Measure various factors that provide information about the basic body conditions of the patient.
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4 Main vital signs T-P-R-BP
\ * Temperature * Pulse * Respirations * Blood Pressure
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other vital signs--Pain
\ *  considered the 5th vital sign. Can be *acute or chronic.* Pain is what the person says it is! * Scale - 0 to 10 * Patients are asked to rate their level of pain on the 0 – 10 scale * If patient is a child or nonverbal, FACES pain scale is used
\ * Awake, Alert and Oriented to (person, place, time) - AAOx3
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other vital signs--
* Patients response to stimuli * Pulse oximetry reading 95%+
other vital signs--
* Patients response to stimuli * Pulse oximetry reading 95%+
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\ * Accuracy is essential because they are:
* Used to detect problems * Monitor the effectiveness of medication * Make a diagnosis
* You should ALWAYS report abnormality or change * If unable to get reading, ask another person to check
\*\*\*Guidelines for “normals” will vary according to state laws and policies of health care agencies.Â
It is your legal responsibility to know and follow guidelines for your state and agency.
\
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temperature: 96.6 to 100.6 F avg 98.6
\ * **a measurement of the balance between heat lost and heat produced** * Heat is lost thru perspiration, respiration, & excretion (urine & feces) * Heat is produced by the metabolism of food; and by muscle and gland activity * A constant state of fluid balance, known as __**homeostasis**__, is the ideal health state in the human body.Â
\ * The rates of chemical reactions in the body are regulated by body temp.  * If body temp is too high or too low the body’s fluid balance is affected
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oral
(PO) -Mouth; *most common*, convenient
\-blue
\-
* **Factors that can alter temp in mouth** * **Eating, drinking (hot or cold)**Â * **Smoking** * **Wait at least 15 min before taking temp**
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rectal
\ * Â (R or pr)- Rectum; **most accurate**, invasive * red
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axillary
\ * (Ax) -Under the armpit; **least accurate** * blue
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temporal
\ * (T)- Side of head; easy to use, accurate
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Tympanic
* Â (Tymp) __**or**__ Aural - in the ear canal; accurate * *Usually used for infants to 3 years* * Measures infrared energy from bloodÂ
\ * body temp >104oF rectally * Prolonged exposure will cause brain damage or serious infection * >106oF will lead to convulsions, brain damage, or death
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pulse(P or HR) 60-100
\ * The **blood pushing against the wall of an artery** as the heart contracts and relaxes. In other words- it is a throbbing of the arteries (that is **FELT**) caused by contractions of the heart. * Rate - # of beats per minute (bpm) * Rhythm – refers to regularity of beats * Volume – refers to strength * Bounding/Full: * Normal/Strong: * Weak: * Thready:
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pulses
* __Pulses that are PALPATED (felt)__
on an __**artery**__
* **Temporal** – sides of the forehead * **Carotid** – sides of the neck * **Brachial** – inner aspect of forearm at the ante-
        cubital space
* **Radial** – inner aspect of the wrist, above thumb * **Femoral** – inner aspect of the upper thigh * **Popliteal** – behind the knee * **Dorsalis pedis** – top of the foot arch * **Posterior tibial**- behind ankle on lateral side ofÂ
the foot.
\n **Apical Pulse** is AUSCULTATED (Heard)
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apical pulse
\ * Taken with a __**stethoscope**__ at the apex of the heart * Use diaphragm (flat, flexible disk) * __**Actual heartbeat is heard (auscultated) & counted**__ * Pulse Deficit – take the apical then the radial pulse, then subtract the radial from the apical = difference is the pulse deficit * Occurs with pts with heart conditions * Heart is weak & does not pump enough blood to produce a pulse
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bradycardia
pulse
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tachycardia
\ * pulse >100 bpm
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rhythm
\ * Rhythm refers to the regularity of the pulse (the spacing of the beats) * Regular * Irregular - arrhythmia * Usually caused by a defect in the electrical conduction pattern of the heart
depressant drugs, physical training, sleep, heart disease, coma
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respiration(R or RR) 12-20 breaths per min in adults
* **Dyspnea** – difficult or labored breathing * **Apnea** – absence of respirations * **Tachypnea** – RR >20 breaths per minute * **Bradypnea** – RR
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cheyne-stokes respiration
frequently noted in dying patient
periods of dyspnea followed by periods of apnea that causes fluctuating carbon dioxide levels
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rales or crackles
bubbling or noisy sounds
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wheezing
high pitched whistling
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rhonchi
rattling snoring sounds
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blood pressure (BP)
***pressure that the blood exerts on the walls of the arteries***
* __**Systolic BP (top/first number)**__ * **Pressure occurs in the walls of the arteries when the left ventricle of the heart is** __**contracting and pushing blood into the arteries**__
\ * **Normal range 100 to 120**
\ Â Â Â Â Â Â **mm Hg**
* __**Diastolic BP (Bottom/second number)**__ * **The constant pressure in the walls of the arteries when the left ventricle of the** __**heart is at rest, or between contractions.**__Â Â
Blood has moved forward into the capillaries and veins, so the volume of blood in the arteries has decreased.
\ * **Normal range 60 – 80 mm Hg**
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causes of inaccurate BP
\-__Increased activity__: the patient to sit quietly for at least 5 minutes before BP is taken.
 You should wait 30 seconds between each reading if you are having to repeat the BP for any reason
\-__Size and placement of the cuff__: It contains a rubber bladder that fills with air to apply pressure (squeeze) to the arteries.Â
\-If its **Too small = inaccurate high reading**
**-**If its **Too large = inaccurate low reading**
\ **-**__Patient positioning__: Patient should be sitting with feet flat on the floor (do not cross legs)
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pulse pressure
* The __difference__ between Systolic BP and Diastolic BP
\ * Important indicator of the health and tone of the arterial walls
\ * **Normal range 30 – 50 mm Hg** * **120/80     120 – 80 = 40 pulse pressure**
\ Helps to see trends in blood pressure and heart function.Â
**A high pulse pressure can be caused by an increase in blood volume or heart rate, OR a decrease in the ability of the arteries to expand.**
\
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prehypertension
120-139 mmHg Systolic OR 80-89 mmHg Diastolic.
120-139/80-89 mmHg
\ * Condition can harden arteries, dislodge plaque, and block blood vessels that nourish the heart
\ * They don’t have “high blood pressure” but are at risk for developing hypertension (HTN) if lifestyle changes do not occur such as proper nutrition and exercise program.
\
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hypertension(HTN)
higher than 140/90
silent killer
arteriosclerosis
leads to kidney failure, stroke, heart disease
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hypotension
less than 90/60
\ * May occur with heart failure, dehydration, depression, severe burns, hemorrhage, and shock
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orthostatic or postural hypotension
\ * **Sudden drop in both SBP & DBP when a person changes positions** * Caused by the inability of blood vessels to compensate quickly to positional change * Signs/Symptoms: lightheaded, dizziness, blurred vision