What are the main vital signs?

1. HR

2. BP

3. Body temp

4. respiration rate

(5.) sometimes pain is referred to as a vital sign.

Oral: 96.8 - 99.3

avg = 98.6

Rectal: 97.8 - 100.3

pyrexia - above 100 degrees F

hyperpyrexia - above 106 degrees F

oral cavity

rectum

axilla

ear canal

occasionally the inguinal fold

1. time of day (temp usually lower in the AM)

2. Age (body temp decreses with age and is slightly increased in the very young)

3. environmental temp.

4. infection (temp increases)

5. physical activity (body temp increases)

6. emotional status

7. site of measurement (higher rectally, lower in the axilla area)

8. menstrual cycle (body temp higher at time of ovulation)

9. oral cavity temp (body temp reading may actually reflect oral cavity temp is something hot or cold was imbibed in the last 14-30 mins)

what is the normal range for resting pulse?

(adult, newborn, and child 1-7 yrs)

adult = 60-100 beats per min

newborn = 100-130 bpm

child age 1-7 = 80-120 bpm

1. age (people older than 65 yrs may exhibit a decreased pulse rate, whereas adolscents and younger usually exhibit an increased rate)

2. gender (males usually slightly lower than females)

3. environmental temp. (pulse rates usually increase with increased temp, and decrease with lower temps)

4.  infection (pulse tends to increase with major infectious process)

5.  physical activity (normally pulse rate should rise with increase in physical activity, plateau at a steady state of exercise, then decrease as exercise declines)

6. emotional status (pulse rate increases during episodes of high stress, anxiety, or emotion [like anger or fear], and may decrease when the person is asleep or in a state of extreme calm)

7. medications (usually meds are to decrease pulse rate)

8. cardiopulmonary disease (hypertension/hypotension)

9. physcial conditioning (people who perform vigorous, sustained aerobic exercise will exhibit a lower-than-normal pulse rate)

tachycardia - greater than 100 bpm (rapid HR)

bradycardia - fewer than 60 bpm (slow HR)

1. temporal (anterior and adjacent to ear)

2. carotid (inferior to angle of mandible and anterior to SCM muscle)

3. brachial (medial to biceps in antecubital fossa)

4. radial (at wrist in volar forearm medial to styloid process of radius)

5. femoral (at the femoral triangle slightly lateral and anterior to inguinal crease

6. popliteal (midline of posterior knee between tendons of hamstring muscles)

7. dorsal pedal (along midline or slightly medial on dorsum of foot [in between 1rst and 2nd metatarsals])

8. posterior tibial (medial aspect of foot inferior to medial malleolus)

birth to 3 months: 85-90/35-65

3 months to 1 year: 90-100/60-67

1-4 yrs: 100-108/60

4-12 yrs: add 2 mmHg per year to 100 mmHg/60-70

PREHYPERTENSION: 120-139/80-89

STAGE 1: 140-159/90-99

STAGE 2: 160-179/100-109

STAGE 3: 180-209/110-119

STAGE 4: greater than 210/ greater than 120

(all numbers expressed in mmHg)

Describe the 5 Korotkoff's sounds

1. the first faint, clear tapping sounds are detected and gradually increase in their intensity.  Initial indication of of systolic pressure in an adult. 

2. the sounds heard have a murmur or swishing quality to them

3. the sounds become crisp and louder than those previously heard

4. there is a distinct and abrupt muffling of the sounds until a soft, blowing quality is heard.  thsi phase is the initial indication of the diastolic pressure and is the best indicator of diastolic pressure in adults, according to the American Heart Association

5. the sounds essentially disappear totally.  the phase is also referred to as the "second diastolic pressure phase"

1. age

2. physical activity (systolic pressure should gradually increase with exercise, plateau as exercise intensity plateaus, and then gradually decrease as exercise intensity declines; it should return to normal within 3-5 minutes after termination of exercise; the diastolic pressure should remain relatively unchanged throughtout the exercise period, although and increase of 10-15 mmHg is not uncommon; an increase of more than 15 mmHg constitutes abnormality.)

3. emotional status (BP will increase during episodes of high stress, anxiety, or emotion)

4.  medications (increase or decrease depending on meds)

5. size and condition of arteries (arteries that have a reduced lumen size will produce an increased BP value)

6. arm position

7. muscle contraction (use of arm muscles may increase BP measurement)

8. blood volume (BP decreases when there is a loss of blood and increases with an increase in blood volume)

9. dehydration (a significant decrease in body fluids may cause low BP)

10. cardiac output (SBP increases with increased cardiac output)

11.  site of measurement (BP measurements are generally higher in left upper extremity than in the right upper extremity; also, if the thigh is used, the SPB is usually higher than that found in the arm due to use of a widder bladder in the cuff)

12-18 respirations per minute for adults

30-50 resp/min for infants

abnormal for adults = above 20 or below 10 resp.min

define following terms:

1. dyspnea

2. rales

3. stridor

4. apnea

5. orthopnea

1. labored breathing

2. abnormal breathing sound

3. abnormal breathing sound

4. absence of breathing

5. difficulty breathing while recumbent

1. age (both very young and very old people have higher respiratory rates)

2. physical activity (RR is higher during exercise --> rate and depth of respiration increase))

3.  emotional status (RR is higher during episodes of high stree/anxiety --> rate and depth of respiration increase)

4. air quality

5. altitude (higher altitudes cause the RR to increase until person is acclimated)

6. disease (disease that affects various components of the pulmonary system usually increase the RR and may also increase depth of respiration)

List the structure associated with the following type of pain:

1. cramping, dull, aching

2. sharp, shooting

3. sharp, bright, lightning-like

4. burning, pressure-like, stinging, aching

5. deep, nagging dull

6. sharp, severe, intolerable

7. throbbing, diffuse

1. muscle

2. nerve root

3. nerve

4. sympathetic nerve

5. bone

6. fracture

7. vasculature

1. simple descriptive pain distress scale

2. 0-10 numerical pain distress scale

3. visual analog scale

4. thermometer pain rating scale

5. faces pain rating scale (for children)