CH 10: Vital Signs

always remember to follow these standard precautions

for vital signs... you measure these 4 things....

1. temperature

2. respiratory rate

3. pulse

4. blood pressure

what is 40.0C in F?

104F

what is 37.0C in F?

98.6F

What is 35C in F?

95F

rectal temp measure _____-____C higher than oral

() reading is the most accurate/close to core temp but invasive

() is preferred for critical care bc of its accuracy

() readings are in between oral and rectal

() readings are the most variable/unreliable

0.4-0.6

rectal

rectal

temporal

tympanic

for rectal temp position pt _____ _____ , don gloves, place cover on thermometer probe, apply lubricant, insert _____inch ifor adults and ____inch for infants <6months, leave until beep DO NOT LET GO, then clean pt

left lateral, 1 inch, 1/2 inch

mean oral temp in a resting adult

temperature above _____ is considered febrile

97.7F

100.4F

should you report in C or F (usually C unless your agency uses F

document temp and _____

route

oral temp is the most convenient and commonly used. sublingual pocket has rich blood supply from carotid arteries that quickly responds to changes in inner core temp. wait no less than ___ min if pt has recently eaten, had hot/cold liquid, smoked

15

electronic thermometers are used for oral, axillary, and rectal temps. blue tipped is for () red tipped is for ()

blue is oral and axillary. red is rectal.

__________ temp used in peds often due to ease

tympanic membrane (eardrum)

for tympanic membrane temp place covered probe tip in ear canal, aim infrared beam at tympanic membrane, straighten ear canal for adults do this by ______ for children under 3 ________. activate device and read temp in 2-3 seconds.

pull pinna up and back, pull pinna straight down

temporal artery thermometer slides probe ()

reading takes 6 seconds

questionable reliability and not as accurate as other methods

across forehead then behind ear

what about those non-contact infrared thermometers that are common now?

BAD, less accurate than other measures and are not sensitive to temperatures above 37.5°C

pulse, use the pads of your first 3 fingers, palpate the radial pulse at the flexor aspect of the wrist laterally along the radius bone

30 sec interval most accurate/efficient when hr is regular

REGULAR RHYTHM: count number of beats in 30sec then multiply by 2

IRREGULAR RHYTHM: count for a full min

make sure to start your first count as "zero"

assess () () and ()

rate, rhythm, force

diff pulse locations

superficial temporal artery, common carotid artery, brachial artery, radial artery, femoral artery, popliteal artery, posterior tibial artery, dorsalis pedis artery

bradychardia is ______bpm in adult

< 50 bpm

bradycardia can be caused by

meds, well-trained athlete (they have a stronger more efficient heart that pushes larger stroke volume w each beat)

tachycardia is _______bpm in audlts

> 95 bpm

tachycardia can be caused by

anxiety, exercise, fever, sepsis, stress, pain and more

can low pulse be normal?

yes (ie., well trained athletes)

if a pulse is not palpable, a _________ may be used

doppler

______________ pulses run higher and have a different scale of normal readings

pediatric

what is a regular pulse tempo?

even tempo

what is an irregular pulse tempo?

uneven tempo

the _______ ________ reflects the strength of the heart's stroke volume

pulse force

what scale number pulse force is considered regular

2+

_______ pulse force is considered absent

0

______ pulse force is considered weak/thready

1+

_______ pulse force is considered bounding or full. is this normal?

3+. no, normal is 2+ bounding pulse is not super worrisome though pregnancy can cause it but so can hyperthyroidism...

for respirations, breathing should be relaxed/regular/automatic/silent

- do not tell pt u are counting their resp

-count for at least 1 full min

-record # of breaths per min and character of breaths (even, shaky,etc

yay

respiratory rate normal range

12-18 breaths/min

is respiration faster or slower in infants and children

faster

newborn resp rate immediatley post birth

30-50 breaths/min

at age ___ when alveolar development is complete, resp rate slows to the same as adults and you can use adult normal ranges

8

pulse:respiratory rate RATIO

4:1

tachypnea is ______breaths/min

above 25

bradypnea is ________breaths/min

8-12

() Force of blood pushing against the side of its container, the vessel wall

() Maximum pressure felt on the artery during left ventricular contraction, or systole

() Elastic recoil, or resting, pressure that the blood exerts constantly between each contraction

() Difference between systolic and diastolic pressures and reflects the stroke volume

() Pressure forcing blood into the tissues averaged over the cardiac cycle

blood pressure

systolic blood pressure (SBP)

diastolic blood pressure (DBP)

pulse pressure

mean arterial pressure (MAP)

if you get an abnormal reading on a pulse oximeter, you should

move it around because it could be due to placement, dark nail polish, etc.

pulse oximeters show

both the pulse and oxygen saturation

what is a normal oxygen saturation reading for an adult?

