Vitals Flashcards
5 Vitals
-Temperature
-Pulse
-Respiratory Rate
-Blood Pressure
-Pulse Oximetry
-Temperature
-Normal
-Adults 98.6*F or 37*C -Hypothermia (Low temp) < 95*F -Exposure, increased Heat loss, Diaphoresis (Sweating) blood loss, hormone imbalance, hypothalamus injury. -Hyperthermia (High tmp) >100*F -Increased environmental temps, decreased loss (Too many clothes), drugs or medication reaction, hormone imbalance, infection/ Illness
-Pulse
-Direct indicator of heart actions
-Note rate and rhythms -Capillary refill, indicative of local perfusion - > 3 seconds = poor perfusion
-Normal Pulse
-Adults 6-100 bpm
-Children have a higher rate
-Bradycardia
Slower heart rate < 60 bpm
-Tachycardia
(fast heart rate) > 100 bpm
-Hypothermia, fever, emotional stress, heart abnormality, blood volume loss
-Rhythm of the heart may be irregular due to
cardiac arrhythmias or changes in vascular system affecting blood flow
-Measuring pulse
-Most Common site - Radial Artery
-Others: Brachial, ulnar, femoral, carotid, apical, temporal, popliteal, posterior tibial. -Use two fingers, and press firmly but gently over pulse site, do not use thumb -Count for a full minute, if irregular rhythm otherwise count for 15 seconds and multiply by 4.
-Respiratory Rate
-Number of breaths in 1 minute intervals
-Important to count when patients are not aware
-Respiratory Rate -Normal
-Adults 12-20
-Children have a higher rate -Note, rate depth, pattern, rhythm, and degree of labor, I:E ratio (inspiration to Expiration)
-Eupnea
Normal restful breaths
-Hyperpnea,
deep breaths
-Hypopnea
Shallow breaths
-Tachypnea
increased respiration rates
-Caused by, anxiety, exercise, fever, hypoxemia -May indicate respiratory failure
-Bradypnea
decreased rate
-Caused by, narcotics, head injury, hypothermia
Respiratory rate is best to count after….
pulse rate
-Count full min if irregular
-Blood Pressure
-Measurement of pressure within arterial systems
-Factors of BP
-measuring for pumping action of heart, resistance in cardiovascular system, elasticity of vessel walls, blood volume,viscosity of blood (thickness)
-Systolic pressure, when the ventricles contract -Diastolic pressure, when ventricles are at rest -At this point, the aortic valve closes and pushes the blood through the arterial system -The more important measurement of the two
-MAP:
Mean Arterial pressure, average of both systolic and diastolic pressure
-Normal BP
-Adults 120/80
-Children have lower blood pressure
-Hypotension
(low BP)
-Shock, hormone imbalance, depressant drugs, postural (Positioning) Fluid loss.
-Hypertension
(High BP)
-Cardiovascular imbalance, hormone imbalance, exercise, stimulate drugs, emotional stress, renal failure, fluid retention
-Acceptable Systolic
90-140
-Acceptable Disstolic
60-90
BP is measured by:
sphygmomanometer
how to use sphygmomanometer
-Cuff placed snugly around 1 inch above antecubital space (bladder should be over the brachial artery)
-Have patient relax muscle in arm
-Palpate brachial pulse and inflate cuff
-Slowly deflate cuff, note pressure, when sound 1st appears, systolic
.Note pressure when all sounds cease, diastolic
-Pulse Oximetry
-Plethysmography (Sp02)
-5th Vital Sign -Measurement of % red blood cells carrying something (Usually O2) -Uses different wavelengths of red light passed through capillary bed(Nails) -Can be continuous or spot check and is non invasive
-Pulse Oximetry -Problems:
Ambient light, motion artifact, cold, anemia, PaO2, Vs. SPO2
-Rule 1#: Treat the patient not the monitor
-Pulse Oximetry vital readings
-Normal 93-97% SaO2
-Critical Values < 88% (Except Chronic Lung Patient)
-Heart Sounds
-Normal sounds
-Sounds created by closure of the heart valves -Sound 1 normal sound created by the closure of valves at the beginning of ventricular contraction (Lub sound) -Sound 2 normal sounds created the the systolic ends and ventricles relax typically during inspiration (Dub sound) -Sounds 3, and 4 murmurs are abnormal and suggest heart failure, stenosis (extra sounds generated by aberrant blood flow)
-Auscultation
