Patient Assessment: Vitals

Monday, June 9, 2014

Review

Let’s review the 4 vital signs! Heart rate Respiratory rate Blood pressure Temperature

Heart Rate What does heart rate

tell you? Tells you part of the

patient’s story – how your body is being supplied by oxygenated blood

Where can you measure heart rate? 11 sites, 8 discussed last

class How do you describe

(document) heart rate? Site, rate, rhythm, depth

Respiratory Rate Describe the process of breathing

Inhalation and expiration: exchange of gases in the body

What does respiratory rate tell you? Tells you how much oxygen you may need,

and how much carbon dioxide to expel How does respiratory rate relate to

heart rate? Hold your breath Your body needs oxygen, but needs to also

get rid of gas wastes: CO2

Blood Pressure What is blood pressure?

A ratio of the pressure in your arteries when your heart contracts & relaxes

Systolic vs diastolic What is hypotension vs hypertension?

Hypo – below normal, ie. shock Hyper – above normal, ie. cardiovascular disease

What does blood pressure tell you? Tells you whether oxygenated blood is getting

delivered properly

Temperature What does temperature tell you?

The body self-regulates its temperature to ensure cellular reactions work best

What is hypothermia vs hyperthermia? Temperature below or above normal can

seriously affect body function What is the difference between core

and peripheral temperature? Core: taken by ear (T) & rectum (PR) Peripheral: taken by armpit (Ax), mouth

(PO)

Let’s Take Some Vitals!

Manual blood pressure 1) Make sure patient has not been doing

any strenuous activity for about 5 minutes. 2) Take cuff and secure it around patient’s

arm, placing the tubing centre to the patients brachial artery site

3) Locate the radial pulse, and inflate the cuff until you cannot feel the pulse anymore (obliteration), making note of the mmHg

Let’s Take Some Vitals! Manual blood pressure continued

4) Now place your stethoscope on this site and listen for a pulse. Inflate cuff above the obliteration point by 30-40mmHg.

5) Slowly deflate cuff at 2-3mmHg per second, and make note when you begin to hear the pulse again. That’s your systolic!

6) Continue to deflate and make note when you no longer hear the pulse. That’s your diastolic!

Vital Signs Review GameHeart Rate

Respiratory Rate Temperat

ure

Blood pressu

re

Critical thinkin

g100 100 100 100 600200 200 200 200 700300 300 300 300 800400 400 400 400500 500 500 500

HR 100

What is the normal heart range for an adult?

60-100

Back to the Board

HR 200

What is the normal heart rate range for an infant?

110-180 BPM

Back to the Board

HR 300

What is tachycardia?

Increased heart rate over the normal range

Back to the Board

HR 400 There are 11 sites to palpate pulse. 8 were in

the last presentation: name 3 of these sites.

Apical Radial Femoral Popliteal Brachial Carotid Dorsalis pedis Temporal

Back to the Board

HR 500

What are the 4 components of documenting of heart rate?

1) Site 2) Rate 3) Rhythm 4) Depth

Back to the Board

RR 100

How is respiratory rate measured?

Respirations per minute

Back to the Board

RR 200

What is the normal range for a child?

20-25 respirations per minute

Back to the Board

RR 300

Name 2 of the 3 components of documenting respiratory rate.

1) Rate 2) Rhythm 3) Depth

Back to the Board

RR 400

What is the process in which your diaphragm flattens and chest expands allowing exchange of oxygen in your lungs?

Inhalation

Back to the Board

RR 500

Name 2 things that can affect your ability to breath: Bonus points if you can explain how.

Airway is obstructed Lung tissue is poor (ie. inflammation,

thickened) Lung cannot inflate properly (ie.

collapsed, pressure against lung space)

Back to the Board

Temp 100

What is the normal range for temperature?

35.0-37.5*C

Back to the Board

Temp 200

What site is denoted by the letter “O”?

Oral temperature site

Back to the Board

Temp 300

Name the 4 sites to take temperature.

Oral Rectal Axillary Tympanic

Back to the Board

Temp 400

What is the difference between core and peripheral temperatures?

Core refers to temperatures closest to internal organs

Peripheral refers to temperatures away from internal organs

Back to the Board

Temp 500

Which type of temperature sites is the most accurate? Bonus points if you can explain why.

Core temperature sites such as tympanic & rectal

Because they are a better at measuring the temperature of your internal organs and less influenced by fluctuations of your environment

Back to the Board

BP 100

What is the normal blood pressure of an adult?

120/80

Back to the Board

BP 200

What is the unit of measure for blood pressure?

mmHg or “millimetres of mercury”

Back to the Board

BP 300

What is the difference between systolic & diastolic pressures?

Systolic is a measures of the pressure in the arteries when the heart contracts

Diastolic is a measure of the pressure when the arteries relax

Back to the Board

BP 400

What is the normal blood pressure of an infant?

90/55

Back to the Board

BP 500

Give 3 symptoms of hypotension.

Dizziness, light-headedness, syncope (fainting), cold/clammy skin, fatigue, shallow breathing, blurred vision, lack of concentration, nausea

Back to the Board

Critical Thinking 600

BEFORE taking vital signs, what are some observations you can make that may affect how you interpret your findings?

Back to the Board

Critical Thinking 700

A 20 year old man comes into the ER with a stab wound to the stomach. His vitals are T-37.2*C (PO), BP-88/60, HR-121, RR-24. Explain the relationship between his blood pressure and his heart rate.

Back to the Board

Critical Thinking 800

A 77 year old lady becomes increasingly confused so her family takes her to see the doctor. Her vitals are T-37.7*C (PO), BP-109/68, HR-108 and RR-18. The nurse takes a rectal temperature and it’s T-38.2*C (PR). What does this finding mean?

Back to the Board