CLASS 2 - VITAL SIGNS Flashcards
What are the special considerations you would take when performing an assessment of an infant (0-1 or 2y) in terms of:
- positioning
- preparation
- sequence of assessment
The major task to achieve is their trust + increase their comfort. A parent should always be present to understand normal growth + dvlpmnt and for the child’s feeling of security.
Positioning
- supine on padded examination table.
- Once the baby can sit without support (~6mo), as much of the examination as possible should be performed while the baby is in the parent’s lap.
- by ages 9-12 mo the baby is acutely aware of their surroundings. Anything outside of their range of view is “lost”, so keep parents in full view.
Preparation
- maintain warm environment
- have parents remove clothing of infant (leave diaper on if a boy)
- keep hands + stethoscope warm
- use soft, crooning voice
- eye contact
- smile
- smooth + deliberate mvmts
- offer pacifier or bright toy to distract baby when being fussy
- let them touch the stethoscope
Sequence
- if baby is sleeping, listen to heart, lung, and abdominal sounds first.
- perform the least distressing steps first and save invasive steps (examining eye, ear, nose, throat) until last
- elicit moro (startle) reflex at end of exam bc it may cause baby to cry
What are the special considerations you would take when performing an assessment of a toddler (1 or 2 - 3y) in terms of:
- positioning
- preparation
- sequence of assessment
The major task to achieve is their trust + increase their comfort. A parent should always be present to understand normal growth + dvlpmnt and for the child’s feeling of security.
Positioning
- sitting up in parent’s lap for all of examination
- when the toddler must be supine (for abdominal examination), move chairs to sit knee-to-knee with parent, and have toddler lie in parents lap w toddler’s legs in your lap
Preparation
- security object such as a blanket or teddy bear is helpful
- greet child + accompanying parent by name. For a child 1-6 yo, focus on parent more to allow the child to gradually warm up to you and size you up, then turn your attention gradually to the child, at first to a toy or object they are holding, or compliment the child’s clothes or hair.
- signs the child is ready: eye contact, smiling, talking to you, accepting a toy or piece of equipment
- they do not like to be w/o clothing. Have the parent undress the child one piece at a time
- do not offer the child a choice as they like to say “no”. Use clear, firm instructions.
- however, children like to make choices. Enhance autonomy when possible by offering limited options. “Should i listen to your heart next, or your tummy?”
- demonstrate procedures on parent or a plush toy
- praise child when they are cooperative
Sequence
- begin w games such as cranial nerve testing
- start w non-threatening areas
- save distressing procedures for last
What are the special considerations you would take when performing an assessment of a preschooler (3-6yo) in terms of:
- positioning
- preparation
- sequence of assessment
Children this age are often cooperative, helpful, and easy to involve. However, they fear any body injury or mutilation and so the child will recoil from invasive procedures.
Positioning
- 3 yo children: parent should be present, child may be held on parent’s lap during examination
- 4 or 5 yo will usually feel comfortable on the “big kid” examination table
Preparation
- don’t offer a choice when there isn’t one.
- enhance autonomy - limited choices when possible.
- allow child to play w equipment to reduce fears
- have them “help” you by holding equip
- use games (listening to teddy bear heart sounds, blow out penlight, etc)
- examine thorax, abdomen, extremities, and genitalia first
- assess head, eye, ear, nose, + throat last.
What are the special considerations you would take when performing an assessment of a school age child (6-12yo) in terms of:
- positioning
- preparation
- sequence of assessment
Positioning - sitting on examination table
Preparation - break ice w small talk about family, friends, sports, music, school; demonstrate equipment; children should undress on their own - leave underpants on, don a gown and use a drape
Sequence - H2T
What are the special considerations you would take when performing an assessment of an adolescent (13-18yo) in terms of:
- positioning
- sequence of assessment
Positioning - sitting on examination table, examine adolescent alone w/o parent or sibling present
Sequence - H2T, examine genitalia last
What are the special considerations you would take when performing an assessment of an older adult (60+)?
