Basic Observations Flashcards
What is the pulse?
A pressure wave which is transmitted through the arterial tree and the rhythmic expansion and recoil of the elastic arteries as the left ventricle ejects blood into the circulation
What are the indications to measure a pulse?
- On admission (baseline)
- To monitor deviations
- To monitor wellbeing
- During labour
- During auscultation
- PN assessment (if required)
- SROM
What does pulse rate mean?
Number of beats per minute
What does pulse volume mean?
The force with which the heart beats, indicating the amount of blood being pumped through the heart. Can be:
- Strong
- Full/bounding
- Weak /thread
What does pulse rhythm mean?
The spacing of the heartbeats (regular/normal or irregular/intermittent)
What are the three main places to take a pulse?
Carotid (neck)
Brachial (elbow)
Radial (wrist)
How long should we measure a pulse for?
1 minute
What is tachychardia?
Heart rate over 100bpm.
What is bradychardia?
Heart rate below 60bpm.
What is a normal pulse range?
Between 60-100bpm
How does maternal BPM change during pregnancy?
Increases 10-20bpm from 7-32 weeks gestation. Lowers slightly during third trimester but increases during labour.
What is the procedure for taking a pulse reading?
- Obtain informed consent
- Ensure woman is comfortable
- Wash hands
- Locate radial artery and press index and middle finger gently but firmly while supporting the arm
- Count for 60 seconds
- Repeat (can count for 30 seconds and double)
Try and use the same wrist and same HCP for continuity and to reduce mistakes
What is bradypnoea and tachypnoea?
Bradypnoea - Resp rate less than 12bpm
Tachypnoea - Resp rate above 20bpm
What is the normal range for newborn respiratory rate?
30-60bpm
What is the normal range for adult respiratory rate?
12-20bpm
What is the procedure for measuring respiratory rate?
- Count breaths by observing chest movement over 60 seconds
2. Record
Why might you NOT obtain informed consent for measuring respiratory rate?
It makes people aware of their breathing and may affect the findings
What is the normal range for temperature?
36.0-37.5 degrees Celsius.
Where are the 5 temperature recording sites?
- Skin
- Mouth (under tongue)
- Rectal
- Axillary (armpit)
- Ear (tympanic membrane)
A temperature of 38 degrees Celsius can indicate what?
Low grade pyrexia - mild infection, allergy, labour
How does the body adapt to heat loss?
Shivering
Goose bumps
Behavioural changes
How does the body adapt to heat production?
Sweating
Flushed skin
Behavioural changes
What is the procedure for measuring temperature?
- Obtain informed consent
- Wash hands
- Place disposable cover on thermometer
- Place thermometer in correct position and press start (preferably in same position to ensure continuity)
- Remove when the instrument indicates to do so
- Read temperature and document findings
- Discard probe cover
