Week 1: Vital signs Flashcards
Apical pulse
Pulse at the point of maximal impact can be heard or palpated at the apex of the heart
Most accurate pulse (can be measured accurately and invasively)
Apical-Radial Pulse
When you compare the apical and radial pulse points to check for rhythmic abnormalities
Two ppl needed to assess: one assesses apical while the other assesses radial simultaneously
Apnea
pauses in breathing
Ausculatory gap (3)
- The period where the sounds disappear for 10-40mm Hg and then return
- If we don’t account for this, we can under-estimate Systolic BP or over-estimate diastolic BP
- ABNORMAL FINDING, Occurs in 5% of ppl with hypertension
Blood Pressure
- Force of pulsing blood under pressure from cardiac activity pushing against arterial walls
- Indicator of cardiovascular health
Influenced by:
- Cardiac Output (CO) - volume of blood from heart into ventricles
- Peripheral vascular resistance - caused by vessel diameter
- Volume of circulating blood - abnormal high or low(more common)
- Viscosity/thickness of blood
- Elasticity of vessel walls
Bradycardia
Slow HR (<60bpm)
Bradypnea
Slow breathing (<12 breaths per minute)
Core Temperature and examples (6)
Temperature of deep tissues (37C)
- Tympanic membrane
- Temporal Artery
- Esophagus
- Pulmonary artery
- Urinary Bladder
- Rectum
Diastolic pressure
elastic recoil or the resting pressure that the blood exerts constantly between contractions
Dyspnea
difficulty breathing or breathlessness
Dysrhythmia/arrhythmia
abnormal HR, regularly irregular or irregularly irregular
Hypertension
High BP (>140/90)
Hypotension
Low BP (< 90/x)
Korotkoff sounds
The 5 sounds that are auscultated during BP measurement
No sound = occlusion of brachial artery
Phase 1 = systolic pressure (taps) as artery begins to open
(Auscultatory gap)
Phase II-III: swooshing/knocking turbulent blood flow
Phase IV: Muting/muffling/blowing
Phase V = silence (diastolic pressure)
Pain
The “unpleasant sensory and emotional experience associated with actual or potential damage, or described in terms of such damage”
Influences vital signs and vital signs measurement findings
The 5th Vital Sign
Pulse Deficit
Difference between apical and radial pulses
Sign that heart is contracting inefficiently, unable to transmit a pulse to peripheral pulse sites
Pulse oximetry
Measures pulse saturation of oxygen (SpO2)
Assesses:
- effectiveness of diffusion and profusion processes
- effectiveness of any other airway or breathing interventions, such as O2 therapy
Pulse pressure
- The difference between systolic and diastolic pressure
- Can indicate hearth health
- Can be caused by decrease in elasticity of the vessels (hardening)Optimal <120/<80
Normal <135/<85
Hypotension < 90/x
Hypertension >140/90
Pyrexia
Fever
Systolic pressure
max pressure felt in artery during Left-Ventricular contraction (systole)
Tachycardia
Fast HR: >100bpm
Tachypnea
Fast breathing: >20 breaths per minute
Vital Signs (5)
- Temperature
- Pulse
- Blood Pressure
- Respiration
- Oxygen Saturation
- Pain
Importance of vital signs (4)
- Provide vital information about bodily functioning
- Help determine patient baseline, monitor condition, identifies problems
- Contributes to problem solving and decision making
- Evaluated in terms of norms and the patients baseline - trends
Body Temperature
Body heat produced by bodily processes minus (-) heat lost to external environment
Regulated by thermoregulation from hypothalamus in the mid-brain
Surface temp sites (3)
36-38C
Mouth
Axillae
Skin
Temperature norms for adults
Avg. oral or tympanic 37 C
Avg. Rectal 37.5 C
Avg. axilla 36.5 C
Types of thermometers
- Electronic
- Disposable
- Tympanic thermometer (TMT)
- Infrared tympanic thermometer (ITT)
- Non-contact infrared thermometer (forehead)
- Temporal Scanner
- Swan Ganz (pulmonary artery)
Pulse
- the palpable bounding of blood flow noted at various points on the body
- Provides info on the status of the circ. System
Pulse Sites
- Carotid (emergencies, due to proximity of artery to heart and brain)
- Apical (most accurate, but more invasive)
- Brachial (groove between biceps and triceps muscles at antecubital fossa)
- Radial (radial or thumb side of forearm at wrist)
Normal Pulse Ranges
Infants: 100 – 160 Toddlers: 90 – 140 Preschoolers: 80 – 120 School-agers: 75 – 120 Adolescents: 60 – 100 Adults: 60 – 100
Radial Pulse Assessment (4)
- Strength (force)
- Rhythm (regular or irregular)
- Rate
- Equality (bilateral)
Apical Pulse Assessment (2)
- Rhythm (regular or irregular)
- Rate
Pulse Strength (force)
Full/bounding (running) = 3+
Strong/normal = 2+
Weak/thread = 1+
Absent/non-palpable = 0
When to take apical pulse
