Clin Skills 2 Midterm

Normal Blood Pressure

<120/<80mmHg

Elevated Blood Pressure

Systolic 120-129 mmHg and diastolic less than 80 mmHg

Stage 1 Blood Pressure

Systolic 130-139 or diastolic 80-89mmHg

Stage 2 Blood Pressure

Systolic >140 mmHg or diastolic >90 mmHg

Diagnosis of hypertension

Based on >2 readings obtained on >2 occasions

Urgency HTN

>180/>120 mmHg without evidence of organ damage (normal funduscopic exam and no evidence of headache, dizziness, chest pain, confusion, etc)

Emergency HTN

>180/>120 mmHg with evidence of organ damage (normal funduscopic exam or evidence of headache, dizziness, chest pain, confusion, etc)

Normal temperature 

98.6 F

Normal temperature range

97.5 F - 98.9 F

Factors which may influence accuracy of temperature

Eating, drinking, chewing gum, smoking 15 minutes prior, talking &/or breathing through the mouth during a reading

Pyrexia (fever)

infection, heat exhaustion, malignancy, medications

Hyperpyrexia (extreme fever 106.7F+)

Bleeding in brain, infections, sepsis, immune disorders

Hypothermia (low temperature)

exposure to cold, paralysis, excess alcohol, starvation, hypothyroidism, hypoglycemia

Normal range for heart rate

60-100 bpm

Factors which may influence accuracy of pulse

White coat/anxiety, stress, smoking, exercise, caffeine

Tachycardia (>100 bpm)

heart & lung disease, fever, hyperthyroid, electrolyte imbalance

Bradycardia (<60 bpm)

heart disease, medication, inflammatory disease, hypothyroid, electrolyte imbalance

Small/Weak Pulse

diminished pulse pressure; contour: upstroke is slowed and peak prolonged

Large/bounding pulse

increased pulse pressure; contour: rapid rise and fall with brief peak

Bisferiens pulse

increased pulse pressure; contour: double systolic peak

Pulsus alterans pulse

alternating pulse pressure; contour: amplitude varies, rhythm stays the same

Paradoxical pulse

pulse pressure no changes; contour: amplitude decreases on quiet inspiration (10mmHg+)

Normal range for respiratory rate

12-20 rpm

Bradypnea

slow rate, regular depth, regular rhythm

Tachypnea

rapid rate >20 rpm, shallow depth, regular rhythm

Hyperpnea

rapid rate >20 rpm, deep inspiration, regular rhythm

Obstructive respiration

regular rate, shallow depth, prolonged expiration

Sighing respiration

regular rate, frequent increases in depth, regular rhythm

Ataxic (Biot’s) 

alternating rate, depth, rhythm

What are the 4 primary vital signs?

Temperature

Pulse rate

Respiratory rate

Blood pressure

5th vital sign

pain

or pulse oximetry (blood oxygen levels)

6th sign

no standard/more informal

based on situation and discipline 

arteriosclerosis

hardening and thickening of arterial wall

decrease blood flow

atherosclerosis

type of arteriosclerosis

-build up of waxy plaque which slowly blocks the lumen and decreases blood flow

What side of the stethoscope do you use when auscultating arteries?

bell

bruit

normal: no audible sounds is heard in the arteries from blood flow

abnormally: audible swooshing sound heard over peripheral artery

Coarctation

stricture or narrowing of the wall of the aorta

Methods to take temperature

oral

tympanic

temporal

axillary

rectal

rectal temperature

range: 0.5-1 degrees higher than oral temperature

tympanic temperature

range: 0.5-1 degrees higher than oral temperature

axillary temperature

range: 0.5-1 degrees lower than oral temperature

temporal temperature

range: 0.5-1 degrees lower than oral temperature

what is the “gold standard” of measuring temperature?

