Vital Signs: Oxygen Saturation, Pulse, and Blood Pressure

Flashcards covering oxygen saturation monitoring, pulse site locations, grading of pulses, heart rate abnormalities, and blood pressure measurement principles.

Pulse Oximetry Sites

The most common locations to measure oxygen saturation are the finger or the earlobe.

Conditions Decreasing Oxygen Saturation

Physiological factors including pneumonia, chronic lung disease (like $COPD$ or emphysema), asthma, and lung swelling.

Tachycardia

A resting heart rate that is greater than $100$ beats per minute ($bpm$).

Tachypnea

An increase in respiratory rate, often a compensatory response to low oxygen levels.

Restlessness

An initial sign of low oxygen saturation levels, frequently observed in pediatric asthma patients.

Neurological Symptoms of Low Perfusion

A decrease in mental alertness and an increase in confusion due to a lack of oxygen to the brain tissue.

Fowler's Position (Semi vs. High)

A nursing intervention for low oxygen where the head of the bed is raised; Semi Fowler's is $45$ degrees and High Fowler's is $90$ degrees.

Nasal Cannula

A first-line oxygen administration device consisting of two forks placed into the nose and tubing that wraps around the ears.

Cyanosis

A blue coloration on mucous membranes like the lips or gums, signifying a decrease in oxygen.

Pallor

A lack of color in the mucous membranes, signifying a decrease in oxygen.

Normal Pulse Range

The expected range for an adult heart rate is between $60$ and $100$ beats per minute ($bpm$).

Bradycardia

A heart rate that is less than $60$ beats per minute ($bpm$), which is considered normal for professional athletes.

Carotid Pulse

A central pulse site located on either side of the neck between the trachea and the sternocleidomastoid muscle, primarily used in $CPR$.

Temporal Pulse

A pulse site located at the temples, lateral to the eyes; it is thin and easiest to palpate on infants.

Brachial Pulse

Located in the antecubital fossa ($AC$) or inside of the elbow; it is used as the marker for manual blood pressure cuff placement.

Radial Pulse

The most common peripheral pulse site used for routine vitals, located on the thumb side of the wrist.

Femoral Pulse

Located in the groin midway between the hip and pubic bone; used for central line access or cardiac caths.

Popliteal Pulse

Located behind the knee toward the midline; essential for assessing perfusion in patients with below the knee amputations ($BKA$).

Posterior Tibial Pulse

A pulse site located behind the ankle used to assess circulation to the foot.

Dorsalis Pedis

A faint pulse site on the top of the foot between the first and second metatarsals; often requires a Doppler to hear.

Pulse Grade: $0$

An absent pulse indicating no perfusion to the limb.

Pulse Grade: $1$

A weak or characteristically faint pulse.

Pulse Grade: $2$

A normal pulse strength, which is the baseline for the majority of patients.

Pulse Grade: $4$

A bounding pulse that may be visible on the skin without palpation.

Valsalva Maneuver

The act of bearing down or exhaling with a closed mouth which triggers the vagus nerve to decrease the heart rate.

Pulse Deficit

A clinical finding where there is a difference between the apical and radial pulse; a difference of $5$ or more is concerning for perfusion issues.

Apical Pulse Site

Located on the left side of the chest at the midclavicular line in the fifth intercostal space.

Systolic Blood Pressure ($SBP$)

The top number in a blood pressure reading representing the maximum force when blood is pumped out of the heart.

Diastolic Blood Pressure ($DBP$)

The bottom number in a blood pressure reading representing the pressure when the heart is relaxed and refilling.

Blood Pressure Cuff Sizing Rules

The cuff length should be $80\%$ of the patient's arm and the width should be $40\%$ of the arm.

Blood Pressure False Readings (Sizing)

A cuff that is too small causes a false high reading, while a cuff that is too large causes a false low reading.