- positioning - needs to be organized + energy/time efficient –> sitting or lying; can be supine, semi-recumbent, semi-Fowler’s - HOB 30
- Pace of exam may need to be slowed w rest periods.
- Visual / hearing impairments v confusion - do not confuse them.
- do not startle your patient - announce what you are doing + ask for permission
What are some things you would assess in terms of a patient’s physical appearance?
age, sex, gender expression
LOC
Skin colour (is it even? Appropriate for their ethnicity? Redness?)
Facial features (any signs of distress? symmetrical face?)
What are some things you would assess in terms of a patient’s body structure?
stature, nutrition, symmetry, posturem position, body build, contour
What are some things you would assess in terms of a patient’s behaviour?
facial expression (does it match their mood + affect?)
mood + affect
speech (do they articulate clearly? rapid speech? disorganized? slow speech?)
dress (appropriate for the weather?)
personal hygiene (are they clean?)
–> tells us about coping and client’s ability for self care
What are some things you would assess in terms of a patient’s mobility?
Gait
ROM
Give a brief walk through of a full H2T assessment of a patient
Hair: no lumps, lesions, infestations
Head shape - normal cephalic?
If they wear glasses, what for? Ask them to take glasses off and examine pupils. Are they equal + round? Use penlight to be sure they react to light, make sure eyes accommodate bilaterally by making them look at the pen as you move it to their nose.
Pull down lower eye. Is conjunctiva pink? Is the sclera white?
EARS: any hearing aids? Any environmental factors like at work any loud noises, etc. Look inside ears for redness, drainage. Note any piercings. Any skin breakdown behind ears?
NOSE: ask patient to tilt head up + proceed to look inside nose for drainage, redness, signs of deviated septums. Have you had any trauma to the nose? Any surgeries? Ask patient to plug one nostril and breathe in. repeat on other side.
MOUTH: ask patient to open up + say ah. Look at mucous membranes in cheek – are they pink + moist? Are their teeth intact? Does their uvula rise + fall midline? Note their lip colour + any dryness.
NECK:
ROM: Cervical spine - ask patient to look up + down and to both sides.
Carotid arteries – check for carotid pulse
auscultate on neck
CHEST
Examine patient for laboured breathing (are they using accessory muscles?)
Auscultate for long sides on front (anterior) and back (posterior) side
Auscultate for heart sounds on anterior + posterior
Check for heart murmurs w/ bell of stethoscope
ARMS
• note lumps, legions, scars, radial pulse, capillary refill
• fingernails, signs of clubbing
Lay patient back, listen to pulse for 1 full minute
Since patient is laying down, check abdomen next. Lift patient’s shirt. Note contours of abdomen. Position of umbilicus. Any lumps, lesions, pulsations, scarring, hernias. Auscultate abdomen (aorta, all 4 quadrants for active bowel sounds)
Palpate areas of stomach + ask for pain, report any tenderness.
Check pulse on feet
Have patient lift up knees and check for edema on lower extremities
Sit patient up – check muscle strength on upper and lower extremities
What is crepitation?
Crunching / popping sensation/sound in tissue or joints
OTC account for what % of administered drugs
60%
Define homeostasis and give examples. Is it constantly present?
stability of systems that maintain life
pH, concentration of ions in ECF, osmolality , glucose levels, arterial oxygen tension
constantly present
Define allostasis and give examples. Is it constantly present?
Adaptation to changing internal + external environment (how our body adapts when we become sick) arterial BP, heart rate, body core temp, conc of circulating horomes, sleep-wake cycle, energy metabolism temporary process (ex - under stress)
Describe systemic circulation
LA / LV to aorta and body and back to RA / RV
arteries supply tissues w oxygenated blood, veins return blood to pulm circ
Describe pulmonary circulation
RA / RV –> pulm artery to lungs –> pulm veins to LA/LV
takes deoxy blood to lungs, reoxygenates it and returns it to systemic circ
What is the formula for Cardiac Output?
