Vitals - Midterm

Question 1

what are vitals

Answer 1

objective measure of physiological function

Question 2

what are vitals used for

Answer 2

a baseline

Question 3

when is a baseline needed

Answer 3

patients over 65 or under 2
debilitated patients
sedentary patients
patient with cardiovascular issues

Question 4

HR/pulse rate

Answer 4

heart rate: direct measurement taken at heart w/ EKG, palpation on heart of ventricular beats per min

pulse rate: indirect measurement of contraction of left ventricle

-not always 1:1 with HR b/c not all ventricular contracts are strong enough to produce a pulse distally

Question 5

amplitude of pulse rate

Answer 5

0 = absent
1+ = weak/thready
2+ = normal
3+ = strong
4+ = bouncing

Question 6

what is peripheral patency

Answer 6

the ability to get blood to an area of the body

can provide signs of occlusion (blockage or vascular insufficiency)

measured in distal pulse and graded on amplitude

capillary refill

Question 7

what is capillary refill

Answer 7

push down on an area to occlude it then remove pressure - color should return >2 seconds

can also be measured w/ reactive hyperemia test

-elevate limb for 1 minute then return to level and color should be normal in 2-3 seconds

Question 8

heart rate norms

Answer 8

<6 months = 100-160
1 yr= 90-150
3 yr = 80-115
5 yr = 70-115
10 to adult = 60-100
Bradycardia = <60 bpm
tachycardia >100 bpm

Question 9

max HR

Answer 9

208 - (0.7 x age) for healthy adults

1 SD of HR max is 10-12 bpm

Question 10

target HR

Answer 10

minimal HR a person should sustain during exercise to train the CV system effectively

HR reserve method

Question 11

HR reserve method

Answer 11

HR + ([HR max - HR rest] x 0.60 or 0.80)

Question 12

normal HR response to exercise

Answer 12

increases, plateaus and decreases following intensity of exercise

should begin to return to resting value after 2 minutes

Question 13

palpation of HR

Answer 13

HR never measured with pulsoximeter

30 seconds over a distal part with pads of index finger and middle finger

Question 14

what is blood pressure

Answer 14

reflects CO, peripheral vascular resistance, and other hemodynamic factors

measured w/ sphygmomanometer (indirect measure of pressure of blood flow in an artery)

Question 15

what is considered systolic

Answer 15

systolic - first sound (BP at time of contraction of ventricle, palpated pulses)

Question 16

what is considered diastolic

Answer 16

diastolic- last sound (BP at time of rest period of the heart, time b/w palpated pulses, blood flow is laminar here)

Question 17

what are korotkoff sounds

Answer 17

sounds hear

phase 1 - systolic

phase 5 - diastolic

Question 18

BP norms

Answer 18

normal

elevated

hypertension stage 1

hypertension stage 2

hypertension stage 3

Question 19

normal BP

Answer 19

systolic - less than 120

and

diastolic - less than 80

Question 20

elevated BP

Answer 20

systolic - 120-129

and

diastolic- less than 80

Question 21

hypertension stage 1

Answer 21

systolic - 130-139

or

diastolic- 80-90

Question 22

hypertension stage 2

Answer 22

systolic- 140 or higher

or

diastolic- 90 or higher

Question 23

hypertension stage 3

Answer 23

systolic- 180 or higher

and/or

diastolic- higher than 120

*requires immediate MD attention

Question 24

orthostatic hypertension

Answer 24

drop on 20 mmHg of systolic or 10 mmHg BP upon changing position

can be counteracted by sitting at the edge of the bed until “lightheadedness” passes and performing LE movements

Question 25

cuff size (BP)

Answer 25

American heart association specify that proper cuff bladder length of 80% and width of at least 40% of arm circumference wrong size can lead to error of 2-10 mmHg

Question 26

measuring BP

Answer 26

place cuff 2.5 cm about antecubital fossa palpate radial pulse and pump cuff until occluded then pump 20-30 mmHg more can vary 10 mmHg between arms (always take higher pressure) round to nearest 2 mmHg

Question 27

BP red flags

Answer 27

no rise in BP in proportion to increases intensity of activity decrease greater than 10 mmHg systolic over 240 mmHg increase > 20 mmHg diastolic during activity

Question 28

respiratory rate

Answer 28

one breathing cycle measure visually, by palpation and auditory no units

Question 29

RR norms

Answer 29

1:2 ratio of inspiratory time to expiratory time

Question 30

how do you measure RR

Answer 30

measure for 30 seconds then double if NO pulmonary diagnosis present (use 60 if pulmonary diagnosis present) document rate, depth, regularity and use of accessory muscles if present

Question 31

RR norms

Answer 31

newborns= 30-60 6 months = 24-38 5 years = 20-24 10 years = 16-22 14 years = 14-20 adult = 12-20 (can go to 25-35 w/ exercise)

Question 32

temperature

Answer 32

can use dorsal portion of hand or thermometer

Question 33

temp norms

Answer 33

98.6 hypothermia - rectal temp below 94 hyperthermia - rectal temp above 106

Question 34

pain is...

Answer 34

subjective

Question 35

how is pain measured

Answer 35

visual analog scale wong-baker scale (smiley faces) body diagram questionnaires