Vitals Flashcards
(56 cards)
1
Q
5 Vitals
A
-Temperature
-Pulse
-Respiratory Rate
-Blood Pressure
-Pulse Oximetry
2
Q
-Temperature
A
-Normal
-Adults 98.6*F or 37*C -Hypothermia (Low temp) < 95*F -Exposure, increased Heat loss, Diaphoresis (Sweating) blood loss, hormone imbalance, hypothalamus injury. -Hyperthermia (High tmp) >100*F -Increased environmental temps, decreased loss (Too many clothes), drugs or medication reaction, hormone imbalance, infection/ Illness
3
Q
-Pulse
A
-Direct indicator of heart actions
-Note rate and rhythms -Capillary refill, indicative of local perfusion - > 3 seconds = poor perfusion
4
Q
-Normal Pulse
A
-Adults 6-100 bpm
-Children have a higher rate
5
Q
-Bradycardia
A
Slower heart rate < 60 bpm
6
Q
-Tachycardia
A
(fast heart rate) > 100 bpm
-Hypothermia, fever, emotional stress, heart abnormality, blood volume loss
7
Q
-Rhythm of the heart may be irregular due to
A
cardiac arrhythmias or changes in vascular system affecting blood flow
8
Q
-Measuring pulse
A
-Most Common site - Radial Artery
-Others: Brachial, ulnar, femoral, carotid, apical, temporal, popliteal, posterior tibial. -Use two fingers, and press firmly but gently over pulse site, do not use thumb -Count for a full minute, if irregular rhythm otherwise count for 15 seconds and multiply by 4.
9
Q
-Respiratory Rate
A
-Number of breaths in 1 minute intervals
-Important to count when patients are not aware
10
Q
-Respiratory Rate -Normal
A
-Adults 12-20
-Children have a higher rate -Note, rate depth, pattern, rhythm, and degree of labor, I:E ratio (inspiration to Expiration)
11
Q
-Eupnea
A
Normal restful breaths
12
Q
-Hyperpnea,
A
deep breaths
13
Q
-Hypopnea
A
Shallow breaths
14
Q
-Tachypnea
A
increased respiration rates
-Caused by, anxiety, exercise, fever, hypoxemia -May indicate respiratory failure
15
Q
-Bradypnea
A
decreased rate
-Caused by, narcotics, head injury, hypothermia
16
Q
Respiratory rate is best to count after….
A
pulse rate
-Count full min if irregular
17
Q
-Blood Pressure
A
-Measurement of pressure within arterial systems
18
Q
-Factors of BP
A
-measuring for pumping action of heart, resistance in cardiovascular system, elasticity of vessel walls, blood volume,viscosity of blood (thickness)
-Systolic pressure, when the ventricles contract -Diastolic pressure, when ventricles are at rest -At this point, the aortic valve closes and pushes the blood through the arterial system -The more important measurement of the two
19
Q
-MAP:
A
Mean Arterial pressure, average of both systolic and diastolic pressure
20
Q
-Normal BP
A
-Adults 120/80
-Children have lower blood pressure
21
Q
-Hypotension
A
(low BP)
-Shock, hormone imbalance, depressant drugs, postural (Positioning) Fluid loss.
