Chapter 11

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  1. Vital Signs
    • Respiration
    • Pulse
    • Skin
    • Pupils
    • Blood Pressure
    • Pulse Oximetry
  2. Baseline Vital Signs
    The first set of measurements you take, to which subsequent measurements can be compared
  3. Sphygomomanometer
    Blood pressure cuff
  4. Normal Respiration
    Involves average chest wall motion, which is at least 1 inch of expansion in an outward direction
  5. Shallow Respiration
    Indicated by only slight chest or abdominal wall expansion upon inhalation
  6. Labored Respiration
    Where the patient is working hard to breathe, is indicated by an abnormal sound of breathing that may include grunting or stridor(a harsh high pitched sound);use of accessory muscles
  7. Noisy Respiration
    May include snoring, wheezing, gurgling, crowing, or stridor
  8. Carotid Artery
    On either side of the neck in the groove between the trachea and the muscle mass
  9. Femoral Artery
    In the crease between the lower abdomen and the upper thigh
  10. Radial Artery
    Proximal to the thumb on the palmar surface of the wrist
  11. Brachial Artery
    On the medial aspect of the arm, midway between the shoulder and the elbow between the biceps and triceps muscles
  12. Popliteal Artery
    In the crease behind the knee
  13. Posterior Tibial Artery
    Behind the medial malleolus (ankle bone)
  14. Dorsalis Pedis Artery
    On the top of the foot on the great-toe side
  15. Strong Pulse
    Refers to a pulse that is both full and normally strong
  16. Weak Pulse
    Doesn't feel full or may be difficult to find and palpate
  17. Regular Pulse
    A normal pulse that occurs at regular intervals with a smooth rhythm
  18. Irregular Pulse
    One that occurs at irregular intervals
  19. Pulsus Paradoxus
    A decrease in the strength of the pulse during the inspiratory phase of the patient
  20. Conjunctiva
    Mucous membranes that line the eyelids
  21. Paleness or Pallor
    May be a sign of extreme vasoconstriction, blood loss, or both
  22. Blue-gray or Cyanosis
    Indicates inadequate oxygenation or poor perfusion
  23. Red Color or Flushing
    May be a sign of heat exposure, peripheral vasoconstriction, or very late finding in carbon monoxide poisoning
  24. Yellow Color Jaundice
    May indicate liver disease
  25. Mottling
    Discoloration similar to  cyanosis but with a blotchy pattern

    May be seen in some shock patients or patients with blood pooling in the extremities for a long period of time
  26. Diaphoresis
    Profuse sweating
  27. Dilated Pupils
    May indicate cardiac arrest or the use of certain drugs, including LSD, amphetamines, atropine, and cocaine
  28. Constricted Pupils
    May indicate a central nervous system disorder, the use of narcotics, glaucoma medications, or a brightly lit environment
  29. Equality of Pupils
    Unequal size may indicate a stroke, head injury, injury to the eye or nerve that controls the pupil
  30. Pupil Reactivity
    Pupils that remain midsize may indicate cranial nerve damage
  31. Systolic Blood Pressure
    The amount of pressure exerted on the walls of the arteries during the contraction and ejection of blood from the left ventricle
  32. Diastolic Blood Pressure
    The amount of pressure on the artery walls while the ventricle is at rest and not contracting
  33. Pulse Pressure
    The difference between the systolic blood pressure and diastolic blood pressure

    • <25% of systolic would be considered a narrow pulse pressure
    • >50% of systolic would be considered a widened pulse pressure
  34. Methods of Measuring Blood Pressure
    Auscultation: listening for the systolic and diastolic sounds through a stethoscope

    Palpation: feeling for the return of the pulse as the cuff is deflated
  35. Orthostatic Vital Signs Test AKA Tilt Test
    Patient with suspected volume loss

    Place patient in supine position and measure blood pressure and heart rate, then stand patient up and after 2 mins reassess blood pressure and heart rate
  36. Pulse Oximetry
    Method of detecting hypoxia in patients by measuring oxygen saturation levels in the blood
  37. Open-ended Questions
    Requires the patient to respond with a descriptive or more detailed answer
  38. Closed-ended Questions
    Often a rapid-fire-type question that requires a "yes" or "no" answer
  39. SAMPLE History
    • Signs and Symptoms
    • Allergies
    • Medication
    • Pertinent Past History
    • Last Oral Intake
    • Events leading to the injury or illness
  40. OPQRST
    • Onset
    • Provocation
    • Quality
    • Radiation
    • Severity
    • Time
Card Set
Chapter 11
Baseline Vital Signs, Monitoring Devices, and History Taking
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