General Assessment & Vitals Flashcards
Standard Precautions
- Apply to care of all patients
- Used when there is a risk of potential exposure to: blood, bodily fluids/secretions/excretions (except sweat), non-intact skin, mucous membranes
- Comprised of two main components: hand hygiene, PPE (serves as protective barrier; includes gowns, gloves, masks, face shields, goggles)
Steps of Hand Hygiene
5 Steps: Wet, Lather, Scrub, Rinse, Dry
(1) Wet hands w/ clean water, turn off the tap and apply soap
(2) Lather hands by rubbing them together with soap
(3) Scrub hands for at least 20 seconds
(4) Rinse hands
(5) Dry hands with clean disposable towel
Standard Precautions means:
- Washing hands
- Wearing gloves
- Wearing a mask
- Wearing goggles
Vital Signs
- Blood Pressure
- Temperature
- Respiratory Rate
- Heart Rate
Stethoscope
- amplifies and transmits internal body sounds of heart, lungs, bowels and blood vessels
- used to listen to blood vessel sounds when taking BP
- Consists of Bell and Diaphragm (head); Bell = low pitched (vascular turbulence), Diaphragm = high pitched (breath/heart sounds)
- Ear tips should face forward in the ear canals
Single Headed Tunable Stethoscope
- press lighter for bell function
- press harder for diaphragm function
3 Types of Sphygmomanometers
- Mercury (no longer used)
- Aneroid
- Digital
What is the gold standard for taking BP?
Manual BP by listening (auscultation)
How BP works:
- Air in the bladder compresses the artery stopping blood flow
- As cuff deflates, circulation starts moving through the artery - turbulent flow which is audible
- First sound is Systolic BP
- Diastolic BP is when the sound stops
BP Measurement:
(1) Cuff selection – length >80% of the circumference of the upper arm, width >40% of the length of the upper arm
(2) Wrap around upper arm – cuffs lower edge one inch above antecubital fossa
(3) Press Stethoscope bell or diaphragm over brachial artery just below cuffs edge
(4) Support arm at heart level
(5) Rapidly inflate cuff to 180 mmHg
(6) Release air from cuff at moderate rate
(7) Listen with stethoscope and observe sphygmomanometer
(8) Report Systolic/Diastolic
Minimizing Errors while taking BP
- Patient should: avoid smoking, caffeine, and exercise >30 min prior to measuring BP; sit quietly for 5min with feet on floor
- Exam room quiet and warm
- Arm should: be free of clothing, dialysis fistulas, cut down scars and lymphedema; needs to be supported (cradled in examiner’s arm or on table at heart level/4th intercostal space)
- Pick correct sized cuff
Measurement is falsely ____ if cuff is too small
Elevated
Measurement is falsely _____ if cuff is too big
Low
Pulse Locations
- Radial artery
- Dorsalis pedis artery
- Carotid artery
- Brachial artery
- Abdominal aorta
- Femoral artery
- Popliteal artery
- Posterior tibial artery
What is a normal resting heart rate?
60-100 BPM