22
Q
-Hypertension
A
(High BP)
-Cardiovascular imbalance, hormone imbalance, exercise, stimulate drugs, emotional stress, renal failure, fluid retention
23
Q
-Acceptable Systolic
A
90-140
24
Q
-Acceptable Disstolic
A
60-90
25
BP is measured by:
sphygmomanometer
26
how to use sphygmomanometer
-Cuff placed snugly around 1 inch above antecubital space (bladder should be over the brachial artery)
-Have patient relax muscle in arm
-Palpate brachial pulse and inflate cuff
-Slowly deflate cuff, note pressure, when sound 1st appears, systolic
.Note pressure when all sounds cease, diastolic
27
-Pulse Oximetry
-Plethysmography (Sp02)
-5th Vital Sign
-Measurement of % red blood cells carrying something (Usually O2)
-Uses different wavelengths of red light passed through capillary bed(Nails)
-Can be continuous or spot check and is non invasive
28
-Pulse Oximetry -Problems:
Ambient light, motion artifact, cold, anemia, PaO2, Vs. SPO2
-Rule 1#: Treat the patient not the monitor
29
-Pulse Oximetry vital readings
-Normal 93-97% SaO2
-Critical Values < 88% (Except Chronic Lung Patient)
30
-Heart Sounds
-Normal sounds
-Sounds created by closure of the heart valves
-Sound 1 normal sound created by the closure of valves at the beginning of ventricular contraction (Lub sound)
-Sound 2 normal sounds created the the systolic ends and ventricles relax typically during inspiration (Dub sound)
-Sounds 3, and 4 murmurs are abnormal and suggest heart failure, stenosis (extra sounds generated by aberrant blood flow)
31
-Auscultation
-One of the most commonly used physical assessment techniques
-Lung sounds can be normal or adventitious (abnormal)
-Listen in sequence over the back and anterior chest. Refrain from listening anteriorly because it easy of access
32
-Auscultation -Normal breath sounds
-Bronchial/ Tracheal breath sounds
-Heard over the trachea or btw scapula posteriorly
-Louder and higher pitched
-Loud and long expiration often longer than inspiration
-If heard in periphery of lung could be abnormal
33
-Bronchovesicular
-Heard over the main bronchus area
- Medium pitch
-Expiration is equal to inspiration
34
-Vesicular
-Heard over most lung fields
-Soft and low pitched
-Inspiration last longer than expiration
35
-Adventitious breath sounds “Crackles”
-Also known as rales
-can be course cracked or fine crackles
-Fine = Results when the terminal airways pop open late in inspiration because of fluid or secretions have accumulated
-Sounds that wax and wane during each respiratory cycle
-Usually heard at the end of inspiration
-Fine in quality and high pitched
-Most often heard over the lung base
-Most common condition is CHF/Pulmonary edema ( Fine crackles at the base.)
36
-Adventitious breathing sound “Rhonchi” (course crackles)
-Ronchi is deep rumbling sounds that is more pronounced on expiration
-Likely to be continuous and can be palpated
-Caused by air passing through an airway partially obstructed by thick secretion
-Coarse crackles secretion in large airways rumbling on inspiration and expiration
-Both can usually be cleared or improved through suctioning or coughing
37
-Adventitious breathing sounds “Wheezing”
-Can be high or low pitched
-Musical or whistling in nature
-Caused by air passing through narrowed airways
-Can have inspiratory wheezing, expiratory wheezing or both
-Often heard with bronchospasms, asthma, foreign, body aspiration
38
-Adventitious breath sounds “stridor”
-Crowing sound commonly caused by inflammation of the larynx and trachea. Usually on inspiration only
-Can be heard after extubation
-Most commonly associated with children with croup
-Often relieved with cool aerosol therapy of racemic epinephrine
-Marked inspiratory stridor is an emergency and requires quick action (Intubation)
39
-Adventitious breathing sounds “Pleural Friction rub”
-Continuous grating sound, such as rubbing two pieces of leather together/ balloons
-Sounds produced when the visceral and parietal pleura of the lungs become inflamed
-May accompany pleural effusion, lung trauma, pleurisy
-Usually localized area
40
-Grunting and stertor
Grunting is often displayed in newborns with respiratory distress
-Occurs when baby exhales against a closed glottis is closed in an attempt to maintain lung volume
-Stertor is noisy breathing sounds displayed during inhalation by babies
-Low pitched snorting/ snoring sound. Sound that arises from vibrations of fluid or tissue that is relaxed and flabby.
41
-Other lung sounds
-Bronchophony
-Auscultates over an area of suspected consolidation the patient speaking ninety nine, intensity is increased and clearly audible if consolidation is present
-Egophony
-Having the patient say the letter E and it sounds like an A over consolidated lungs
- Whispering pectoriloquy
-Patient is asked to whisper numbers 1,2,3. Normal sounds is soft, but with lung consolidation, it is clearly audible
42
-Patient Assessment
-Medical History
-Respect patient
-Remain professional
-Establish rapport and obtain essential information
-Open ended questions (Not yes or no)
-Demographic data
-Data and source of information (and reliability)
-Description of condition
-Current complaint (CC)/ reason for seeking treatment
-History of present illness (HPI)
-Past medical history
-Family history
-Social / environmental history
43
-Patient Assessment
-History of present illness (HPI)
-Onset, severity, location, quality, aggravations, alleviations factors (OLD CART)
44
-Review of symptoms
-Respiratory - cough, hemoptysis, sputum, chest pain, shortness of breath, hoarseness/ change in the voice, dizziness/ fainting, fever or chills, peripheral edma.
