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70 Cards in this Set
- Front
- Back
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Vital signs used to |
measure patients condition ID problems Evaluate response to intervention |
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When to do you take vitals |
Admission Routine schedule Before after procedures Before administering meds which affect VS When a patient reports feeling different |
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Normal Vitals - TPR B/P |
Temp 96.8 to 100.4
Pulse 60 to 100 Respirations 12 to 20 B/P systolic < 120, diastolic <80 Pulse pressure 30 to 50 |
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temperate ranges |
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Rectal temperature problems |
Vagal response for patients with cardiac repsonse |
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Neural Regulation of Body temp |
Hypothalamus |
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Vascular regulation of body temp |
Vasoconstriction/Vasodilation |
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Burn patients are high risk for |
temperature loss |
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Heat production |
Basal metabolic rate increased thyroid hormones muscle movements shivering |
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Heat Loss occurs from the following |
Radiation, convection, conduction, evaporation |
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Conduction |
direct contact heat xfer |
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Convection |
air movement heat xfer |
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Radiation |
Heat xfer from indirect contact. i.e cold rooms |
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evaporation |
heat xfer or loss from liquid to gas change |
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Infants can not |
shiver |
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Febrile seizure occur |
seizure due to high fever (6 months to 3 yrs) |
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Mild elevation of temp |
up to 102.2 |
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Pryogens |
trigger immune response part of immune system |
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Infants temp that is significant |
>100.4 |
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Brachycardia |
<60 BPM |
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Tachycardia |
>100 |
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stroke volume |
60-70mL/beat |
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SV x HR = |
CO cardiac output |
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Normal Cardiac output |
4-6 L/min |
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SA node |
normal pacemaker 60-80 BPM |
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AV node |
backup pacemaker 40-60 BPM |
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Location of pulses |
Carotid Brachial Apical Brachial Radial Femoral Posterior Tibial Dorsalis Pedis |
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Carotid pulse |
access one at time |
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Apical pulse |
auscultate used for irregular HR or prior to administering meds |
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Femoral pulse |
shock or arrest |
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Pulse Character |
1 - diminished 2 - normal 3 - strong 4 - bounding |
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Pulse deficit indicate |
abnormal heart rhythms |
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Factors that affect Pulse |
age exercise temperature emotions drugs Postural changes O2 sat Pain |
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Ventilation |
movement of gases of CO2 and O2
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Diffusion |
gas exchange |
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Perfusion |
delivery of O2 |
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Hypoxemia |
Low O2 in the blood |
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early signs of Hypoxemia |
restlessness, confusion, anxiety |
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late stages of hypoxemia |
cyanosis, tachycardia, bradycardia |
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Eupnea |
Normal breathing |
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Bradypnea |
<12 |
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Tachypnea |
>20 |
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Apnea |
no respiration |
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Dyspnea |
difficulty breathing |
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Hyperventilation |
fast, excessive breathing |
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Hypo-ventilation |
slow, breathing |
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Cheyne Stokes |
end of life breathing, set pattern, gradual increase of breathing, apnea, then restarts |
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Kussmaul |
associated with DKA (hyperventilation) |
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O2 saturation normal |
>95% |
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sites to access to check O2 saturation |
finger, toes, forehead, earlobe |
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what affects accuracy of O2 sat |
sweating, cold, nail polish, compromised vascular system, edema |
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critical report for O2 when |
<90% |
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Systolic |
contraction of ventricles |
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Diastolic |
heart at rest |
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Pulse pressure |
difference between systolic and diastolic 30 - 50 mm HG (normal) |
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Blood pressure depends upon |
Cardiac Output Peripheral vascular resistence (afterload) Blood volume (preload) Viscosity - (hematocrit) Elasticity |
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Viscosity - High |
dehydration = low B/P |
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Viscosity - low |
Edema - High B/P |
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Do not perform B/P on arms with |
Shunt Mastectomy trauma IV |
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MAP |
mean aterial pressure |
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Mean Arterial pressure |
average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle |
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Orthostatic (Postural) Hypo-tension |
Changes in B/P due to position changes |
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SX of Orthostatic (Postural) Hypo-tension |
weakness, dizziness |
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Orthostatic signs from supine to standing position |
Decreasing SBP of 20 mm Hg or more Decreasing DBP of 10 mm Hg or more Increasing HR > 20 beats/min |
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when measuring B/P cuff should be what size to the arm |
40% greater |
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first sound you hear during auscultation when checking B/P |
systolic |
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Last sound you hear during auscultation B/P |
diastolic |
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False high reading B/P |
small cuff deflating to slow arm below heart |
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False low reading B/P |
cuff to big deflate to fast arm above heart |
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don;t use electronic measure of BP |
irregular heart rate vascular obstruction shivering seizures excessive tumors SBP<90 |
