ch.11 vital signs and history taking

adult normal respiratory rate

12-20 per minute

adolescent (12-15 years) normal respiratory rate

12-20 per minute

school-age child (6-11 years) normal respiratory rate

18-25 per min

preschooler (3-5 yrs) normal respiratory rate

20-28 per min

toddler (1-2 yrs) normal respiratory rate

22-37 per min

infant (<1 yr) normal respiratory rate

30-53 per min

neonate birth (1 month) normal respiratory rate

40-60

when to ventilate a patient?

an adult patient breathing at a rate greater than 40 per min

an infant or young child breathing at a rate greater than 60 per min

normal respiration

average chest wall motion (1 inch of expansion)

does not use accessory muscles

exhalation is typically twice as long as inhalation

quiet

shallow respiration

slight chest expansion

typically indicates inadequate tidal volume

requires positive pressure ventilation by bag-valve device or positive airway pressure

labored respiration

indicated by grunting or stridor (harsh, high-pitched sound) and sometimes gasping

use of accessory muscles

may be retracting of skin in children and infants

noisy respiration

may including snoring, wheezing, gurgling, crowing, or stridor

listen to chest with stethoscope to determine if sounds are present on both sides or to identify other sounds

snoring

audible without stethoscope

tongue partially blocking upper level of pharynx

gurgling

audible without a stethoscope

fluid in upper airway

stridor or crowing

audible without stethoscope

patrial obstruction of upper airway at level of larynx

wheezing

audible with stethoscope

constriction and inflammation reducing diameter of bronchioles in lungs

crackles (rales)

audible with stethoscope

fluid surrounding and filling alveoli

rhonchi

audible with stethoscope

mucus blocking larger bronchioles

Cheyne strokes

respiratory rate and tidal volume increase and decrease followed by apnea for up to 10 seconds

biot

similar to Cheyne strokes except tidal volume has no change

apnuestic

long periods of inhalation

ataxic

irregular pattern of rate and tidal volume

complete irregularity

agonal

long periods of apnea with gasping breath

kussmaul

rapid, deep, and labored

central neurogenic hyperventilation

deep and rapid with at least 25 breaths per minute but with a regular pattern

PRBELLS

pulse

respiration

blood pressure

eyes

lungs

level of consciousness

skin/sugar/spo2

adult range of normal heart rate

60-100

adolescent (12-15) range of normal heart rate

60-100

school-aged child (6-11) range of normal heart rate

75-118

preschooler (3-5) range of normal heart ratedle

80-100

toddler (1-2) range of normal heart rate

98-140

infant (<1) range of normal heart rate

100-180

Neonate (<1) range of normal heart rate

100-205

pulsus paradoxus

decrease in strength of the pulse when the patient is inhaling

may indicate severe cardiac or respiratory injury or severe blood loss

rapid, regular, and full pulse

possibly exertion, fright, fever, high blood pressure, or very

early stage of blood loss

rapid, regular, and thready pulse

Reliable sign of shock, often evident in early stage of

blood loss

slow pulse

head Injury, barbiturate or narcotic use, some

poisons, possible cardiac problem or other medical

conditions such as hypothyroidism

No pulse

Cardiac arrest, profound hypotension

tachycardia

heart rate >100 bpm

bradycardia

heartrate <60 bpm

moist skin

may indicate shock; poisoning; heat related; cardiac; or diabetic

diaphoresis

profuse sweating

skin color: pallor

Vasoconstriction, blood loss, shock, heart attack, fright, anemia, fainting, or emotional distress

skin color: cyanosis (blue-gray)

Inadequate oxygenation or perfusion (shock), Inadequate respiration, or heart attack

skin color: flushing

Heat exposure or carbon monoxide poisoning (late)

jaundice

liver disease

PERRLA

pupils

even

round

reactive to

light

adaptable

adult normal blood pressure

systolic

• 120 or less

diastolic

• 80 or less

adolescent normal blood pressure

systolic

• 110-131

diastolic

• 64-83

preadolescent normal blood pressure

systolic

• 102-120

diastolic

• 61-80

school aged normal blood pressure

systolic

• 97-115

diastolic

• 89-112

preschooler normal blood pressure

systolic

• 89-112

diastolic

• 46-72

toddler normal blood pressure

systolic

• 89-112

diastolic

• 42-63

infant normal blood pressure

systolic

• 72-104

diastolic

• 37-56

neonate normal blood pressure

systolic

• 67-84

diastolic

• 35-53

SpO2

Normal:97-100%

Hypoxia: <94%

Severe hypoxia: <90%

Limitations to pulse oximeter

Shock

Hypothermia

Excessive patient movement

Nail polish

Carbon monoxide exposure

Anemia