Download Patient Assessment: Vitals

Monday, June 9, 2014

Let’s review the 4 vital signs!
 Heart rate
 Respiratory rate
 Blood pressure
 Temperature

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

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

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

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)

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

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!
Heart
Rate
Respiratory
Temperature
Rate
Blood
Critical
pressure thinking
100
100
100
100
600
200
200
200
200
700
300
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300
300
800
400
400
400
400
500
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500
500

What is the normal heart range for an adult?

60-100
Back to the Board

What is the normal heart rate range for an
infant?

110-180 BPM
Back to the Board

What is tachycardia?

Increased heart rate over the normal range
Back to the Board

There are 11 sites to palpate pulse. 8 were in the
last presentation: name 3 of these sites.

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Apical
Radial
Femoral
Popliteal
Brachial
Carotid
Dorsalis pedis
Temporal
Back to the Board

What are the 4 components of documenting
of heart rate?

1) Site
2) Rate
3) Rhythm
4) Depth


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Back to the Board

How is respiratory rate measured?

Respirations per minute
Back to the Board

What is the normal range for a child?

20-25 respirations per minute
Back to the Board

Name 2 of the 3 components of documenting
respiratory rate.

1) Rate
2) Rhythm
3) Depth

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Back to the Board

What is the process in which your diaphragm
flattens and chest expands allowing
exchange of oxygen in your lungs?

Inhalation
Back to the Board

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
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What is the normal range for temperature?

35.0-37.5*C
Back to the Board

What site is denoted by the letter “O”?

Oral temperature site
Back to the Board

Name the 4 sites to take temperature.

Oral
Rectal
Axillary
Tympanic
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Back to the Board

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

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

What is the normal blood pressure of an
adult?

120/80
Back to the Board

What is the unit of measure for blood
pressure?

mmHg or “millimetres of mercury”
Back to the Board

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

What is the normal blood pressure of an
infant?

90/55
Back to the Board

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

BEFORE taking vital signs, what are some
observations you can make that may affect
how you interpret your findings?
Back to the Board

A 20 year old man comes into the ER with a
stab wound to the stomach. His vitals are T37.2*C (PO), BP-88/60, HR-121, RR-24.
Explain the relationship between his blood
pressure and his heart rate.
Back to the Board

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), BP109/68, 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