Module 4 Flashcards
List the normal ranges of vital signs for an adult
1) Temp: 36-38 degrees celsius. (oral/tympanic/temporal).
2) Pulse: 60-100 beats per minute. 2 most common pulse sites: radial and apical.
3) Respiration: 12-20 breaths per minute.
4) Oxygen Saturation: 95-100%. 2 sites to measure O2 SAT: digit or earlobe.
5) Blood pressure: 120 Hg mm for systolic, 80 Hg mm for diastolic.
Describe the physiology of a fever.
Fever = alteration in the hypothalamic set point. Pyrogens (bacteria & viruses) cause a rise in body temp. Pyrogens act as antigens, triggering immune system responses.
Hypothalamus raises the set point, and the body produces & conserves heat. When the fever “breaks,” the person becomes afebrile = experiences chills, shivers, feels cold (body temp is rising). The chill phase resolves when the new set point (higher temp) is achieved.
Next phase = Plateau –> chills subside, person feels warm & dry. If the new set point is “overshot” or the pyrogens are removed, a febrile episode occurs (third phase).
The hypothalamus set point drops (heat loss). Skin is warm and flushed (vasodilation). Diaphoresis –> evaporative heat loss. Fever = cellular metabolism increases & O2 consumption rises. Heart & respiratory rates increase to meet the increased metabolic needs of the body for nutrients (produces more heat).
What are factors that influence Temperature?
Age, exercise, hormone level, circadian rhythm, stress, environment.
What are factors that influences the increase and decrease in Pulse?
Increased: Short-term exercise, standing up or sitting, positive chronotropic medications, acute/sharp pain, anxiety, asthma or COPD (diseases causing poor oxygenation), fever or heat, loss of blood
Decreased: Relaxation, negative chronotropic medications, long-term exercise, unrelieved severe pain, hypothermia, lying down
What are factors that influence Respiration?
Exercise, anxiety, acute pain, smoking, medications, body position, neurologic injury, and altered hemoglobin levels.
What factors influence O2 Sat?
Nail polish/studs, dark skin pigment, patient motion, jaundice, outside light sources, carbon monoxide (all can interfere with the LED light transmission)
Reduction of arterial pulsations: Peripheral vascular disease, low cardiac output, hypotension, edema, hypothermia, pharmacological vasoconstrictors
Describe the cardiovascular physiology that creates a peripheral pulse.
As the stroke volume ejection reaches the aorta, the walls of the aorta distend, a “pulse wave” is created and travels towards the distal ends of the arteries. Once the pulse wave reaches the distal/peripheral arteries, it can be palpated - (peripheral pulse)
Describe how the diaphragm and intercostal muscles contribute to the mechanics of breathing (physiology of respiration).
During inspiration, the respiratory centre sends impulses along the phrenic nerve, causing the diaphragm to contract. Abdominal organs move downward and forward, increasing the length of the chest cavity to move air into the lungs. The diaphragm moves approximately 1 cm, and the ribs retract upward from the body’s midline approximately 1.2 to 2.5 cm.
During expiration, the diaphragm relaxes and the abdominal organs return to their original positions. The lung and chest wall return to a relaxed position.
What does the arterial oxygen saturation assessment measure? (physiology of O2 Sat).
The amount of oxygen bound to hemoglobin molecules (oxygen saturation)
What is systolic blood pressure? What is diastolic blood pressure? What is pulse pressure? (physiology of blood pressure).
Systolic blood pressure: Peak of maximum pressure when ejection occurs
Diastolic blood pressure: Minimum pressure exerted against the arterial wall at any time.
Pulse pressure: The difference between systolic and diastolic pressure.
Physiology of BP: refers to the force that is exerted onto the walls of an artery by the pulsing blood under pressure from the heart
How do you take a radial pulse?
Radial pulse:
Assist patient to supine position (lying on back), easy access to pulse signs and no restrictions to arteries
Place tips of middle 3 fingers over groove along radial or thumb side of patient’s inner wrist. Lightly compress fingertips against patient’s radius, stopping pulse initially, and then relax pressure so that the pulse becomes easily palpable.
After feeling of regular pulse, look at watch and began to count pulse rate.
Regular pulse = count pulse for 30 seconds and multiply by 2.
Irregular pulse = count for 1 min.
How do you take an apical pulse?
Apical Pulse:
Heart is located behind and to the left of the sternum. Find angle of Louis just below suprasternal notch between sternal body and manubrium, it can be palpated as a bony prominence.
Slip fingers down each side of angle to find second intercostal space. Move fingers down left side of sternum to fifth ICS and laterally to the left midclavicular line.
Place diaphragm of stethoscope over PMI at the fifth ICS, at left MCL, and auscultate for normal S1 and S2 heart sounds
look at watch and begin counting.
Regular = count for 30 seconds and multiply by 2
Irregular or on cardiovascular medication = count for full min.
How do you determine someone’s respiration rate?
Check for factors that can affect respiratory rate, such as exercise, anxiety, acute pain,
smoking, and medications.