95-100% on room air

a measure of how much hemoglobin is currently bound to oxygen compared to how much hemoglobin remains unbound in the blood

oxygen saturation

abnormal oxygen saturation

<95% on room air

maximum pressure during left ventricular contraction

systole

the top blood pressure reading

systolic

the bottom blood pressure reading

diastolic

recoil/resting pressure between each contraction

diastole

systolic BP minus diastolic BP = () this reflects the stroke volume

pulse pressure

_______ _______ reflects stroke volume

Pulse pressure

when performing a blood pressure cuff reading, you should make sure the cuff is

the correct size and inflated to maximum level

how should you deflate the blood pressure cuff?

slowly and evenly

generated when a blood pressure cuff changes the flow of blood through the artery

Korotkoff sounds

Korotkoff sounds

a) Systolic = 1st sound you hear

b) Diastolic = last sound you hear before silence

delete

delete

do not obtain blood pressure readings on

mastectomy arms or other injured areas

syncope

when should you take serial measurements of pulse and BP? (3)

1. you suspect volume depletion

2. when the person is known to have hypertension or is taking antihypertensive medications

3. when the person reports syncope or near syncope (ie., dizziness)

describe how you would take orthostatic (or postural) vital signs

-have person rest supine for 3-5 min

-then take baseline BP and pulse

-have patient sit up, assess BP and pulse

-have patient stand up, assess BP and pulse

-after an extra 3 minutes, take BP and pulse again

when performing an orthostatic vital sign measurement, a patient would have orthostatic hypotension is their systolic pressure drops _______ or if their diastolic pressure drops _________ after standing

20 mm Hg or more

10 mm Hg or more

__________ ___________ blood pressure changes are caused by abrupt peripheral vasodilation without a compensatory increase in cardiac output.

orthostatic hypotension

Orthostatic changes commonly occur with.... (4)

-prolonged bed rest,

-older age,

-hypovolemia,

-some medications

you perform an orthostatic vital sign assessment on a patient. their systolic pressure decreased 8 mm Hg when they changed from sitting to standing. do they have orthostatic hypotension?

no bc for systolic it has to drop 20 mm Hg or more from sitting to standing

normal bp range audlt

120/80 or less

Systolic: 120 or less

Diastolic: 80 or less

Elevated BP range adult

120-129 / less than 80

Systolic: 120-129

Diastolic: 80 or less

high blood pressure hypertension stage 1

130-139 / 80-89

Systolic: 130-139

Diastolic: 80-89

high blood pressure hypertension stage 2

140+ / 90+

Systolic: 140+

Diastolic: 90+

hypertensive crisis range (when doctor needs to be immediately consulted)

180+ / 120+

Systolic: 180+

Diastolic: 120+

underweight BMI

normal BMI range

overweight BMI

obesity class 1

obesity class 2

extreme obesity

<18.5

18.5-24.9

25-29.9

30-34.9

35-39.9

40+

ADULT VITAL SIGNS

normal oral temp

normal rectal temp

normal mean oral

abnormal fever/hyperthermia

abnormal hypothermia

normal oral range: 96.4-99.1 f

normal rectal temp: 97.1-100.1 f

mean oral: 97.7 f

fever: 100.4 f more

hypothermia: 96.4f less

ADULT VITAL SIGNS

normal pulse rate

abnormal bradycardia

abnormal tachycardia

normal pulse rhythm

abnormal pulse rhythm

normal pulse force

abnormal pulse force (3 answers)

50-95 bpm

less than 50

more than 95

even tempo, regular

irregular, uneven tempo

2+

0=absent, 1+=weak/thready, 3+=bounding/full

ask the prof if i need to memorize this pic

ask prof if i need to memorize vital signs in f and c

did u?