When pulse is irregular, take radial pulse fo 60s and then check apical pulse to compare for pulse deficit
Respiration
The mechanism that the body uses to exchange gases between atm and blood, blood and cells
Ventilation
- Movement of gases in and out of lungs… breathing
- Processes determined by looking at respiratory rate, depth, and rhythm
Diffusion
Movement of oxygen and CO2 between alveoli and RBC
Perfusion
Distribution of RBC to and from the pulmonary capillaries
Respiratory rate in adults
12-20 breaths per minute
Assessing respiration (4)
- Rate
- Depth - deep, normal or shallow
- Ryhthm - regular or irregular
- Sound - audible digression from normal or effortless breathing
Range of SpO2
- 93-100% (95-99% avg)
- Depends on patient’s condition (i.e. lung conditions like COPD) and orders
Factors Affecting Respiration (7)
- Exercise
- Acute Pain
- Anxiety
- Smoking
- Medications
- Neurological Injury
- Hemoglobin Function
Factors influencing BP (6)
- Age
- Stress
- Ethnicity
- Daily variation
- Medications
- Activity, weight, smoking
BP Ranges
Optimal: <120/<80
Normal: <135/<85
Hypotension: < 90/x
Hypertension: >140/90
BP cuff size and placement
- Should be 40% of upper-arm circumference
- Bladder covers 80% of adults arm and 100% of child’s arm
*should not be in armpit and should be 2.5cm from brachial pulse
Common errors in BP Measurement (8)
- Faulty arm position or arm not supported
- Wrong cuff size
- Not inflating high enough – missing auscultatory gap
- Too much pressure on brachial artery with diaphragm of stethoscope
- Deflation of cuff (too slow or too fast)
- Observer error
- Eye not level with mercury/pressure manometer
2-Step BP Reading
- Check baseline info and determine best site to use (i.e. don’t use same arm as IV)
- Have pt rest about 1min before assessing standing BP, or at least 5min on a pt who is sitting or lying down
- Make sure they haven’t had caffeine, exercised, or smoked for 30min before reading
- Position forearm at heart level. Support it with palm up
- Palpate brachial/radial artery, remove restricting clothing
- Wrap cuff snuggly around upper arm, with bladder (plastic piece inside the cuff) above the artery, with centre of the cuff over the artery, 2.5cm above site of pulsation
- Position the meter at eye level
- Place fingers of non-dominant hand on the artery, not touching cuff
- Note the pressure at which the pulse disappears, and continue to inflate cuff another 30mmHg
- Step 1: Slowly deflate cuff, note the point at which the pulse reappears (palpated systolic pressure)
- Fully deflate the cuff.
- Step 2: Place stethescope on the artery, not touching cuff
- Close valve on pressure bulb, then inflate cuff about 30mmHg above pt’s estimated systolic pressure
- Release bulb and allow needle to fall 2-3mmHg per second, note the point on the meter when you hear the first clear 1st Korotkoff sound, sound will increase in intensity. Continue to deflate cuff slowly.
- When sound disappears, note pressure to the nearest 2mmHg (5th Korotkoff sound).
- Listen for 20mmHg after the last sound, then release bulb entirely.
- Take BP again in 2min, use second set of measurements as pt baseline. If readings are more than 5mmHg apart, additional readings are required.
Cardiac Output and BP
Increased CO (related to strove volume and HR) = increased Blood volume = increased BP
Peripheral Vascular Resistance and BP
PVR = resistance to blood flow determined by tone and diameter of vessels (vasodilation/constriction)
Increased PVR = increased BP
Blood volume and BP
Increased blood volume = increased BP
Blood viscosity and BP
More viscous = higher BP
Arterial elasticity and BP
More elastic the arteries, lower the BP
Hardening of arteries with age = increased BP
Factors affecting Body Temperature (7)
- Age (decreases with age)
- Exercise
- Hormone levels
- Circadian Rhythm (time of day… lower during sleep)
- Stress (higher stress = higher heat)
- Environment
- Fever
Mechanism of a Fever
- Pyrogen triggers immune response.
- Hypothalamus raises body’s set-point to enhance immune response (febrile)
- Body works to produce and conserve heat to meet this new set point.
- Pt. feels chilled until new set-point is reache
- When pathogens are removed, hypothalamus lowers set-point
- Skin warms and flushes to lose heat and return to natural temp (afebrile)
Respiratory assessment involves… (2)
Observation of both depth and rhythm of chest-wall movement
Types of sphygmomanometers (2)
Aneroid
Mercury
Pulse Oximetry Sites (4)
- Digit (finger/toe)
- Ear lobe (good for low sat)
- Bridge of nose
- Sole fo newborn’s foot
Automatic BP cuff
Pros: calibrated, accurate
Cons: risk of mechanical error