CO = HR x SV
expressed in L /min
What is cardiac preload?
- The volume of blood returned to the heart at the end of diastole that exerts pressure on the ventricle walls
- The filling force applied to the heart.
Describe the Frank-Starling Mechanism
when the heart stretches, it generates more force to effectively pump the increased load.
this has limits as the heart needs to stay elastic.
What is cardiac afterload?
- the pressure the ventricles must overcome to eject blood into the arteries.
- during contraction, the L ventricle must generate more pressure than aortic diastolic pressure
- also called SVR.
what is the relationship between afterload and stroke volume?
increased afterload can decrease stroke volume
What is the formula for MAP?
MAP = (SBP+DBP+DBP)/3
What MAP value is required to perfuse your brain? (aka the normal value)
65
What is the formula for BP?
BP = CO x SVR
or (HR x SV) x SVR
What are the 5 factors that control BP?
- CO
- Vascular resistance
- Volume
- Viscosity
- Elasticity of arterial walls
How does CO affect BP?
increased CO –> increased BP
decreased CO –> decreased BP
How does Vascular Resistance affect BP?
Increased resistance (vasoconstriction) --> increased BP Decreased resistance (vasodilation) --> decreased BP
How does Volume affect BP?
decreased volume (ex - hemorrhage) --> decreased BP increased volume (increased sodium and water retention, IVF overload)
How does Viscocity affect BP?
increased viscosity (increased hematocrit in polycythemia) –> increased BP
How does Elasticity of arterial walls affect BP?
increased rigidity, hardening as in arteriosclerosis (heart pumping against greater resistance) –> increased BP
What are the 6 vital signs?
Temperature BP pulse respirations oxygen saturation pain ***
Which vital signs reflect perfusion?
Which vital signs reflect gas exchange?
BP + Pulse
RR + O2 Sat
What are normal temperature ranges for:
- newborns
- pediatric patients
- adults
- older adults
newborns: 36.5-37.6
pediatric patients: 36-38
adults: 36-38
older adults: 36-37.2
which temperature is considered a critical value?
38.5
which body part controls temperature and acts as a thermostat mechanism?
how is this different in children?
the hypothalamus.
children until ~6 yo don’t have a fully developed hypothalamus
What is hyperthermia?
Elevated body temp as a result of the body’s inability to promote heat loss or reduced heat production (ex - heat stroke)
what is hypothermia?
which values indicate mild hypothermia?
moderate hypothermia?
severe hypothermia?
occurs when heat loss during prolonged exposure to cold overwhelms the body’s ability to produce heat.
mild: 34-36
moderate: 30-34
severe: < 30
An immunocompromised patient’s temperature has raised 1.5 degrees above their baseline temp. What does this imply?
This implies that the patient is febrile.
Identify the 5 routes of temperature measurement
Oral Axillary (under armpit) Rectal Tympanic membrane Temporal artery
what are the advantages of taking oral temperature? what are the disadvantages?
advantages: accessible site, no position changes required, comfortable for patients; provides accurate reading of surface temp and reflects rapid changes in core temp
disadvantages: readings easily affected by smoking, eating, oxygen delivery; not suitable for patients who have had oral surgery, suffered trauma, history of epilepsy, shaking chills; don’t use in infants + small children or in confused / unconscious / uncooperative patients; risk of exposure to bodily fluids
what are the advantages of taking axillary temperature? what are the disadvantages?
advantages: safe + non-invasive, appropriate for use in newborns and in uncooperative / unconscious patients
disadvantages: long measurement time, requires continous positioning by nurse, measurement time lags at sites of core temp, requires exposure of thorax which can result in temp loss, especially in newborns.
what are the advantages of taking rectal temperature? what are the disadvantages?
