skin tears, maceration or excoriation
Stage 2
Full thickness tissue loss Subcutaneous fat may be visible, but bone, muscle or tendon are not. Slough may be present but does not obscure the depth of the tissue loss May include undermining and tunneling, epidermal rolling/ridging/epibole Varies by anatomical location
◦ (bridge of nose, occiput do not have subcutaneous fat
and can have a shallow stage 3) ◦ Areas of high fat tissue content may have very deep
stage 3
Stage 3
Full thickness tissue loss Exposed bone, tendon or muscle (visible and palpable)
Slough or eschar may be present Often includes undermining and tunneling Depth varies by anatomical location
Stage 4
Full thickness skin loss Base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or by eschar (tan, brown, black)
Until enough slough/eschar is removed to expose the base of the wound, no stage can be determined Stable, dry, adherent eschar in heels should be left alone
Unstageable
