Basic Observations Flashcards
What are baseline observations? (8)
Respiratory rate, rhythm and depth
Pulse rate, rhythm and volume
Capillary Bed Refill (CBR)
Pulse oximetry
Blood pressure
Blood glucose
3 lead ECG
Conscious Level (AVPU)
What does AVPU stand for?
Alert
Verbal
Pain
Unresponsive
What should be done if a patient has reduced level of consciousness?
Do a baseline observation including a head to toe assessment
When should baseline obs be taken earlier on?
If the primary survey was positive
When would a baseline obs be taken later on?
If the primary survey was negative meaning the results fall into normal range for he patient, we would do history taking before conducting baselines obs.
What is an adults normal respiratory rate?
12-20 breaths per minute
What is the normal respiratory rate for birth to 1 year?
30-40 breaths per minute (bpm)
What is the normal respiratory rate for a 1 year old?
25-35 bpm
What is the normal respiratory rate of a child 2-5 years old?
25-30
What is the normal respiratory rate for a child 5-12 years old?
20-25 bpm
What factors increase the respiratory rate? (5)
Exercise Stress/anxiety Fever Hypoxia (lack of oxygen in the tissues) Pain
What is tachypnoea?
Abnormally fast respiratory ate above 20 breaths per minute (bpm)
What factors decrease the respiratory rate? (4)
Opiates (eg. Morphine and heroin)
Hypothermia (cold temp)
Depression of CNS
Severe fatigue
What is bradypnoea?
Abnormally slow respiratory rate less than 12 breaths per minute
What else would you have to document other than breaths per minute in terms of respiration?
Where respiration is normal, shallow or deep
When would a pulse oximetry be used?
If the patient is presenting with a respiratory problem or appears short of breath
It can also be used before and after oxygen therapy as a baseline and indicator of efficacy of treatment
What is a pulse oximetry? (4)
A device that uses a red and infrared light to measure the peripheral ratio of oxyhaemoglobin (haemoglobin with oxygen attached) to haemoglobin (a protein in erythrocytes(RBCs) that can carry oxygen and other gases).
The device shines the red and infrared light through the tissues with oxyhaemoglobin absorbing more infrared light and haemoglobin more red light.
The sensor detects the amount of absorbed light and displays the result as a percentage on the machine.
It also measures pulse rate, although this should not replace an actual pulse check because it does not give an indicator of rhythm or volume
What is normal oxygen saturations?
94-98%
What is oxygen saturation documented as?
SPO2
Saturation Potential of Oxygen
How do you use a pulse oximeter? (5)
Turn on the machine
Place probe into the area to be measured (usually a finger, but could be a toe or ear lob)
Wait for the readings to settle on the machine (they can fluctuate for a short time after application of the probe)
Check the pulse to ensure it matches the reading on the machine
As long as they match, record SPO2 reading
What factors can affect the accuracy of pulse oximetry?
Nail varnish Cold extremities Poor peripheral circulation Motion (shaking etc) Strong ambient lighting Carbon monoxide poisoning Dark skin
What are some limitations of pulse oximetry? (8)
Colour interferences:
Nail polish said to affect validity of SPO2 measurements.
Carbon monoxide poisoning:
Due to affinity of CO to haemoglobin, CO would cause oxygen to disassociate from haemoglobin and would instead combine to form carboxyhaemoglobin. Pulse oximeters are unable to detect this change from oxyhaemoglobin to carboxyhaemoglobin resulting to inaccurate results being displayed
Poor peripheral circulation:
Being cold or having hypotension can cause poor pumping of liquids into organs and tissues (perfusion), affecting pulse waves that that are detected by the pulse oximeter. As well as, blood levels below 80mmHg systolic can lead to inaccurate and unreliable results of pulse waves
Motion artefact:
Tremors, seizures and shivering can effect signal detection of pulse waves
High intensity lighting:
The light would interfere with the probe leading to false readings. This can be overcome by reducing bright light sources.
Age, sex and dark skin:
These factors are stated not to interfere with SPO2 readings, but recent studies have shown that dark skin can reduce oxygen sats that are recorded. But further research is required to support this claim
High bilirubin levels in hepatitis and cirrhosis of the liver and some blood dyes used in angiography:
The problem with these is that it can cause the colour of the blood
Naturally fast pulse rate:
Conditions that affect pulse may reduce accuracy. For instance, atrial fibrillation
When taking pulse, what should be considered?
The pulse rate
Rhythm (steady or erratic?)
Volume (weak or strong?)
What is the normal pulse rate of an adult?
60-100 beats per minute (bpm)
What is the normal pulse rate of a child from birth to 1 year?
