Vitals expected ranges Flashcards
Adult BP expected reference range
Systolic 90 to 119; Diastolic 60 to to 70 mm Hg
Adult pulse expected reference range
60 to 100 bpm
Adult body temp expected reference range
35.9° to 38° (96.7° to 100.5° F)
Adult respiration expected reference range
12 to 20 breaths/minute
Adult oxygen saturation expected reference range
95% to 100%
Sites for measuring BP
upper arm and thigh
Manifestations of bradypnea
dizziness, fatigue, confusion, impaired coordination
Elevated BP
Systolic 120 to 129 and Diastolic less than 80
Stage I hypertension
Systolic 130 to 139 OR Diastolic 80 to 89
Stage II hypertension
Systolic 140 or higher OR Diastolic 90 or higher
Hypertensive crisis
Systolic higher than 180 AND/OR Diastolic higher than 120
When is orthostatic hypertension indicated?
-decrease in systolic BP of greater than or equal to 20 mm Hg
-increase in diastolic BP of greater than or equal to 10 mm Hg
-within 3 minutes of change of position
What to do to check for orthostatic hypotension?
-take BP with pt laying supine
-take BP with pt sitting on side of bed
-take BP with pt standing
When is hypotension indicated?
Lower than 90/60 mm Hg
What are symptoms of hypotension?
dizziness, tachycardia, pallor, increased sweating, blurred vision, nausea and confusion
When is BP not supposed to be used on a limb?
-IV line
-arteriovenous shunt or fistula
-side of mastectomy or axillary lymph node removal
What is eupnea?
normal, unlabored respiration; one respiration to four heartbeats
What is tachypnea?
increased respiratory rate; may occur in response to an increased metabolic rate
breaths greater than 24 a minute
What is bradypnea?
decreased respiratory rate; occurs in some pathologic conditions
breaths less than 10 a minute
What is apnea?
periods when no breathing occurs
What is dyspnea?
difficult or labored breathing
What is orthopnea?
changes in breathing when sitting or standing
What is hyperpyrexia?
Fever equal to or greater than 41° C (106)
When should you not use oral temp on a pt?
oral cavity disease
nose or mouth surgery
risk of seizures
receiving O2 via mask
When should you not use tympanic temp on a pt?
drainage from the ear
ear pain
ear infection
scars on tympanic membrane
Where should a temporal temperature not be taken?
on side of head that pt has been lying on or over scar tissue, open lesions or abrasions
When should rectal temp not be used?
on children with diarrhea
pts who have undergone rectal surgery
pts who have diseases of the rectum
cardiac or cardiac surgery pts
How do you document temp?
record temp in EHR
identify site used if other than oral
report abnormal findings to the primary care provider
How do you document pulse?
Record pulse rate
Amplitude and quality (bounding, full, expected, diminished, absent)
rhythm (regular or irregular)
Identify site of assessment (apical, radial, femoral, carotid)
Report abnormal findings to primary care provider
How do you document respirations?
Respiratory rate
depth
rhythm
report any abnormal findings to the primary care provider
How do you document BP?
record findings on EHR or flow sheet
place readings under time of acquiring BP not time of entering the values
report any abnormal findings to the primary care provider
Identify arm used and site of assessment for BP (if other than brachial used)
How do you document pulse ox?
Date and time of reading
SPO2 value
amount of oxygen and delivery method (if pt is on O2)
Lung assessment (if relevant)
any relevant interventions required as a result of the reading
What does afebrile mean?
normal body temperature
What chemicals are released in the body when additional heat is required?
epinephrine and norepinpehrine
What is an example of radiation?
The body gives off waves of heat from uncovered surfaces
What is an example of convection?
An oscillating fan blows currents of cool air across the surface of a warm body
What is an example of evaporation?
Body fluid in the form of perspiration and insensible loss is vaporized from the skin
What is an example of conduction?
The body transfers heat to an ice pack, causing the ice to melt
What are pyrogens?
substances that cause fever
What is tachycardia?
HR of 100-180 bpm
What are some tachycardia causes?
elevated temp
condition causing poor oxygenation of the blood
exercise
pain
strong emotions
some medications
What is bradycardia?
HR below 60 bpm
What are some bradycardia causes?
sleep
hypothermia
aging
medications
vagal stimulation (body movement)
How do you document bradycardia?
report any difficulty breathing, changes in LOC, decreased BP, EKG changes, chest pain
What parts of the brain control respiratory rate and depth?
medulla and pons
What activates respiratory rate and depth?
impulses from chemoreceptors
What is the most powerful respiratory stimulant?
CO2
What is primary hypertension?
characterized by increase above normal in both systolic and diastolic pressures
no known cause
What is secondary hypertension?
caused by another disease condition
common causes include kidney disease, adrenal cortex disorders, and aorta disorders
What is a neurogenic fever?
fever of unknown origin (38.9° C or 101° F)
lasting longer than 3 weeks
does not respond to antipyretics
result of damage to hypothalamus
increased intracranial pressure
When is an axillary temperature used?
when both oral and rectal sites are contraindicated or inaccessible
What can cause tachypnea?
exercise
age
increased metabolic rate
any condition causing increased CO2 and decrease in O2
increased altitude
anemia
anxiety
What can cause bradypnea?
increased intracranial pressure
Medications (opioids like morphine and hydromorphone)
Expected range for school age BP
94 to 106/ 55 to 62 mm Hg
Toddler heart rate expected range
80 to 130 bpm
Expected reference range for toddler respiratory rate
25 to 30 breaths/min
School age expected reference range for heart rate
74 to 110 bpm
Adolescent expected reference range for heart rate
70 to 100 bpm
School age child expected reference range for respiratory rate
18 to 30 breaths/min
Preschooler respiratory reference range
22 to 34 breaths/min
Preschooler expected reference range for heart rate
75 to 129 bpm
Infant expected reference range for heart rate
80 to 140 bpm
