Vital Signs (chapter 6, 16)

contourthe _____ refers to how the *pulse gradually rises up to touch of finger and then dies off*amplitudethe _____ refers to the pulse's *force*rhythm(*steadiness*); can be irregular or regularcontour*how the pulse rises and falls*; pliableamplitude*force* 0 to 4 scale 0= absent 2= normal 4= bounding 1= decreased 3= increased60-100bpmpulse rate: normal range?70bpmpulse rate: average?50-60bpmpulse rate: conditioned athletes or those taking beta blockers?>100bpmpulse rate: tachycardia?<60bpmpulse rate: bradycardia?contour and amplitudetypically _____ and _____ are *not documented unless abnormal*; when it is not mentioned it is implied to be normal1 minutefor respirations, observe and count number of cycles that occur in _____ -note: rate, rhythm, symmetry, pattern (depth)chestfor *respiration*, observe rise and fall of _____ in *adults*abdomen/bellyfor *respiration*, observe rise and fall of _____/_____ in *infants**12-20* cycles per minuterespiration *normal* cycles?depth/pattern and symmetryfor respiration, note that _____/_____ and _____ are often *not mentioned* unless it is *abnormal*; when not mentioned it is implied to be normalblood pressure_____ _____ is a *peripheral* measurement of *cardiovascular function*indirectfor _____ blood pressure; use a stethoscope and aneroid or mercury sphygmomanometeraneroidan _____ often becomes inaccurate with related use and the passage of time and thus requires *recalibration* (for indirect peripheral blood pressure measurement)adultwhich type of BP cuff? -cuff with range markers assures proper size -width should be *1/3 to 1/2* the circumference of the limbchildrenwhich type of BP cuff? -width should cover *@ 2/3 of the upper arm or thigh*arterycorrect BP cuff size ensure *equal pressure* will be exerted around the _____use a peds cuff around the radial artery for an adultwhat can you do if no large cuff available?-too small of a cuff and the pressure will be too high of a reading -too large of a cuff and the pressure will not be enough to get an accurate reading; low BP want to ensure equal pressure around the arterywhat is the importance of finding the correct size cuff for your pt?-clothing -flexed -brachialBP technique: -arm should be free of _____ -support the arm in a slightly _____ position -position cuff over _____ artery with lower boarder 2-3c, above the antecubital crease and secure snugly -palpate brachial artery usually just medial to the biceps tendonpalpebral systolic blood pressure-palpate (brachial or radial) pulse, inflate cuff, note when pulse obliterated, deflate slowly, note reading when pulse returns ---> this number is termed the *????* -deflate then reinflate to 20-30mmHg higher than this reading; listen with stethoscope180-palpate pulse, apply stethoscope, inflate to _____mmHg; if pulsations heard, inflate to 200mmHg or until pulsating obliteratedinaccuratenote: *slow/repeated* inflations give _____ readings!systolic (top number)when taking BP: sound *first* heard?diastolic (bottom number)when taking BP: sound that *disappears*?2 consecutive_____ _____ *beats* indicates the *start of systole*deflate cuffwhen the sounds end (after diastolic pressure is obtained) what do you do?Korotkoff sounds_____ _____ are *low pitched*, best heard with *bell*Korotkoff sounds2 consecutive beats indicate the systolic pressure and beginning of *phase 1* of the _____ _____auscultatory gap_____ _____ is a *period of silence*, may be present in some pts but not always! sounds are heard, disappear, and then reappear 10-15mm Hg laterseated-when recording the BP, most often the *first sound (systolic)* and the last audible sound or the point at which the crisp sounds become *muffled (diastolic)* are documented -standard readings based o _____ *position* using *right arm*pulse pressurethe _____ _____ is the *difference between systolic and diastolic* pressures; measure change in BP during *contraction* of the heart30-40 mmHgnormal pulse pressure?measures the change in BP during *contraction* of the heartwhat does the pulse pressure measure?lowthe if *pulse pressure* is _____: *error*; CHF, shock (decreased stroke volume*highif the *pulse pressure* is _____: *stiffened major arteries*, aortic regurgitation, hyperthyroidism, drug side effectnormalsystolic < 120 diastolic < 80prehypertensionsystolic 120-139 diastolic 80-89stage 1 HTNsystolic 140-159 diastolic 90-99stage 2 HTNsystolic 160 > diastolic 100 >10BP tips: reading between arms may *vary* as much as _____mmHgright_____ sided arm tends to be a *higher BP* then the other pressure15 secondsavoid slow/repeated inflations -inaccurate readings due to venous congestion -allow _____ _____ between inflations or *remove cuff and elevate arm 1-2 minutes*sitting, supine, standinghow can BP be measured (position wise)?sittingBP while _____ is a normal screening for most pts; always perform *bilaterally*orthostatic BP-pt on *antihypertensive medications* -depleted blood volume postural lightheadedness, weakness, faintingMUST BE IN THIS ORDER supine seated standingorder to obtain *orthostatic blood pressure*?postural hypotension_____ _____: *drop in systolic BP* by 20* mmHg or more and *drop in diastolic BP by at least 10* mmHghypothalamusbody temperature *regulated* by the _____body temperatureassessment of _____ _____ helps assess *severity of illness*98.6 F or 37 C range: 97.2-99.9 36.2-37.7normal body temp?oral, rectal, axillary, tympanic, temporalmethods for taking temp?axillary_____ temperature method is *best for neonates*tympanic (TM)*shares blood with hypothalamus*; must properly manipulate auricle to straighten the ear canaladults*up and back* for _____ (TM temp reading)infant*down* in an _____ and young child (TM temp reading)fever_____ is al elevation of thermoregulatory set point; results in increase core body temp above baselinepyrogensmicroorganisms invade body causing *release* of _____ that travel to the hypothalamus101temp of _____F in otherwise healthy pt considered fever; some variations in definitionheight and weight-*without shoes, coat, heavy outer clothes* -height usually measured on a platform scale with height attachment -shouldnt allow pt to step on scale with *bare feet*; use paper towel, socks or something similar -make sure *scale is balanced*BMI_____ is the *most common method* for assessing *nutritional status and total body fat* undernourished < 18.5 appropriate 18.5-24.9 overweight 25-29.8 obese 30-39.9 extremely obese 40 and >pulse oximetry_____ _____ measures the *oxygen saturation* of *hemoglobin*; indirect measure of how much oxygen the blood is carrying -expressed as a percent94-100%_____-_____% for a *healthy* pt on *room air*90% or above_____% or *above* for a pt with *mild respiratory disease* on room airbelow 90%_____ _____ indicated *hypoxia* and need for *supplemental oxygen*red and infraredobtaining pulse oximetry: -a sensory is attached to the pt -the sensor emits both _____ light and _____ lightinfrared*oxygen hemoglobin* absorbs more _____ lightred*deoxygenated hemoglobin* absorbs more _____ lightpercentagethe ratio of absorption of these 2 laughs is given as a _____distal finger or toepulse oximeter placement---*most commonly* applied site is the _____ _____ or _____ear lobe or pinnaother acceptable placement for the pulse oximeter?foot, palm, and great toe or thumb*infant sites* for pulse oximeter placement?bridge of the nose_____ of the _____ may be used in an adult with *poor distal circulation*nai polishobtaining a pulse Ox reading: -*remove excess dirt, _____ _____, nail tips* -place transducer on the pts nail bed -turn on monitor -oxygen saturation will be displayed as a percenton the pts *nail bed*where to place Ox transducer?reasons for not detection a pulse ox measurement-pt has *no pusle* -transducer not applied propriety -transducer cannot read through physical barriers -transducer cable not contented to the monitor -monitor not turned on -low batterylow flow statesshock, hypothermia, hypovolemia -invalid pulse ox readingCO poisoningomitted false reader CO as O2anemias (sickle cell)monitor measures good oxygenation but cannot detect low Hgb96% (pulse ox) 92% (nasal O2)documentation pulse Ox _____% room air, pulse Ox _____ on nasal O2subjectivepain assessment: pain is _____ since people have different thresholds to pain -many factors impact the perception and interpretation of pain -pain can be associated with changes in other vital signspain from 1-10 Wong/Baker faces rating scalepain assessment scales (2)?comparativedue to its subjectively, often more useful as a _____ to prior or future pt encounters