rectal temperature

normal rectal temperature

99.6 F

infrared tympanic thermometers

commonly used in clinics

studies have been shown to have relatively high specificity

0.5-1 degree higher than oral

temporal artery thermometer

least accuracy of the common methods

technology has increased sensitivity

0.5-1 degree lower than oral

diurnal temperature

in most people, there is a diurnal (daily) variation in body temperature of 0.5-2 degrees

lowest ebb: during sleep temperature may fall as low as 95.5 F

basal body temperature

temperature upon waking  

normal temperature

98.6 F

normal temperature range

97.5 F-98.9 Fthe typical range of body temperature fluctuations in humans, indicating a healthy state.

elevated temperature reading

results from:

-previous ingestion of warm substances

-recent strenuous activity

-a warm bath/hot tub

-a recently smoked cigarette/other

-inadequate shaking down of the thermometer (older mercury/glass types)

low temperature readings

results from:

-incomplete closure of the mouth

-breathing through the mouth

-recent ingestion of cold substances

-tachypnea (respiraotry rate more than 20/minute)

consider retaking:

-reinstruct

-wait until mouth is warmer

pyrexia: defined as fever

-body temperature is elevated above one’s normal temperature

-one definition- if the oral temperature reaches 99 F in a patient at bedrest

-infection, heat exhaustion, malignancy, medications

hyperpyrexia: extreme fever 106.7 F

-bleeding on the brain, infection, sepsis, immune disorders

fever of undetermined origin: defined as fever of at least 101 F

-lasts for more than 3 weeks

-no explanation despite thorough history and examination

-an occasional phenomenon

-formerly fever of “unknown” origin

hyperthermia: defined as overheated body

-exposure to cold

-drug and alcohol intoxication

-starvation

-hypothyroidism, hypoglycemia

-paralysis

-severe metabolic acidosis (decreased PH and bicarbonate concentration in the body fluids, caused either by the accumulation of acids or by abnormal losses of fixed base from the body, as in diarrhea or renal disease)

chills

-subjective reports of shivering or shaking

-chills often accompany fever

-associated with rapid changes in temperature (results from involuntary muscle contractions that occur in response to a sudden lowering of body temperature below the prevailing set point, shivering causes heat)

night sweats

-subjective reports of nocturnal sweating

-profuse sweating at night

-can be idiopathic or due to menopause

-chronic debilitating affections with low-grade fever (lymphoma, tuberculosis, aids)

pulse locations

-radial

-ulnar

-brachial

-carotid

-femoral

-popliteal

-dorsalis pedis

-posterior tibial

occasionlly radial artery has an anomalous course. Why?

-pulse is impaired or absent

-if this happens, check proximal (brachial/axillary) pulses & the ipsilateral ulnar pulse before concluding that the pulse is absent

-pathological reason: thrombosis involving one subclavian, axillary or brachial artery

pulse rate rate

60-100 bpm

normal pulse rate in children

90-120 bpm 

-the younger the higher

Who might have a pulse rate around 50 bpm?

well conditioned athletes

Do men or women generally have slightly higher pulse rates?

women

Pulse rate documentation

Rhythm:

-regular

-irregular

-irregular with respiration

Amplitude/intensity:

-bounding

-amplitude diminished

Contour:

-Smooth

-Irregular

Tachycardia: >100 bpm

-electrolyte imbalance

-emotional stress

-smoking

-exercise

-alcohol/caffeine (large amounts)

-medication side effects

-heart related conditions (hypertension, congenital heart issues, heart failure, cardiac arrhythmias)

-certain lung disease

-fever

-hypertension

-thyroid disease (hyperthyroid)

Bradycardia: <60 bpm

-electrolyte imbalance

-medications

-heart conditions (heart tissue damage related to aging, congenital heart defect, infection of heart tissue)

-inflammatory disease (rheumatic fever/lupus)

-hypothyroidism

-obstructive sleep apnea

Normal pulse

Pressure of the pulse: normal

Contour: smooth and rounded

Small/Weak Pulse

Pressure of the pulse: diminished

Contour: upstroke slow, peak prolong

Causes: decreased stroke volume (heart failure), hypovolemia, aortic stenosis, an increased peripheral resistance (cold exposure and congestive heart failure can cause this)

