lab values Flashcards
What are the vital signs?
Temperature, HR, RR,BP, O2,Pain
Can the UAP take vitals?
Yes, but the RN is responsible in documenting and reporting abnormal values to provider
When are vitals measured?
- Initial contact with the patient
- Before and after invasive procedure or surgery
- Before, after and during medications affecting heart, respiration and temperature
- Before, after and during blood transfusion
- When the patient state changes and they verbally say they are feeling off
- Before and after intervention (ambulation)
- When fever or infection is present (2-4 hours)
- During physical assessment
What is normal body temperature?
Convert F to C
Convert C to F
F: 97.5-99.5
C: 36.4-37.5
(F-32)x5/9
(Cx9/5)+32
Common measurement sites for temeprature?
Oral, head, axillary, rectal, ear
What is the difference between oral and rectal temperature?
rectal temperature is always 1 degreed F higher
What is the difference between oral, ear and axillary temperature?
axillary and ear are always 1 degrees F lower
Temperature and consideration
Temp is low in the morning and normal high at afternoon (increase metabolism)
Temp is high after exercise
High if infection
High-normal consistently during pregnancy
High during stress
Low before ovulation and high during menstruation
Why is it a red flag if your unable to get a temperature?
Indicative of hypothermia, especially in infants and elderly
Consideration for Oral temperature?
Has not smoked, drank coffee, or something hot/cold within 15-30 mins
Consideration for Oral temperature?
Rectal is taken when patient has jaw surgery, nasal congestion, nasal or mouth surgery
Thermometer is lubricated and inserted 1.5 inches in adult and .5 in infants
When is temperature not taken rectally?
Make sure patient does not have rectal surgery, hemmorhoids, fecal impaction, rectal bleeding or diarrhea, if patient is a cardiac patient (the probe can stimulate the vagus nerve in the rectum and cause dysryhtmia)
What is the least accurate measurement to take temp?
axillary
Client is told to hold the probe tightly and rest the arm on the chest
Consideration for tympanic temp?
Do not take if ear discharge, inflammation, infection or object in the ear
Ear wax and infection can change the temperature
If patient is sweating during temporal temp check what to do?
Use the neck behind the ear to check the temp
What is the pulse an indicator of?
The circulatory status, the pulse is assessing the status of the heart
Pulse=HR
HR and changes
Slows with age
increases stress, exercise, pain
Hemorrhage and low bp increases the HR
What do you assess when taking the pulse?
strength, rhythm, equality, rate
What are the pulse points?
- Temporal - anterior or front of the ear
- Carotid- groove in between the trachea and sternocleidomastoid muscle
- Brachial- above the elbow,in between the bicep and tricep, towards the pinky side, on the antecubital fossa
- Radial - towards the thumb side
- Ulnar- towards the pinky
- Femoral- below the inguinal ligament, in between the pubis symphysis and anterior superior illiac spine
- Popliteal- behind the knee
- Dorsalis pedal- anterior of the foot; in line with the groove between the extensor tendonds of the big and first toes
- Posterior tibial; behind and below the medial malleolus
- Apical- left midclaviular, 5th intercostal muscle
When is the apical pulse checked for one whole minute?
Before administration of beta blockers, digoxin and on children under 2
What is pulse deficit?
When the radial pulse is lower than the apical pulse. This means that there is inadequate perfusion and the heart is not contracting right.
Check apical and then radial right away, or have one check radial and one apical at the same time
Report to he provider right away
What causes decrease respiration?
Head injury, increased intracranial pressure and opioids
When should you assess respiration?
After checking the radial pulse but have the hand on the pulse
the RR can be counted for 30 sec and then multiplied
what is bp?
Force on the arterial wall from pulsating blood from the pressure of the heart
what is pulse pressure?
the difference between systolic and diastolic pressure
how to obtain orthostatic vital signs?
check bp when supine, sitting and then standing (1-3 mins)
Factors affecting BP?
increases as you age increases due to stress lowest in the early morning, increases during the day and peaks in the afternoon or evening males have higher bp after puberty woman have higher bp after menopause
what medications cause decrease in BP
Antihypertensive and opioids
BP and extremity to use?
Do not use on arm with mastectomy, axillary surgery, IV fluids, disease or trauma, fistula or shunt
Ensure that the client has not smoked or exercised 30 mins before the BP reading
If cuff too big then reading will be lower and vice versa
Whats pulse ox?
Oxygen saturation of hemoglobin Sa02
What do you do if pulse ox reading is low?
Instruct patient to take deep breaths and recheck and alert the provider
What effects the light transmission of the pulse ox?
nail polish, anemia, hypotension, vascular disorders, sensor movement
Where can you place the pulse ox ?
finger, nose, ear, forehead, toe
The types of pain
Acute/Transient Chronic/non cancer Chronic episodic Cancer Idiopathic
What is idiopathic pain
True chronic pain that does not have an identifiable physical or psychological cause
What are the types of conventional non pharmacological pain management?
1.Cutaneous stimulation -
( massage, heat, cold pressure, vibration, therapeutic touch
2.TENS- transcutaneous or percutaneous nerve stimulation
battery. operated device that delivers low electrical current to the skin and underlying tissue to block pain
Binders/slings/supportive devices such as pillows -
Elevation of the affected body part can reduce swelling
3.Heat and cold application - cold reduces swelling
In some conditions these treatments may require approval from the provider
Ice or heat applications should be applied with a barrier such as a towel only for 15-30 mins; if patient has loss of sensation or discomfort then stop
CAM
Used alongside pharmacological intervention ; some herbal treatments are considered pharmacological so may require provider approval
What are pharmacological pain interventions?
NSAID and aspirin (non-opioids), opioids, acetaminophen
What do you have to know about NSAID and aspirin?
Contraindicated in individuals with gastric irritation or ulcer or bleeding disorder.These medication can increase the risk of bleeding or amplify anticoagulant effects. Advice to take with snack or milk.
What type of medication is ibuprofen?
NSAID
What do you have to know about ibuprofen?
Can result in hypoglycemia if patient is also taking anti diabetic medications; can cause toxicity if taken the calcium channel blocker
What is the antidote for acetaminophen?
Acetylcysteine