Vital Signs, Vascular, Lymphatic, Integumentary Systems

norm temp

98.6-99.3 degrees F

norm HR/PR

60-100 bpm

norm RR

12-20 rpm

norm BP

120/80 mmHg

norm SpO2

98%

taking vitals are a quick window into…

general health screening, systems review (cardiopulm, neurological, thermoregulatory, NMS pain), baseline for comparision pre- & post-activity, tolerance of mobility/exercise/treatment, specific populations, diagnostic/prognostic clues

a ___ of VSs is more useful than a single value

trend

VSs in rehab

temp, HR/PR, RR, BP, SpO2, pain, gait speed

VSs don’t exist in a ___, consider influences such as …

vacuum; pt demographics, behavior/lifestyle, situation

body temp

heat production (shiver) & loss (sweat); reflects a heat-balance problem

fever temp

>=100.4 degrees F

the ___ of measurement can change the number, such as …

route; oral, rectal, axillary, tympanic, temporal sites (not interchangeable)

pulse deficit

simultaneous difference in HR at apical & PR at a peripheral site, which should be the same; indirect marker of LV contraction & circulatory response, arrythmia

tachycardia

>100 bpm

bradycardia

<60 bpm

central/cardiac pulse sites & use

carotid artery, apical auscultation; use when peripheral pulse is difficult to palpate, to confirm rhythm, to prioritize centrla circulation

UE pulse sites & uses

radial artery, brachial artery; use for routine measurement or BP in infants

LE pulse sites & uses

femoral artery, popliteal artery, dorsalis pedis artery, post tibial artery; use to assess regional perfusion & compare sides

pulse rate technique

count beats for 60 sec when irregular or when precision matters; count beats for 30 sec*2 for regular rhythm & regular visitors

pulse rhythm technique

count beats for full 60 sec if irregular & consider apical assessment/telemetry/medical follow-up depending on context

pulse amplitude/force scale (O’Sullivan scale)

4+ = full/bounding, can’t be obliterated

3+ = normal/expected intensity

2+ = weak/difficult to palpate, may be obliterated

1+ = weak/diminished intensity, thready/comes & goes

0 = absent, not palpable

HR should ___ w/ ___ dynamic workload

rise; incr

HR_max estimate can guide ___, but can be lowered w/ ___ at a given submax workload

intensity; training

factors that modify HR response

age, fitness, medications (beta-blockers), autonomic dysfunction, temp, dehydration, pain/anxiety, illness, arrhythmia

concerning factors that modify HR response

failure to rise when expected, disproportionate tachycardia, symptomatic bradycardia, new irregularity, slow recovery, symptoms out of proportion

when measuring routine rate, use ___ artery

radial

when measuring irregular rhythm, use ___ artery for full minute

apical

when to measuring BP, use ___ artery

brachial

when measuring distal perfusion, use ___ arteries

dorsalis pedis, post tibial

when measuring side-to-side vascular question, compare ___

bilaterally

arterial insufficiency tests

capillary refill, dependent rubor/elevation, handheld doppler ultrasound, ankle-brachial index (ABI)

venous insufficiency/DVT tests

venous filling/leg elevation, medical referral, Well’s Criteria; Homan’s sign no longer reliable

Well’s criteria (3-level)

used to test venous insufficiency/DVT; swelling, paralysis/paresis, cancer, activity

high risk > 2 → urgent diagnostic pathway for prox leg vein ultrasound

mod risk = 1-2 → DVT not ruled out, refer for diagnostic work

low risk < 1 → D-dimer pathway, follow-up

ventilation

air moving in & out of lungs

pulmonary gas exchange

O2/CO2 cross thru alveolar-capillary membrane; dependent on ventilation & perfusion

transport

O2 carried by hemoglobin; dependent on blood flow

bradypnea

<10 breaths/min

tachypnea

>24 breaths/min

resting HR:RR ratio

4:1

when counting RR, do it ___ so the pt doesn’t change their breathing when they know you are counting

quietly

breathing is influenced by …

chemistry, position, activity, emotion, disease, consciousness

PaO2

partial pressure of oxygen dissolved in arterial plasma; measured from arterial blood gas (ABG), reflects oxygen tension & not Hgb saturation directly

