Chapter 3,4,6 : Techniques/Equipment and Expected Vital Signs Flashcards
Infection Control
discipline concerning controlling and decreasing the risk of spreading infections
Standard Precautions
minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered
Inspection
data obtained by a visual examination of the body, including body movement and posture, as well as that obtained by smell
Palpation
using the hands to feel texture, size, shape, consistency, pulsation, and location of certain parts of the patient’s body
Percussion
performed to evaluate the size, borders, and consistency of internal organs
- doing a sort of hitting motion to evaluate the internal organs
Tympany
heard over the abdomen
- occurs as a result of distension
- abdomen sounds like a drum
(stomach, and gas bubbles)
Resonance
heard over healthy lung tissue
- hollow
Hyperresonance
heard in overinflated lungs
- heard in various abnormal pulmonary conditions
- booming
Dullness
heard over the liver
- thudlike
Flatness
heard over bones and muscle
- extremely dull
Auscultation
listening to sounds within the body
Supine
flat on your back
- most relaxed position and provides easy access to pulse sites
Dorsal Recumbent
flat on back with knees raised (on table) and bent outwards
Sims
slightly on stomach with left leg bent and right leg straight
- used to expose rectal area
Prone
completely on the stomach
- used to assess the extension of the hip joint
Lateral Recumbent
lay on your side
- used in detecting murmurs
Tripod Position
sit slightly forward, bracing the arms on your knees
- helps open up the airways making it easier to breathe
Systolic Blood Pressure
the maximum pressure exerted on arteries when the ventricles contract or eject blood from the heart
Diastolic Blood Pressure
the minimum amount of pressure exerted on the vessels; this occurs when the ventricles relax and fill with blood
Pulse Pressure
the difference between the systolic and diastolic pressure
- the force the heart generates each time it contracts
Orthostatic Hypotension
low blood pressure when you stand up from sitting or lying down
Oscillometer Blood Pressure
blood pressure reading you get from an automatic cuff device
Korotkoff Sounds
sounds you hear from the blood pulsating through the artery again
Physiologic
relating to the functioning of living bodies or their parts
Diurnal Variations
fluctuations that occur during each day
Oxygen Saturation
percentage of oxygen in a person’s blood
What are the Vital Sign Ranges for a Infant ?
RR: 30-60
HR: 120-160
What are the Vital Sign Ranges for a Toddler ?
RR: 24-40
HR: 90-140
What are the Vital Sign Ranges for a School-Age Kid ?
RR: 18-30
HR: 75-100
What are the Vital Sign Ranges for a Adolescent ?
RR: 12-16
HR: 60-90
BP: 110-131/64-83
What are the Vital Sign ranges for a Adult ?
RR: 12-20
HR: 60-100
BP: <120/<80
What is the Temp range for Ped and Adult patients ?
96.4-99.1 F
What is a General Inspection and what does it include ?
observations you make from the very beginning (the moment you meet the patient)
- Appearance
- Body Structure and Position
- Body Movement
- Emotional and Mental Status
When taking the pulse of an infant/kid where do you take it’s pulse and for how long ?
the apical pulse and for the full 60 secs
True or False
Is an irregular respiratory rate normal in infants ?
True
What causes BP increases ?
- Age: increases as you age
- Emotions: anxiety, anger, stress
- Pain
- caffeine, smoking 30 minutes before
- obesity
What causes False Low BP ?
- arm above heart level
- cuff is too wide
- not inflating cuff enough
- deflating cuff too fast
- pressing diaphragm too firmly on brachial artery
What causes False High BP ?
- patients legs crossed
- arm below heart level
- cuff bladder is too narrow
- reinflating of cuff without complete deflation
- failure to wait 1-2 mins before repeat
In Fluid Retention, what # of fluid increases the # of weight ?
1 L of fluid increases weight by 2.2 lbs
What is Somatic (parietal) Pain ?
caused by inflammation of structure
- pain is sharp and well-localized
What is Neuropathic Pain ?
nerve pain
- shooting, tingly, numbness, zaps
What is Referred Pain ?
located away from the tissue damage itself
- pain in shoulder can mean a heart attack
What is Visceral Pain ?
dull pain that is poorly localized
- arises within the abdominal organs
What does OLDCARTS mean ?
O: Onset (When did it begin?)
L: Location (What area is it in?)
D: Duration (How long has it occurred?)
C: Characteristic (How does it feel?)
A: Aggravating/Alleviating (What it feel better or worse?)
R: Related Symptoms (Other symptoms present?)
T: Treatment (What treatment have you tried to make it feel better?)
S: Severity (On a scale from 0-10 how does it feel?)
What pain chart is most appropriate for a Nonverbal Pediatric Patient ?
- either are nonverbal or are babies who can’t speak
FLACC
- used in 2 months to 7 years
- is a chart that assigns points by behavioral observations of the child
What pain chart is good for kids at a speaking age ?
Wong-Baker FACES rating scale
What pain chart is appropriate for a nonverbal adult ?
NVPS
- is a chart that assigns points by behavioral observations through a adult assessment
Do Chronic patients experience a change in their vital signs due to pain ?
not usually because their body is accustomed to the pain
When taking a tympanic temp in an infant/child how do you pull the ear helix ?
tug ear helix down
When taking a tympanic temp in an adult how do you pull the ear helix ?
tug ear helix up
Why is the axillary temp not as accurate ?
poorly reflects core temp because it’s not near any major blood vessels
- 1 degree lower than oral temp
What are some pediatric considerations when taking vital signs ?
- if less than 6 months have them on table/bed
- if greater than 6 months have them on caregivers lap
- do HR and RR before you undress so they aren’t upset which will affect vital signs
- do non-invasive vitals so you don’t get an inaccurate reading (like do HR and RR before assessing eyes)
Where do men and babies usually breathe from ?
more abdominal breathers
What are the different BMI levels ?
Underweight: <18.5
Healthy: 18.5-24.9
Overweight: 25-29.9
Obese: >30
What surface of your hand is most sensitive to vibration ?
ulnar
What surface of your hand is most sensitive to temperature ?
dorsal
What is light palpation used for ?
skin, pulsations, and tenderness
- 1 cm deep
What is deep palpation used for ?
organ size, and contour
- 4 cm deep
What is the diaphragm of the stethoscope used for ?
used for high-pitched sounds like breath, bowel and normal heart sounds
What is the bell of the stethoscope used for ?
used to hear soft, low-pitched sounds like extra heart or vascular sounds (bruit)
- concave in shape
- press lightly or it will function as a diaphragm
What are some considerations for oral temperature ?
- for 5 years- adult
- in adults: smoking, eating, drinking can impact for 10 mins
- place in posterior sublingual pocket
- measures temp of carotid artety
What are some causes of hyperthermia in newborns ?
- viral/bacterial infections
- dehydration
- exposure to heat
What are some causes of hypothermia in newborns ?
- environmental exposure
Where do you listen for the apical pulse in adults ?
5th ICS MCL
(mitral)
How do you measure cuff size for manual BP ?
- should measure between olecranon (shoulder) and acromial process (elbow)
- Cuff bladder length should be 80-100% of arm circumference
- Cuff bladder width should be about 40% of arm circumference