Large/Bounding Pulse

Pressure of the pulse: increased

contour: rapid rise and fall, peak brief

Causes: increased stroke volume, decreased peripheral resistance (fever, anemia, and hyperthyroidism all potential causes), and decreased compliance (aging and atherosclerosis common offenders)

Bisferiens Pulse

Pressure of the pulse: increased

Contour: double systolic peak

Causes: aortic regurgitation, aortic stenosis, hypertrophic cardiomyopathy

Pulsus Alternans

Pressure of the pulse: alternates

Contour: amplitude varies, rhythm same

Cause: left ventricular failure

Paradoxical Pulse

Pressure of the pulse: no change

Contour: amplitude decreased with inspiration (10 mmHg+)

Causes: hypothyroidism, fluid in heart (pericardial tamponade, constrictive pericarditis, obstructive lung disease)

How to palpate a pulse?

-it is usually better to use light pressure using the fingertips for palpation

-can be palpated against a firmer surface, usually bone

Pulse at the wrist

patient hand: palm upward

doctor: places first 2 or 3 fingers on the radial artery (the radial artery is compressed against the distal radius, use finger tips)

Respiration qualities

normal

-rate: 12-20

-rhythm: regular

-depth: regular

-effort: none (occasional sigh is normal, normally there is no evident use of accessory respiratory muscles)

-variable: with fever, rate increases approximately 4 rpm for each degree F above normal

apnea

no breath

bradypnea

rate is slow

hyperpnea & tachypnea

rapid rate of >20 rpm

tachypnea

rate: rapid rate of >20 rpm

rhythm: regular

depth: shallow

hyperpnea

rate: rapid rate of >20 rpm

rhythm: regular

depth: deep respirations of increased volume per breath

bradypnea

rate: slow

rhythm: regular

depth: regular

Cheyne-Stokes

rate: alternating

rhythm: alternating

depth: alternating

Ataxic/Biot’s

rate: unpredictable

rhythm: variable

depth: variable

Sighing

rate: regular

rhythm: regular

depth: frequent increases in depth

obstructive

rate: regular

rhythm: prolong

depth: shallow

Systole

-period of time within the cardiac cycle when the ventricles are contracting

-the value in mm Hg when the sounds start when taking a blood pressure

Diastole

-period of time within the cardiac cycle in which ventricles are relaxed and filled with blood

-The value in mm Hg when auscultation sounds stop when taking a blood pressure

Pulse Pressure range

30-40 mmHg

What is pulse pressure?

The difference between systolic and diastolic blood pressure, indicating the force the heart generates each time it beats.

Korotkoff sounds

Sounds heard through a stethoscope over an artery during blood pressure measurement, indicating the onset and cessation of blood flow.

Auscultatory Gap

A period during blood pressure measurement where sounds are temporarily absent, potentially leading to an underestimation of systolic pressure.

Factors that influence blood pressure

-age

-gender

-technique of examination

-physical exertion

-emotional tension

-pain

what might cause false high readings for blood pressure?

large arms

-pressure applied to cuff must overcome the resistance of the mass before compressing the brachial artery

-an appropriately sized cuff should be used

white coat hypertension

-exhibit elevated blood pressure beyond normal range when in clinical setting

-repeat attempt to take

What can cause high blood pressure?

kidney disease

-chronic glomerulonephritis

-renal artery stenosis

adrenal disease

-pheochromocytoma

-primary aldosteronism

vascular disease

-coarctation of the aorta

What are the signs and symptoms of organ damage?

-abnormal fundoscopic exam

-severe headache

-dizziness

-chest pain

-confusion

hypotension

systolic pressure of 90 to 100 mmHg

orthostatic hypotension

change in position causes lightheadedness or fainting

causes of low blood pressure

-hypertension medication

-blood loss

-dehydration

-cardiac anomalies

-sympathetic failure (parkinson’s disease)

causes of abnormal pulse pressure

-anemia

-hyperthyroidism

-aortic regurgitation

-arteriovenous fistula

-atherosclerosis: aorta and large arteries