SaO2

arterial Hgb oxygen saturation; measured on arterial blood; represents proportion of Hgb binding sites carrying oxygen

SpO2

peripheral oxygen saturation estimated by pulse oximetry; fast & useful for trends

good measuremnet technique for pulse oximetry

warm, perfused extremity; minimize motion; allow reading stabilization; treat at rest, activity, recovery; check that displayed pulse matches pt

common limitations of pulse oximetry accuracy

poor circulation/low perfusion; motion; skin pigmentation, thickness, temp; nail polish/artificial nails; tobacco/dyshemoglobinemias

hypoxemia clues from pulse oximetry

dyspnea/tachypnea; restlessness/anxiety/confusion; cyanosis'; tachycardia/dysrrhythmia; fatigue/exercise intolerance; worsening mental status

BP reflects ___ against ___

flow; resistance

arterial pressure = ___*___

CO*vascular resistance

BP technique sources of error

cuff bladder/improper size, arm position, muscle activity, site/side, repeat readings

elevated BP

120-129/<80 bpm

stage 1 HTN BP

130-139/80-89

stage 2 HTN BP

>140/>90

manual BP technique

1. seated position at quiet rest w/ arm supported at heart level

2. cuff bladder centered over brachial artery

3. palpate radial pulse & inflate cuff until pulse disappears → note level

4. reinflate ~20-30 mmHG above estimated systelic level

5. deflate ~2-3 mmHg/sec while auscultating brachial artery

6. read Korotkoff phase 1 (SBP) & phase V (disappearance, DBP)

7. repeat for unexpected values & average readings when appropriate

contraindications/precautions for manual BP on a limb

vascular access, srugery, injury, lymphedema risk, pt-specific restrictions

in dynamic exercise, ___ rises proportionate to dynamic workload & ___ slightly changes

SBP; DBP

isometric/static exercises can produce substantial ___ in both SBP & DBP

incr

mean arterial pressure (MAP)

avg pressure driving systemic perfusion across cardiac cycle; norm 70-110 mmHg = (SBP + 2 * DBP/3; can turn VSs into physiologic meaning → perfusion of organs depends on adequate pressure

rate-pressure product (RPP)

simple estimate of myocardial work/oxygen demand; HR*SBP; can turn VSs into physiologic meaning → relate symptoms such as angina to myocardial demand

IASP

pain is sensory & emotional, associated w/ actual/potential tissue damage

acute pain

an expected protective response to noxious input/tissue injury; sympathetic & adrenal responses scaled by threat/intensity; closely linked to inflammation/tissue damage; better localized; persists while noxious process is active & should improve w/ recovery

chronic/persistent pain

persists beyong expected tissue healing/becomes a condition in its own right; from acute pain or insidious onset; less proportional to ongoing tissue injury; consider central, peripheral, cognitive, behavioral, emotional, and social factors

cognitive beahvior model of persistent pain

pain experience → thoughts/beliefs → emotion → behaviors → physical consequences → reinforcement of pain → back to start; pain is influenced bby interactions among physical, cognitive, emotional, and behavioral factors

muscle pain descriptors

cramping, dull, aching

peripheral nerve pain descriptors

sharp, bright, lightning-like

bone pain descriptors

deep, naging, dull

vacular pain descriptors

throbbing, pulsing, diffuse

nerve root pain descriptors

sharp, shooting

sympathetic/autonomic pain descriptors

burning, pressure, singing, aching

fracture pain descriptors

sharp, severe, intolerable

quantifying pain & impact

intensity, location, pattern, onset, chronic pain/behavior tools such as fear-avoidance beliefs questionnaire (FABQ) & pain anxiety symptoms scale (PASS)