-One of the most commonly used physical assessment techniques
-Lung sounds can be normal or adventitious (abnormal) -Listen in sequence over the back and anterior chest. Refrain from listening anteriorly because it easy of access
-Auscultation -Normal breath sounds
-Bronchial/ Tracheal breath sounds
-Heard over the trachea or btw scapula posteriorly
-Louder and higher pitched
-Loud and long expiration often longer than inspiration -If heard in periphery of lung could be abnormal
-Bronchovesicular
-Heard over the main bronchus area
- Medium pitch
-Expiration is equal to inspiration
-Vesicular
-Heard over most lung fields
-Soft and low pitched -Inspiration last longer than expiration
-Adventitious breath sounds “Crackles”
-Also known as rales
-can be course cracked or fine crackles
-Fine = Results when the terminal airways pop open late in inspiration because of fluid or secretions have accumulated
-Sounds that wax and wane during each respiratory cycle
-Usually heard at the end of inspiration
-Fine in quality and high pitched
-Most often heard over the lung base
-Most common condition is CHF/Pulmonary edema ( Fine crackles at the base.)
-Adventitious breathing sound “Rhonchi” (course crackles)
-Ronchi is deep rumbling sounds that is more pronounced on expiration
-Likely to be continuous and can be palpated -Caused by air passing through an airway partially obstructed by thick secretion -Coarse crackles secretion in large airways rumbling on inspiration and expiration -Both can usually be cleared or improved through suctioning or coughing
-Adventitious breathing sounds “Wheezing”
-Can be high or low pitched
-Musical or whistling in nature -Caused by air passing through narrowed airways -Can have inspiratory wheezing, expiratory wheezing or both -Often heard with bronchospasms, asthma, foreign, body aspiration
-Adventitious breath sounds “stridor”
-Crowing sound commonly caused by inflammation of the larynx and trachea. Usually on inspiration only
-Can be heard after extubation -Most commonly associated with children with croup -Often relieved with cool aerosol therapy of racemic epinephrine -Marked inspiratory stridor is an emergency and requires quick action (Intubation)
-Adventitious breathing sounds “Pleural Friction rub”
-Continuous grating sound, such as rubbing two pieces of leather together/ balloons
-Sounds produced when the visceral and parietal pleura of the lungs become inflamed -May accompany pleural effusion, lung trauma, pleurisy -Usually localized area
-Grunting and stertor
Grunting is often displayed in newborns with respiratory distress
-Occurs when baby exhales against a closed glottis is closed in an attempt to maintain lung volume -Stertor is noisy breathing sounds displayed during inhalation by babies -Low pitched snorting/ snoring sound. Sound that arises from vibrations of fluid or tissue that is relaxed and flabby.
-Other lung sounds
-Bronchophony
-Auscultates over an area of suspected consolidation the patient speaking ninety nine, intensity is increased and clearly audible if consolidation is present
-Egophony
-Having the patient say the letter E and it sounds like an A over consolidated lungs
- Whispering pectoriloquy-Patient is asked to whisper numbers 1,2,3. Normal sounds is soft, but with lung consolidation, it is clearly audible
-Patient Assessment
-Medical History
-Respect patient
-Remain professional -Establish rapport and obtain essential information -Open ended questions (Not yes or no) -Demographic data -Data and source of information (and reliability) -Description of condition -Current complaint (CC)/ reason for seeking treatment -History of present illness (HPI) -Past medical history -Family history -Social / environmental history
-Patient Assessment
-History of present illness (HPI)
-Onset, severity, location, quality, aggravations, alleviations factors (OLD CART)
-Review of symptoms
-Respiratory - cough, hemoptysis, sputum, chest pain, shortness of breath, hoarseness/ change in the voice, dizziness/ fainting, fever or chills, peripheral edma.