advantages: reliable when oral temperature cannot be obtained
disadvantages: measurement at this site lags behind core temperature changes; should not be used in patients w/ diarrhea, rectal surgery, a rectal disorder, or bleeding tendencies; site should not be used for routine measurement of vital signs in newborns; may be a source of patient discomfort, embarrassment, + anxiety; impacted stool alters readings; risk of exposure to body fluids; lubrication is required
what are the advantages of taking tympanic membrane temperature? what are the disadvantages?
advantages: site is easily accessible w/ minimal patient repositioning; temp can be obtained w/o disturbing/waking patient; provides core reading; measurement is unaffected by oral intake of food / fluids or by smoking; can be used for tachypneic patients w/o affecting breathing; can be used in newborns to reduce handling of infant + subsequent heat loss
disadvantages: measurement variable; hearing aids must be removed; site can’t be used in patients following surgery of ear or tympanic membrane; disposable probe cover comes in only 1 size; device doesn’t accurately measure core temperatures during + after exercise; accuracy of results influenced by size of probe; may be a problem in young children due to the small diameter of their ear canal; not possible to obtain continuous measurement; readings affected by ambient temp devices such as incubators, radiant warmers, + fans
what are the advantages of taking temporal artery temperature? what are the disadvantages?
advantages: takes less time to measure
reflects rapid change in core temp; site easy to access w/o changing patient’s position; measurement is comfortable, no need to remove clothing; useful measurement in premature infants, newborns, + children.
disadvantages: Measurement not effective through head covering (ex – dressing) or hair; Results affected by diaphoresis; Continuous measurement not possible; Fails to detect fever at the 2 critical temps of 38 or greater and 39 in children under 36 mo.
What are the 10 pulse sites
temporal carotid apical brachial radial ulnar femoral popliteal posterior tibial dorsal pedis
what is the one pulse site at which you cannot palpate simultaneously? why?
carotid. could cause patient to faint.
what is the difference between pulse and HR?
We palpate to find the pulse and document rate, force, and rhythm and translate that into a HR
What are normal heart rates for:
- newborns
- pediatric patients
- adults
- older adults
newborns: 70-190bpm
pediatric patients: 60-110 bpm
adults: 80-100
older adults: 60-100
what do +3, +2, +1, and 0 indicate on the pulse strength scale?
+3 - full, bounding pulse
+2 - normal
+1 - weak, thready pulse
0 - absent
What is a pulse deficit?
HR > Pulse Rate
What could be the cause of an absent pulse?
death, weak contractions, cut off of blood supply
What could be the cause of a weak pulse?
Narcotics, shock, dehydration, blockage
What could be the cause of a thready pulse (can barely feel it)?
Often felt in patients who are dying
What could be the cause of a strong, bounding pulse?
over-hydration sepsis infection SNS activity trauma exercise
What is bradycardia?
What is tachycardia?
bradycardia: (< 60) = slow HR
tachycardia: (>100) = fast HR
What is the normal heart rate for conditioned athletes?
50-100 bpm
what are Korotkoff sounds?
sounds of turbulent blood flow through a compressed artery
what is the first korotkoff sound?
tapping
systolic pressure
spurt of blood into constricted artery as pressure in cuff is gradually deflated
what is an auscultatory gap?
the loss of sound btwn SBP + DBP
abnormal, more common w hypertension
what is the 5th Korotkoff sound?
silence
diastolic pressure
what is systolic BP?
what is diastolic BP?
SBP: Peak pressure exerted against the arteries when the heart contracts
DBP: Residual pressure of the arterial system during ventricular relaxation
what are some common errors in BP measurement?
- patient stressed, in pain
- positioning
- cuff size (too tight = high reading, too loose = low reading)
- failure to wait 1-2 mins btwn measures w/ cuff fully deflated
- halting during deflation
- reinflating cuff during measure
- overinflating –> pain
- deflating too quickly
- pushing stethoscope too hard
- never do it over clothing.
what are some influences on blood pressure?
