Vital Signs Notes PDF

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Summary

Vital signs notes....

Description

Measuring Vital Signs vital signs: objective clinical measurements that include T/P/R/BP/O2 sat/pain Normal temperature: 36.5 - 37.5 - peripheral - oral (5 years - adult) - axilla (birth - adult) - tympanic (2 years - adult) - temporal artery (2 years - adult) - rectal (birth - 2 years) - core (invasive) - arterial line (radial or femoral) - geriatric considerations: - tend to have lower body temperatures so may not see an increase in temperature to alert you something is going on with them Pulse - rate — normal: 60-100 bpm - abnormal: - bradycardia - tachycardia - rhythm: - normal: regular - abnormal: irregular - equality Strength/Amplitude Grading Number

Name

Description

0 None

No pulsation is felt with extreme pressure

1 Thready/weak

Not easily felt; disappear under slight pressure

Number

Name

Description

2 normal

Easily felt, disappears under moderate pressure

3 Full/increased

Strong: disappears under moderate pressure

4 Bounding

Strong and does not disappear with moderate pressure

Pulse site to assess/grade: - radial - brachial - carotid - apical - femoral - popliteal - posterior tibialis - dorasalis pedis Respirations - pay attention to the RR of your pt - Assess: - rate - rhythm - depth - pattern - normal: no use of accessory muscles - nasal flaring - pursed lips - cyanosis; orthopnea; or confusion Factors that relate to RR - exercise - medications - anxiety - pain - body position O2 Saturation - oxygen carrying capacity in the blood (%) - utilize a pulse oximeter to obtain saturation reading - normal: >97%

- for patients with chronic conditions affecting -

breathing may be to keep sats at 90% if sats go below 90% assess for confusion

Blood Pressure - systolic - diastolic - normal: or equal to 110

Isolated systolic HTN (ISH)

>140

and/or

< 90

Mercury sphygmomanometer is best noninvasive measure of BP, but toxic, have column. Aneroid - does not contain mercury, have dial. Oscillometric devices (automatic vital machines) measure BP but don’t require auscultation. Accuracy questionable. Can be compromised by irregular HR. When reading is extremely high or low, confirm with auscultatory method. BP cuff - inflatable bladder must cover 80% of upper arm circumference - width should be at least 40% of circumference of arm - too narrow = overestimation - too wide = underestimation - no bulky clothing underneath auscultatory gap: a silent interval in the middle of the Korotkoff sounds during which the pulse wave can still be felt - avoided by inflating extra 20-30 mmHg Checking Orthostatic hypotension

- first check in sitting position - check again in 1-5 minutes when standing Abbreviations in Vital Signs Charting Abbreviation

Defintion

T

Temperature

C

Celcius

F

Farenheit

P

Pulse

bpm

Beats per minute

R

Respirations

SpO2

Oxygen saturation as measured by pulse oximetry

O2

Oxygen

BP

Blood pressure

mmHg

Millimetres of mercury

HTN

hypertension

Q

every

Min

Minute

H

Hour

Some examples of Medication Classes and Potential Vital Signs Effects Medication

Potential Effect on Vital Signs

Opiate analgesics (e.g. morphine)

Lowered respiratory rate, lowered pulse, lowered BP, or orthostatic hypotension

Cardiac glycosides (e.g. digoxin)

Lowered HR, lowered BP

Beta-adrenergic blockers (e.g. Betalol)

Lowered HR, lowered BP

Medication

Potential Effect on Vital Signs

Antihypertensives (e.g. calcium channel, blockers, angiotensinconverting enzyme inhibitors, angiotensin receptor blockers, etc.)

Lowered BP, possible elevated HR, potential for orthostatic hypotension

Antipyretics (e.g. acetaminophen, acetylsalicylic acid [ASA])

Potential to lower body temperature to normal if the patient has a fever

**Review steps for vital signs at end of chapter....