110-160bpm
What is the normal pulse rate of a child at the age of 1?
110-150bpm
What is the normal pulse rate of a child from the age of 2 to 5 years?
95-140bpm
What is the normal pulse rate of a child from the age of 5-12?
80-120bpm
What factors increase pulse rate?
Exercise
Stress/anxiety
Excitement
Cardiac abnormalities
Circulatory abnormalities (shock or dehydration)
Hypoxia (lack of oxygen)
Fever
Pain
Medication
What are some factors that decrease pulse rate?
Relaxation
Cardiac abnormalities
Medication
Can be normal in athletes
What factors can delay capillary bed refill?
Shock Dehydration Fractures Blood clots Heart conditions Decreased peripheral perfusion
What is blood pressure?
It is the force per unit area exerted on a vessel wall by the contained blood. It is expressed in millimetres of Mercury (mmHg)
What does systolic mean?
Pressure against the arterial walls when the heart contracts
What is diastolic?
Pressure against the arterial walls when the heart relaxes
What is the gap between the systolic and diastolic pressure known as?
Pulse pressure
What are two factors of blood pressure?
Elasticity of the arteries near the heart
The volume of blood that is forced into the arteries
What is normal BP?
120/80mmHg
The systolic always always written above the diastolic
Where does BP range?
110/60mmHgb to 140/90mmHg
What is the BP for someone with hypertension (high BP)?
Over 140/90mmHg
What is the BP for someone who is hypotensive (low BP)?
Below 100mmHg
What is the different between the systolic and diastolic called?
The pulse pressure
What BP can indicate a poorly functioning heart?
Readings less than 40mmHg or greater than 60mmHg
What factors can effect BP?
Medical conditions like diabetes
Age
Weight
Diet
Exercise
Alcohol
Smoking
Recreational drugs
Pregnancy
Anxiety
Time of day
Position of the patient - from lying, to sitting, to standing
Pain
Why is it that BP increases when you suddenly stand up?
There is slight restriction of the arteries and blood pressure and therefore the blood to vital organs is maintained
When taking BP, where should the arm be positioned?
In line with the sternum
How would you take a manual BP? (14)
Explain the procedure and gain consent
Expose upper arm and ensure clothing is not restrictive if rolling up a sleeve. Cannot be done over clothes.
Select correct cuff size
I’d cuff does not have range markers, ensure 80% of cuff is covering arm leaving 20% over. It should also cover 40% of patients upper arm
Locate brachial artery
Apply cuff around arm, with arrow directly above brachial artery
Locate the radial pulse and inflate cuff until pulse disappears. Make note of reading
Deflate cuff
Place stethoscope over brachial artery
Inflate cuff 20mmHg over the previous value
Slowly deflate cuff about 2mmHg every second
Make note of when you hear distinct tapping sounds (systolic reading)
Make note of when all sounds disappear (diastolic reading)
Quickly deflate any remaining air and remove equipment
What is the normal systolic BP for a child aged from birth to 1?
70-90 mmHg
What is the normal systolic BP for a child aged 1 year?
80-95 mmHg
What is the normal systolic BP for a child aged 2-5 years?
80-100 mmHg
What is the normal systolic BP for a child aged 5 years?
90-100mmHg
What is the normal systolic BP for a child aged 6-12 years?
90-110 mmHg
What is normal body temperature?
Between 36-37.5 degrees Celsius
What temperature is considered hypothermia?
Below 35 degrees Celsius
What temperature is considered pyrexia or hyperthermia?
Above 37 degrees Celsius
When would you use a Tempa-DOT measurement and how would you use it?
When assessing the temp of an infant because the tympanic thermometer may be too large for their ears.
It is placed under the tongue or under the arm (axilla) and changes colour in response to temp
What is normal blood glucose?
5-7mmol/L
What is considered hypoglycaemia?
Blood glucose below 4 mmol/L
What is considered hyperglycaemia?
Blood glucose above 7 mmol/L
What can cause blood glucose to drop?
Exercise Alcohol Insufficient food Too much insulin Illness (mainly children)
What can cause blood glucose to rise?
Insufficient insulin (in diabetic patient)
Illness or infection
When should testing blood glucose be considered?
Patients with altered consciousness
Diabetes
Convulsions
Collapse
Alcohol consumption
What is the procedure of taking blood glucose reading? (8)
Prepare equipment
Gain consent and ask patient to wash their hands or swab the area
Wash your hands and put in gloves
Use lancet to take drop of blood
Dispose of sharp in sharps bin
Introduce end of strip to drop of blood
Wait for machine to draw up blood and display reading
Offer gauze to stem any bleeding