- age (gradually raises thru childhood)
- gender (post menopause F > M)
- ethnocultural background (African > European)
- diurnal rhythm (late afternoon > early morning)
- weight (increases w obesity)
- exercise (increases during activity)
- emotions + stress (SNS stimulation; fear, anger, pain)
- caution (false measure)
What is hypotension?
What BP readings would indicate this?
low BP
< 95 / 60 w A LOT OF VARIATION
What is symptomatic hypotension?
low perfusion
what is perfusion?
Process of supplying tissues w oxygenated blood
what is orthostatic / postural hypotension?
what patients are at risk for orthostatic hypotension?
- occurs when a normotensive person develops symptoms of low BP when rising to an upright position.
- patients who are dehydrated, anemic, or have experienced prolonged bedrest are at risk for orthostatic hypotension.
what are normal BP readings for:
- newborns
- pediatric patients
- adults
- older adults
- newborns:
SBP: 65-115
DBP: 40-80 - pediatric patients
SBP: 87-117
DBP: 48-64 - adults
SBP: 120-129
DBP: 80-89 - older adults
< 140 / 90
A patient has a blood pressure of 98 / 40 mmHg. The MAP must be greater than 70 mmHg to administer the patient’s antihypertensive medication. Should the nurse give the medication to the patient?
MAP = (SBP + 2DBP) / 3
= (98 + 80) / 3
= (178) / 3
= 59
No, the nurse should not administer the antihypertensive medication.
Why is the SBP higher in older adults?
Due to decreased vessel elasticity
How do you assess respiration rate? How long do you count breaths?
Count the # of breaths per minute
(1 breath = full inspiration and expiration)
30 seconds if regular, 60 if irreg
What is tachypnea?
( > 20 breaths / min)
rate of breathing is regular but abnormally rapid + shallow
What is bradypnea?
< 10 breaths / min
rate of breathing is regular but abnormally slow (normal volume)
What is dyspnea?
Difficult / uncomfortable breathing
What is SOB
Panting, usually w increased resp rate
What is air hunger?
Sensation of not having enough oxygen, gasping
What is the normal ratio of pulse : resp rate?
4 : 1
How can you tell if a patient is experiencing an increased WOB?
Patient is aware of breathing and is requiring exertion, laboured breathing
Pulse : RR near 1 : 1
What are normal respiration rates for:
- newborns
- pediatric patients
- adults
- older adults
newborns: 30-60
pediatric patients: 20-30
adults + older adults: 10-20
What is pulse oximetry? How does the test work?
test used to measure oxygen saturation. The sensor compares the ratio of light emitted to light absorbed by Hgb and converts into a percentage of SPO2
What is the normal range of oxygen saturation?
95-98% on R / A
What is a critical value for oxygen saturation?
< 90%
What is hypoxemia?
What is hypercapnia?
hypoxemia = low levels of arterial O2 hypercapnia = abnormally elevated CO2 levels in the blood
What would a nurse find on assessment for a client who is experiencing distress or clinical decline?
hyper / hypothermia hyper / hypotension hypoxia, hypercapnia increased WOB anxiety, restlessness unresponsiveness pallor cyanosis chest pain confusion blindness severe headaches tachy / bradycardia dyspnea apnea low oxygen saturation
You have a 7 yo patient who is refusing to keep an oral temperature prove in their mouth. Based on the patient’s developmental stage, what could you do to obtain an accurate temperature?
axillary or temporal
Are rectal remperatures recommended for newborns?
no, not routinely.
which temp route is the most accurate?
rectal. more accurate than oral.
Why do children often breathe at a faster rate than adults?
Children’s breathing is much quicker bc they have significantly higher metabolic rates than adults and therefore have higher oxygen demand.
What does it mean when we say a client is “symptomatic”: w an adverse assessment finding (ex high heart rate)?
Don’t just have high heart rate, appears to be affecting them.
