Week 3 Vital Signs Flashcards
what is an indication?
a reason to do/perform a test
what is a contra-indication?
reason to avoid a test
before taking any vital signs what four steps should you perform?
- Hand hygiene
- identify self and patient (Name and DOB)
- inform patient of procedure
- ask patient about anything that will alter vitals (in last 30 min) and document them
what are two indications for taking a temperature?
determines if body temp within normal range, indicates pathological conditions
what are three contradictions for oral measurement of temp
uncoopoerative patient, oral lesions, respiratory distress
what is the coral body temp?
37 DC or 98.6 DF
what organ is the bodys thermostat?
hypothalamus
what are the non-invasive sites to take a temperature?
oral, axilla, rectal
the non-invasive sites give a ____ temperature
estimated
what is the most common and accessible location to take a temp?
oral
what is the most invasive (non-invasive site)
rectal
what is the most accurate site to take a non-invasive body temp
rectal
where is the oral probe placed to take a temperature?
sublingual pocket (under and off to the side of the tongue along the gum line
why is oral temp taken at teh sublingual pocket? t
the temp is generally higher and more accurate here
what is the normal range for an oral temp? what is a fever?
95.9 to 99.9 and 100.0 is a fever
what are some indication in taking a students pulse?
establishes cardiac rate and rhythm
what are some contradictions to taking a pulse?
in general there are none.
what is a peripheral pulse?
palpable pulse felt in an artery
what is a apical pulse
sound! lub dub
where is the most common area to take a peripheral pulse?
radial artery
where (other than radial) can you take a peripheral pulse? (3)
carotid, brachial and femoral artery
where do you listen to apical heart sounds?
the apex (lowest point of the heart) at the point of maximal impulse
if the pulse has a regular rhythm then…
count the beats for 30 sec and x2
if a pulse has an irregular rhythm then…
count the beats for 60 sec
what are the three characteristics of a pulse (palpable)
rate: bpm
rhythm: regular or irregular
strength: how the vessel feels against finger tips bounding, normal, weak, thready, absent
if a machine is used to take a pulse what characteristics are taken?
only the rate (bpm) not rhythm or strength characteristics
how do you locate the point of maximal impulse?
@ 5th intercostal space and mid clavicular line
what characteristics can you get from the apical pulse
rate, rhythm
what is the normal bpm for an adult?
60-100
in general, while awake children have a ____ bpm than adults
higher
what are the four vital signs?
pulse, temperature, respirations, blood pressure
what are the indications (3) (reason to perform) respirations?
provide data to determine adequate ventilation, gas exchange and perfusion
what are the (3) contraindicaitons to performing respirations?
not breathing, in respiratory distress, upper airway obstruction
what controls breathing?
brainstem
what is the difference between ventilation,, exchange, and perfusion
ventilation: mechanical movement of gasses
exchange: movement of O2 and CO2 between alveoli and RBCs
perfusion: distribution of RBCs to and from pulmonary capillaries
in normal breathing describe (active/passive) inspiration and expiration
inspiration: active
expiration: passive
what are the 3 measurement sites for respirations?
- watch the rise and fall of the chest
- watch the rise and fall of the abdomen
- put hands on upper back to feel rise and fall of chest
one respiration is…
one inhalation and exhalation
what are the characteristics of respiration you should note? (3)
rate: respirations per minute
rhythm: regular or irregular
depth: shallow or deep
if the respiratory rate is fast then the depth will be
shallow
most studies support that the normal adult respiratory rate is:
16-24 breaths/minute
what is the most important measurement in all of clinical medicine?
blood pressure
what is the most innacurately performed measurement in all of clinical medicine?
blood pressure
what the the indications for doing a blood pressure? (3)
reflects overall state of hemodynamic interaction between CO and vascular resistance, is an independent risk factor for cardiovascular and renal disease, high BP may be asymptomatic.
what are the contraindications for doing blood pressure? (4)
avoid placing a cuff in the presence of Arterio-venous fistula, mastectomy, swelling of lymph nodes, burns (select an alternate site to measure BP)
what is the ambulatory setting?
a non-hospital setting
define BP
the lateral pressure or force that blood exerts on the wall of the artery
what is the usual site to measure blood pressure?
upper arm or brachial artery
what are alternate (3) sites to measure BP?
forearm, thigh, lower leg
what is auscultation?
the process of listening to the sounds of the heart
what instruments are used to take BP
stethoscope, sphygmomanometer (BP cuff)
how should a person be positioned when taking BP? (3)
sitting or lying at rest for five minutes
arm supported at heart level
feet flat and legs uncrossed
what is the most frequent error in BP measurement?
using an inappropriately sized cuff (a cuff that is too small is used for a larger sized arm)
when placing a BP cuff, the marking on the cuff goes over…
brachial artery
how do you know if a cuff is the correct size?
the wide end of cuff should be 40% the arm circumference and 2/3 of the upper arm length (elbow to armpit)
a cuff that is too large will cause…..
a false low reading
a cuff that is too small will cause…..
a false high reading
the cuff should be inflated to ____ above/below/at the patients ______
30 mmHg above baseline reading
how fast should the cuff be deflated?
2-3 mm Hg/sec
when taking a BP the end of the stethescope goes over the…..
brachial artery
you should take blood pressures…..min apart
30 minutes apart
when do you use the two step method for taking BP?
when you do not know a persons baseline BP?
what are the steps of the two step method of BP?
- apply cuff and palpate artery (radial) distal to the cuff
- inflate cuff and note point at which pulse disappears
- continue palpating and inflate the cuff to 30 mmHg above the point at which pulse disappeared
- deflate the cuff (2-3 mmHg/sec) and note point at which pulse reappears (should be the same as when it disappeared, if not use the larger number) this is your systolic reading
- deflate the cuff fully and wait 30 seconds
- measure the BP with stethoscope going 30 mmHg above the palpated systolic
- first sound is the systolic, last sound is the diastolic pressure readings
what are the normal systolic ranges?
90-140
what are the normal diastolic ranges?
60-90
adults are hypotensive when…
systolic is less than 90
adults are hypertensive when…
greater than 140/90
after you perform all vital sign tests what three things do you do next?
record all readings, report abnormal values to physician, perform hand hygiene
what can a persons height and weight tell you?
general level of health
what is one thing that can cause significant weight gain in one day?
cardiac issues
what is BMI
body mass index, tells you how much you should weigh based on how tall you are