-General Appearance
-Age, height, weight
-Sensorium (level of consciousness)
-Confused, delirious, lethargic, obtunded, stuporous, comatose, “Oriented X 3 , person, place , time.
-Vital signs
-Head, ears, eyes, nose, throat, (HEENT), inspection
-Nasal flaring, cyanosis, pursed lip breathing
-Neck, inspection and palpation
-Position of trachea, jugular venous distention (JVD) enlarged lymph node.
-Thorax, inspection, palpation, auscultation
-Inspection
-Chest configuration
-Barrel chested (Ap diameter increased)
-Pectus carinatum/ pectus Excavatum (caved in chest/ pigeon breasted) -Kyphosis/ scoliosis/ kyphoscoliosis -Notice any bumps, lumps, of concussions
-Inspection
-Breathing patterns and efforts
-Retractions, sinking in of skin overlying the chest wall (Intercostal, supraclavicular, subcostal
-Inspiratory: expiratory ratio (I:E ration) -Kussmaul, deep and rapid breaths
-Biot, short burst of uniform, deep respirations
-Cheyne stokes: increased/ decreased depth and rate with pauses
-Tachypnea, faster than 20 bpm
-Bradypnea, Slower than 12 bpm
-Apnea; Absence of breaths
-Platypnea: difficulty breathing unless laying flat
-orthopnea: difficulty breathing unless reclining. Patient must be sitting up of using several pillows to breath
-Palpation
-Vocal fremitus/ tactile fremitus
-Ninety-nine -Increased vibrations through more solid tissues -Decreases obesity over muscular, hyper inflation -Thoracic expansion/ diaphragmatic excursion- equal bilaterally (Both thumbs should be moving equally )
Percussion
-Tapping on the surface to evaluate underlying tissue
-Indirect,place middle finger on chest, tp sharply with the middle finger of your other hand -Normal resonance, moderately low pitched ringback -Consolidation, decreased or absent resonance = Dull -Hyperinflation , Increased resonance (Hypercasonant)
-Auscultation
-Listening to breath sounds with a stethoscope
-4 parts, Bell, diaphragm, tubing, earpieces -Bell, listen to heart sounds -Diaphragm, listen to lung sounds -Earpieces, directed anteriorly into ears -Normal and abnormal sounds -Soft/rigid -Tenderness
-Extremities
-Clubbing, enlargement of terminal phalanges of fingers and toes
-Compensatory mechanism when someone has chronic hypoxemia -Infiltrative or interstitial lung disease -Bronchiectasis -Some cancers (Lung cancer) -Cyanosis -Pedal edema (Swelling like in feet and hands) -Capillary refill -Peripheral skin temperature and color (pallor, cyanosis, flush.)
-Cardiopulmonary symptoms
-Dyspnea
shortness of breath as perceived by patient
-Measured using a scale (Dyspnea borg scale.)
-Cardiopulmonary symptoms
-Cough
-Cough, Forced expiratory maneuver that expels mucus and foreign materials from airways
-Cough receptors in Larynx, trachea and large bronchi -Effectiveness depends on patient being able to take a deep breath -Dry and loose -Productive or unproductive -Acute or chronic -Time of day
-Cardiopulmonary symptoms
-Sputum production
-Sputum production: Mucus produced in the airways
-Normal is minimal -Mucociliary escalator -Phlegm, material from tracheobronchial tree, not contaminated by oral secretions -Sputum, comes from lungs nut passes through mouth -Purulent, contains pus (Suggest bronchi infection) -Fetid, foul smell -Mucoid, thick and cleat ( Common in airway diseases like asthma )
-Cardiopulmonary symptoms
-Hemoptysis
-Hemoptysis, coughing up blood or blood streaked sputum
-Massive >300 cc over 24 hours -Infection , can be blood streaked -Cancer, TB, trauma, pulmonary embolism
-Cardiopulmonary symptoms
-Chest Pain
-Chest Pain
-Pleuritic (Lungs), literally or posteriorly, worsens on inspiration, sharp stabbing. -Nonpleuritic ( Not the lungs), central anterior, dull ache or pressure, angina, GERD, or gallbladder.
