263 - Vital Signs

Lecture 4: Assessing General Health and Vital Signs 

Interview the client for an accurate survey of their general health status and vital signs

  • Use observational skills, skin color, dress hygiene, posture and gait, age

  • Level of consciousness, face, speech, behaviors, vital signs 


Discuss the components of a general survey.

****COLDSPA & SUBJECTIVE DATA


Discuss and interpret normal and abnormal vital signs (temperature, radial pulse, respiratory rate, pulse oximetry, blood pressure).

TEMP

Hyperthermia (above 38.0°C)

Hypothermia (below 35.9°C)

PULSE

  • 60-100 bpm

  • Amplitude, 0, 1, 2, 3

  • Elasticity (straight & springy)

RESP

  • 12-20

  • Regular and equal rhythym and depth

PULSE OX

>92%

BP

Normal: <120/80

Elevated: 120-129 and <80 mmHg

Stage 1: 130-139 or 80-89 mmHg

Stage 2: ≥140 or ≥ 90

Impacted by:

  • CO

  • Peripheral vascular resistance

  • Circulating blood volume

  • Blood viscosity 

  • Elasticity of vessels 

Orthostatic hypotension, drop of 20mmHg and 10-20% increase in HR when standing

Pulse pressure = systolic - diastolic. Should be 30-50

Korotkoff sounds

Phase I - First appearance of clear, tapping sounds

Phase II - Muffled/swishing sounds

Phase III - Return of loud, crisp tapping sound

Phase IV - Sounds become muffled

Phase V - All sounds disappear


Discuss the vital signs of special populations. 

  • Infant pulse 120-160, resp 30-60, BP 60-80/30-45

  • Children 2-10, pulse 70-110, 10+ 55-90

  • Children (3-5) resp 20-28, (6-11) 18-25, (12-15) 12-20

  • Children BP (1-6) Age+90/53-66, (7-18) 2xage+90/age+52


IN ESSENCE, children have higher pulses and respiratory rates when they are younger. They get lower when they get older. They have lower BPs when they are younger (think tiny hearts). BP will increase with age, and in adolescence children will eventually get to normal adult VS


  • Childbearing women pulse may increase 10-15bpm

  • Geriatric temp is lower 95-97.5.  Pulse more rigid, sys. BP may be higher due to arteriosclerosis. 


Describe the early warning signs associated with vital signs. 

  • Fall risk orthostatic BP

  • Unstable temp and dehydration geriatric 

  • Early warning scores:

  • Low (0-4)

  • Moderate (5-6)

  • High (greater than 7)


Analyze assessment data to make accurate clinical judgments.

  • ID abnormal findings

  •  Cluster data to reveal patterns 

  • Client BP management