What's Your Sign Flashcards
Core Vital Signs
BP, HR, RR
Additional vital signs
Skin, mental status, pupils, capillary refill, pulse oximetry, glucometry, stroke scale
Pressure generated by ventricular contraction
Systole
Pressure exerted by the fluid in the system when the heart is at rest
Diastyloic
BP range males
Usually 3/2
S=100+Age=max 140
D=<90
BP range females
3/2
S=90+age (max 130)
D=<80
Pregnant-3rd trimester 10-15 mmHg lower
BP Range Children-until 10 years
S=80+2x age D=2/3 SBP 70+ 2x age threshold for hypotension 80+2x age threshold for hypertension BP difficult to get until age of 2
Narrowing pulse pressure is what% and would be seen when?
<25%
Chest injury=tamponade, tension pneumothorax
Widening pulse pressure is what % and would be seen when?
> 50%
Increasing ICP
If you have an irregularly irregular pulse you have____ and you are prone to __, __, ___, syncope
Atrial fibrillation
clots, strokes, pulmonary embolism, syncope
Where and why would you palpate a pedial pulse?
Orthopedic injury
Medial malleous-posterior tibial
Dorsalis pedias
If disparate BP and radial pulses (>20), should be concerned about a ____
Thoracic aneurysm
If unequal femoral pulses, should be concerned about an _____
Abdominal aortic aneurysm
As person breathes in, the quality of their pulse weakens when they breathe in
Also, as get BP, sound may disappear as individual breathes in
Pulsus Paradoxus
Pulses paradoxus is indicative of an individual who may have
Tension pneumothorax, pericardial tamponade, profound bronchoconstriction, asthma, COPD
For a pulses paradoxes, when auscultating BP, a paradox greater than ____ is clinically significant
10
What is one assessing when taking orthostatic vital signs?
Assessing hemodynamic status-how stable they are
Why would take orthostatic vital signs?
To see how stable someone is, especially if they seem stable but you suspect they may not be. Assessing whe the patiant has: Abdominal pain (internal bleeding), blood from orifice (vagina, rectal vomiting), nausa/vomiting/diarreha, dizzy/week, syncope/near synope
With orthostatic vital signs, what change in vital signs are you concerned about?
HR increases greater than 20
SBP drops more than 20
Types of skin color:
Normal, flushed, pallor, mottled, cyanotic, jaundice
Glasgow Coma Scale-Eye Opening
4-Alert
3-Verbal
2-Pain
1-Unconscious
Glasgow Coma Scale-Speech
5-Oriented x 4 (person, place, time, event) 4-Confused 3-Inappropiate 2-Incomphrensible 1-Non-verbal
Glasgow Coma Scale-Motor function
6-Obediance 5-Purposeful 4-Withdrawel from pain 3-Decorticate (flexion) 2-Decerebrate (extension) 1-None
In eyeballs looking for:
Reactivity
Equality
Size
For reactivity and eyes, looking for a___
Consenual reponse. If not the case, concerned about a brainstem issue or an eye injury
For Equality and eyes, looking for a consenual reponse. Unequal eyes indicate:
Increasing ICP
Aniscora (under 10% of the population has this)
Pinpoint pupils indicate
Opiate, pontine bleed, cholinergics (i.e. sarine)
Pontine bleed
Intercranial hemorrhage
Dilated pupils indicate
HYPOXIA, SHOCK, Post ictal, stimulants, darkness, alcohal, CNS depressants other than opiates (sleeping pills), TCA, anticholinergics
Fixed-dilated pupils indicate
Brain stem death
Hernation
Gaze types
Conjugate (both eyes tracking together)
Deviated gaze-pupils off to one side, but together
Disconjugate-tracking differently
Deviated gaze indicates
Head injury, stroke, seizure
Disconjugate gaze indicates
congential, occular injury, head injury
Involuntary eye movement
Nystagmus
Type of nystagmus
Horizontal (usually alcohal)
Vertical
Rotational (torsimal)-PCP
One can acquire nystagmus due to
Toxicology, neuro event (stroke or traumatic brain injury), congential
Unequal pupils indicate
Hemmoraghic stroke
Accumulation of fluid in the peritoneum
Asoites
Indicates liver disease or CHF