45
-General Appearance
-Age, height, weight
-Sensorium (level of consciousness)
-Confused, delirious, lethargic, obtunded, stuporous, comatose, “Oriented X 3 , person, place , time.
-Vital signs
-Head, ears, eyes, nose, throat, (HEENT), inspection
-Nasal flaring, cyanosis, pursed lip breathing
-Neck, inspection and palpation
-Position of trachea, jugular venous distention (JVD) enlarged lymph node.
-Thorax, inspection, palpation, auscultation
46
-Inspection
-Chest configuration
-Barrel chested (Ap diameter increased)
-Pectus carinatum/ pectus Excavatum (caved in chest/ pigeon breasted)
-Kyphosis/ scoliosis/ kyphoscoliosis
-Notice any bumps, lumps, of concussions
47
-Inspection
-Breathing patterns and efforts
-Retractions, sinking in of skin overlying the chest wall (Intercostal, supraclavicular, subcostal
-Inspiratory: expiratory ratio (I:E ration)
-Kussmaul, deep and rapid breaths
-Biot, short burst of uniform, deep respirations
-Cheyne stokes: increased/ decreased depth and rate with pauses
-Tachypnea, faster than 20 bpm
-Bradypnea, Slower than 12 bpm
-Apnea; Absence of breaths
-Platypnea: difficulty breathing unless laying flat
-orthopnea: difficulty breathing unless reclining. Patient must be sitting up of using several pillows to breath
48
-Palpation
-Vocal fremitus/ tactile fremitus
-Ninety-nine
-Increased vibrations through more solid tissues
-Decreases obesity over muscular, hyper inflation
-Thoracic expansion/ diaphragmatic excursion- equal bilaterally (Both thumbs should be moving equally )
49
Percussion
-Tapping on the surface to evaluate underlying tissue
-Indirect,place middle finger on chest, tp sharply with the middle finger of your other hand
-Normal resonance, moderately low pitched ringback
-Consolidation, decreased or absent resonance = Dull
-Hyperinflation , Increased resonance (Hypercasonant)
50
-Auscultation
-Listening to breath sounds with a stethoscope
-4 parts, Bell, diaphragm, tubing, earpieces
-Bell, listen to heart sounds
-Diaphragm, listen to lung sounds
-Earpieces, directed anteriorly into ears
-Normal and abnormal sounds
-Soft/rigid
-Tenderness
51
-Extremities
-Clubbing, enlargement of terminal phalanges of fingers and toes
-Compensatory mechanism when someone has chronic hypoxemia
-Infiltrative or interstitial lung disease
-Bronchiectasis
-Some cancers (Lung cancer)
-Cyanosis
-Pedal edema (Swelling like in feet and hands)
-Capillary refill
-Peripheral skin temperature and color (pallor, cyanosis, flush.)
52
-Cardiopulmonary symptoms
-Dyspnea
shortness of breath as perceived by patient
-Measured using a scale (Dyspnea borg scale.)
53
-Cardiopulmonary symptoms
-Cough
-Cough, Forced expiratory maneuver that expels mucus and foreign materials from airways
-Cough receptors in Larynx, trachea and large bronchi
-Effectiveness depends on patient being able to take a deep breath
-Dry and loose
-Productive or unproductive
-Acute or chronic
-Time of day
54
-Cardiopulmonary symptoms
-Sputum production
-Sputum production: Mucus produced in the airways
-Normal is minimal
-Mucociliary escalator
-Phlegm, material from tracheobronchial tree, not contaminated by oral secretions
-Sputum, comes from lungs nut passes through mouth
-Purulent, contains pus (Suggest bronchi infection)
-Fetid, foul smell
-Mucoid, thick and cleat ( Common in airway diseases like asthma )
55
-Cardiopulmonary symptoms
-Hemoptysis
-Hemoptysis, coughing up blood or blood streaked sputum
-Massive >300 cc over 24 hours
-Infection , can be blood streaked
-Cancer, TB, trauma, pulmonary embolism
56
-Cardiopulmonary symptoms
-Chest Pain
-Chest Pain
-Pleuritic (Lungs), literally or posteriorly, worsens on inspiration, sharp stabbing.
-Nonpleuritic ( Not the lungs), central anterior, dull ache or pressure, angina, GERD, or gallbladder.
