Vitals - Midterm Flashcards
what are vitals
objective measure of physiological function
what are vitals used for
a baseline
when is a baseline needed
patients over 65 or under 2
debilitated patients
sedentary patients
patient with cardiovascular issues
HR/pulse rate
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
amplitude of pulse rate
0 = absent
1+ = weak/thready
2+ = normal
3+ = strong
4+ = bouncing
what is peripheral patency
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
what is capillary refill
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
heart rate norms
<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
max HR
208 - (0.7 x age) for healthy adults
1 SD of HR max is 10-12 bpm
target HR
minimal HR a person should sustain during exercise to train the CV system effectively
HR reserve method
HR reserve method
HR + ([HR max - HR rest] x 0.60 or 0.80)
normal HR response to exercise
increases, plateaus and decreases following intensity of exercise
should begin to return to resting value after 2 minutes
palpation of HR
HR never measured with pulsoximeter
30 seconds over a distal part with pads of index finger and middle finger
what is blood pressure
reflects CO, peripheral vascular resistance, and other hemodynamic factors
measured w/ sphygmomanometer (indirect measure of pressure of blood flow in an artery)
what is considered systolic
systolic - first sound (BP at time of contraction of ventricle, palpated pulses)
what is considered diastolic
diastolic- last sound (BP at time of rest period of the heart, time b/w palpated pulses, blood flow is laminar here)
what are korotkoff sounds
sounds hear
phase 1 - systolic
phase 5 - diastolic
BP norms
normal
elevated
hypertension stage 1
hypertension stage 2
hypertension stage 3
normal BP
systolic - less than 120
and
diastolic - less than 80
elevated BP
systolic - 120-129
and
diastolic- less than 80
hypertension stage 1
systolic - 130-139
or
diastolic- 80-90
hypertension stage 2
systolic- 140 or higher
or
diastolic- 90 or higher
hypertension stage 3
systolic- 180 or higher
and/or
diastolic- higher than 120
*requires immediate MD attention
orthostatic hypertension
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
cuff size (BP)
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
measuring BP
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
BP red flags
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
respiratory rate
one breathing cycle
measure visually, by palpation and auditory
no units
RR norms
1:2 ratio of inspiratory time to expiratory time
how do you measure RR
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
RR norms
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)
temperature
can use dorsal portion of hand or thermometer
temp norms
98.6
hypothermia - rectal temp below 94
hyperthermia - rectal temp above 106
pain is…
subjective
how is pain measured
visual analog scale
wong-baker scale (smiley faces)
body diagram
questionnaires
