Vital Signs and Clinical Assessment

What are vital signs?

The most frequently measured objective data for monitoring vital body functions and often the first and most important indicator that a patient's condition is changing.

Why are vital signs obtained?

To determine the status of vital organs, establish a baseline, monitor response to therapy, observe trends in health status, and determine the need for further evaluation, testing, or intervention.

What does q30m mean?

Every 30 minutes.

What does q1h mean?

Every 1 hour.

What does q2h mean?

Every 2 hours.

What is Ideal Body Weight (IBW)?

A weight measurement based on height.

What is assessed during general clinical presentation?

General appearance including breathing pattern, anxiety, restlessness, pain, and bleeding.

What factors should be evaluated when assessing pain?

Location, intensity, onset, and what makes it better or worse.

What is sensorium?

Evaluation of orientation to time, place, and person; assesses mental status.

What scale is used to assess level of consciousness?

Glasgow Coma Scale (GCS).

What is normal body temperature?

98.6°F (37°C).

What is fever?

Elevated body temperature caused by disease; the patient is described as febrile.

What is hyperthermia?

Body temperature higher than normal.

What is hypothermia?

Body temperature below normal.

What is the difference between fever and hyperthermia?

Fever is elevated temperature caused by disease, while hyperthermia is simply body temperature higher than normal.

What are common temperature measurement sites?

Rectal, axillary, oral, and tympanic.

What does pulse assess?

Cardiac rate, rhythm, and strength.

What is the normal adult pulse rate?

60-100 beats/min.

What is tachycardia?

Pulse rate above 100 beats/min.

What is bradycardia?

Pulse rate below 60 beats/min.

What are common pulse measurement sites?

Radial, brachial, femoral, and carotid.

What is respiratory rate (RR)?

The rate of breathing.

What is the normal adult respiratory rate?

12-20 breaths/min.

What is tachypnea?

Respiratory rate above normal.

What is bradypnea?

Respiratory rate below normal.

What is apnea?

Absence of breathing.

What is eupnea?

Normal rate and depth of breathing.

What is normal adult blood pressure?

120/80 mmHg.

What is systolic blood pressure?

Peak pressure during ventricular contraction.

What is diastolic blood pressure?

Pressure when the heart is relaxed.

What is pulse pressure?

The difference between systolic and diastolic pressure.

What is normal pulse pressure?

35-40 mmHg.

What is hypertension?

Blood pressure greater than 140/90 mmHg.

What is hypotension?

Blood pressure significantly less than 120/80 mmHg.

What is paradoxical pulse?

A drop in systolic blood pressure greater than 10 mmHg during inhalation.

What is Glasgow Coma Scale?

A scale used to assess level of consciousness.

What is the purpose of physical examination?

To examine the patient for physical signs of disease and obtain immediate information about health status.

Why is physical examination important?

It is an essential tool that helps with diagnosis and provides immediate, inexpensive clinical information.

What is cyanosis?

Bluish appearance of the skin caused by low oxygen delivery to tissues.

What is diaphoresis?

Excessive sweating.

What is mydriasis?

Dilated and fixed pupils.

What is miosis?

Pinpoint pupils.

What is ptosis?

Drooping eyelids.

What is diplopia?

Blurred vision.

Where should the trachea normally be located?

Midline.

What is normal jugular venous distention (JVD)?

No greater than 3-4 cm at a 45-degree angle.

What are the four basic components of thoracic assessment?

Inspection, palpation, percussion, and auscultation.

What is barrel chest?

Increased anteroposterior (AP) chest diameter.

What is pectus carinatum?

Sternal protrusion (pigeon chest).

What is pectus excavatum?

Inward depression of the sternum.

What is kyphosis?

Abnormal AP curvature of the spine (hunchback).

What is scoliosis?

Abnormal lateral curvature of the spine.

What is kyphoscoliosis?

Combined AP and lateral spinal curvature.

What is Biot's breathing?

Irregular breathing with prolonged apnea.

What is Cheyne-Stokes breathing?

Breathing depth and rate increase and decrease with periods of apnea.

What is Kussmaul's breathing?

Deep and rapid breathing.

What is apneustic breathing?

Prolonged inhalation.

What is paradoxical breathing?

Chest wall moves inward during inspiration and outward during expiration.

What is asthmatic breathing?

Prolonged exhalation.

What are retractions?

Inward depression of skin during inspiration indicating respiratory distress.

What is central cyanosis?

Cyanosis involving the trunk and oral mucosa.

What is palpation?

Touching the chest wall to evaluate underlying structures and function.

What is vocal fremitus?

Vibrations created by vocal cords during phonation.

What is tactile fremitus?

Vibrations felt on the chest wall.

What causes increased tactile fremitus?

Pneumonia, lung tumor/mass, and atelectasis.

What causes decreased tactile fremitus?

Mucus plug, foreign body obstruction, pneumothorax, and pleural effusion.

What is subcutaneous emphysema?

Air leaking into subcutaneous tissue causing crackling sensation during palpation.

What is percussion?

Tapping on a surface to evaluate underlying structures.

What percussion note is normal?

Resonance.

What conditions cause dull or flat percussion sounds?

Heart, mass, tumor, atelectasis, or fluid accumulation.

What causes hyperresonance?

Excessive air or pneumothorax.

What is auscultation?

Listening to chest sounds with a stethoscope.

What are normal breath sounds?

Tracheal and vesicular sounds.

What is wheezing?

High-pitched continuous sound caused by narrowed or inflamed airways.

What are crackles?

Discontinuous breath sounds caused by movement of secretions.

What is stridor?

Sound caused by upper airway obstruction.

What are diminished breath sounds?

Decreased breath sounds.

What is hepatomegaly?

Enlargement of the liver.

What is digital clubbing?

Painless enlargement of fingers associated with chronic hypoxemia.

What is peripheral cyanosis (acrocyanosis)?

Cyanosis caused by poor perfusion of the extremities.

What is normal capillary refill?

3 seconds or less.

What is pedal edema?

Abnormal accumulation of fluid in the ankles.

What is neurological assessment?

A method of obtaining data regarding nervous system function.

Why is neurological assessment important in respiratory care?

Nervous system injuries can affect breathing effort, breathing pattern, and respiratory function.

When is Glasgow Coma Scale commonly used?

After a head injury to assess level of consciousness.

What is the GCS score range?

3 to 15.

What does a GCS score of 15 indicate?

Fully awake.

What does a GCS score of 3 indicate?

Deep coma or death.

What is lethargy?

Drowsy but partially awakens with stimulation.

What is obtundation?

Difficult to arouse and requires constant stimulation.

What is stupor?

Arouses only to vigorous or painful stimulation.

What is coma?

No response to continuous painful stimulation.

What neurological reflexes should RTs be familiar with?

Deep tendon reflexes, gag reflex, cough reflex, and pupillary reflex.

What does PERRLA stand for?

Pupils Equal, Round, Reactive to Light and Accommodation.

What abnormal respiratory patterns may be associated with brain injury?

Biot's, Cheyne-Stokes, Kussmaul's, and apneustic breathing patterns.

What is intracranial pressure (ICP)?

Pressure inside the skull, evaluated during neurological assessment.

Why are clinical laboratory studies important?

They provide important information about a patient's health status.

How should laboratory results be interpreted?

Along with other clinical findings; they are supplemental information.

What does CBC stand for?

Complete Blood Count.

What components are included in CBC? (Complete Blood Count)

WBC (White Blood Cells) and RBC (Red Blood Cells).