VS decision pathway

measure → verify → compare → interpret → act

arterial fluid system

delivers O2 & nutrients under pressure; failure → ischemia, claudication, distal tissue loss

venous fluid system

returns blood toward heart; valves & muscle pumps assist; failure → venous HTN, edema, skin change

lymphatic fluid system

returns interstitial fluid & proteins, supports immune function; failure → protein-rich edema, fibrosis, infection risk

integumentary system functions

barrier, sensation, thermoregulation, immunity & visible evidence; failure → impaired tolerance, healing

wound healing phases

inflammation → proliferation → maturation; phases overlap

things needed for wound healing

oxygen, moisture & cover, nutrition

local limitations of healing

perfusion/ischemia, edema, pressure/shear, bioburden/infection, foreign material/necrosis, repeated trauma, excessive dryness/maceration

systemic limitations of healing

diabetes/neuropathy, nutrition/hydration, smoking, age/fragility, anemia/oxygenation, immune suppression, cardiac/renal/vascular disease

context limitations of healing

med effects, radiation/cancer treatment, adherence & support, off-loading/pressure relief, activity & mobility, compression appropriateness, care environment

arteries

carry blood away from heart at higher pressure; thick, muscular, elastic walls; relatively narrow lumen; no valves; pulse = pressure wave

capillaries

exchange surface b/n blood & tissues; 1-cell thick endothelium; very small lumen; diffusion of oxygen, nutrients, wastes; leukocytes can move into tissues (oncotic pressure)

veins

return blood to the heart at lower pressure; thinner walls; wider lumen; valves limit backflow; muscle pump assists return

peripheral artery disease (PAD)

inadequate arterial inflow due to smoking, DM, HTN, dyslipidemia/hypercholesterolemia, kidney disease, cardiovascular disease, obesity/low activity, older age, trauma, surgery, arterial embolus, hypercoagulable states

arterial insufficiency

dependent w/ rubor of dependency/elevation test; claudication, pain at rest, pain worsened w/ elevation; cool temp w/ pallor elevation; shiny, hairless skin & reduced tissue quality; reduced/asymmetric/absent pulse; distal pain/pressure point wounds; reduced walking endurance → fatigue instead of pain

ankle-brachial index (ABI)

ankle SBP/brachial SBP = norm 1.00-1.40, resting perfusion adequate; guides referral & influences compression, debridement, wound prognosis, exercise safety

chronic venous insufficiency

age, low activity, obesity, pregnancy, long periods of standing/sitting, heredity, prior DVT → edema, skin hyperpigmentation, erythema, skin texture changes, venous ulcers, aching/heaviness, warm temp, pulse present

pressure injury

tissue load exceeds tolerance, shear forces, friction, moisture, malnutrition, impaired perfusion, sensory loss, immobility → ischemia → persistent erythema, nonblanchable redness, firm tissue, tenderness, color change → cell necrosis

pressure injury sites when lying supine

occiput, scapulae, elbows, sacrum/coccyx, heels

pressure injury sites when side-lying

ear, shoulder, ribs, greater trochanter, knees, malleoli

pressure injury sites when sitting

scapulae, spinous processes, sacrum, ischial tuberosities, heels

pressure injury sites when lying prone

cheek/ear, acromion, chest/breast, iliac crest, patella, toes

pressure injury stages

stage 1: skin intact w/ nonblanchable erythema

stage 2: partial-thickness skin loss w/ exposed dermis, wound bed viable, no slough/eschar

stage 3: full-thickness skin loss, visible adipose, granulation, undermining/tunneling

stage 4: full-thickness skin loss, exposed fascia/muscles/tenndon/cartilage/bone

unstageable: full-thickness skin loss w/ obstructive slough/eschar; unconfirmable depth

deep tissue: persistent red/maroon/purple discoloration (blood blister)

lymphedema

reflects impaired lymph transport; developmental abnormal lymphatic vessels/nodes; acquired after cancer treatment, surgery, radiation, trauma, or chronic venous disease; swelling, heaviness, tightness, numbness, fibrosis, recurrent infection risk, impaired would healing, decr ROM & mobility

measuring swelling can be done via tissue quality, ___, ___

girth; volume

diabetic peripheral neuropath can change … function

sensory, motor, autonomic, and vascular

foot screening connects ___ to loading & ___ risk, so we must …

sensation; tissue; inspect skin, sensations, & perfusion/pulses → education

skin descriptors

color, moisture, texture, firmness, temp, elasticity, turgor, asymmetry, contour, shape, hair, nails, lesions