8. Help the patient into a comfortable position, preferably sitting or lying with the head
of the bed elevated 45 to 60 degrees.
9. Ensure that the patient’s chest is visible, moving the bed linen or gown as needed.
10. Place the patient’s forearm in a relaxed position across the lower chest or upper
abdomen, as you would to assess the pulse, or simply place your hand directly over
the lower chest or upper abdomen.
11. Observe a complete respiratory cycle of one inspiration and one expiration.
12. Then look at your watch. When the second hand reaches a number on the dial (or
when the digital display reaches a round number), begin taking the respiratory rate,
counting “one” with the first full respiratory cycle.
A. If the respiratory rhythm is regular, count the breaths for 30 seconds and multiply
by 2. Normally, the respiratory rate ranges from 12 to 20 breaths per minute.
B. If the respiratory rhythm is irregular or less than 12 or more than 20 breaths per
minute, then count the breaths for a full 60 seconds.
13. As you count the rate, note the depth of the respiration by observing chest wall
movement, or do this after counting the rate by palpating chest wall excursion or
auscultating the posterior thorax. Describe the depth as shallow, normal, or deep.
14. Note the respiratory rhythm, which should be regular and uninterrupted, except for an
occasional sigh.
15. Observe for dyspnea, and ask the patient to compare any shortness of breath with his
or her usual breathing patterns.
16. Replace the patient’s bed linen, and discuss your findings with the patient.
17. Help the patient into a comfortable position, and place toiletries and personal items
within reach.
18. Place the call light within easy reach, and make sure the patient knows how to use it
to summon assistance.
19. To ensure the patient’s safety, raise the appropriate number of side rails and lower the
bed to the lowest position.
20. Dispose of used supplies and equipment. Leave the patient’s room tidy.
21. Remove and dispose of gloves, if used. Perform hand hygiene.
22. As part of your follow-up care; compare respirations with the patient’s previous
baseline, usual rate, depth, and rhythm. Correlate the patient’s respiratory rate, depth,
and rhythm with pulse oximetry and arterial blood gas measurements, if available.
23. Document and report the patient’s response and expected or unexpected outcomes.
How do you take someone’s O2 sat?
Select a site for sensor placement, such as the patient’s earlobe, the forehead, the bridge of the nose or a finger. Avoid placing the sensor on a finger on the same side as an electronic blood pressure cuff. Avoid any site that has edema, altered skin integrity, or hypothermia. Select a site that is moisture free. For a finger, remove any nail polish or artificial nail with acetone or polish
remover.
Assess capillary refill. If the capillary refill time is more than 3 seconds, select an alternative site. If the capillary refill is less than 3 seconds, ensure that the site is free
of moisture.
Position the patient comfortably. Attach the sensor to the monitoring site.
Turn on the oximeter. Observe the pulse waveform/intensity display, and listen for a beep. Correlate the oximeter pulse rate with the patient’s radial pulse.
Leave the sensor in place 10 to 30 seconds, or until the oximeter readout reaches a constant value. Read the peripheral oxygen saturation (SpO2) on the digital display. The peripheral oxygen saturation is known as the SpO2.
How do you measure someone’s temporal artery temperature?
Assess for factors that may have caused temp alterations: and help the patient
into a comfortable position that allows easy access to the selected route.
1) Remove the thermometer from the case or charger, and make sure that the patient
is comfortable.
2) Follow the manufacturer’s instructions and either place a disposable cover on the
probe or clean it with disinfectant.
3) Place the probe in the center of the patient’s forehead, and press and hold the red
button.
4) Slowly slide the probe across the patient’s forehead and into the hairline, keeping
it in contact with the skin. Then place the probe on the neck behind the ear.
5) Release the red button, and read the temperature on the thermometer.
6) Tell the patient the temperature, and remove the cover (if used) or clean the
thermometer with disinfectant.
7) Perform hand hygiene.
8) Return the thermometer to the proper storage location.
9) Record the patient’s current temperature, and compare it to the patient’s baseline
or the acceptable range for patient’s age.
How do you take someone’s blood pressure using the one-step method?
Expose the upper arm fully by removing any clothing that is in the way.
Ensure that you have the appropriate size blood pressure cuff for the patient. The
cuff’s width should be 40% of the circumference of the midpoint of the limb on
which it will be used. The cuff’s bladder should encircle at least 80% of the upper
arm.
Palpate the patient’s brachial artery in the antecubital space.
Position the cuff 1 inch above the artery, with the cuff’s arrows centered over the artery. Wrap the fully deflated cuff evenly and snugly around the upper arm.
After relocating the brachial artery, place the stethoscope’s bell or diaphragm chestpiece over it, but do not let the chestpiece touch the cuff or the patient’s
clothing.
Close the valve on the pressure bulb by turning it clockwise until it is tight. Then quickly inflate the cuff 30 mmHg above the patient’s usual systolic pressure.
Release the valve on the pressure bulb, and let the manometer indicator fall 2 to 3 mmHg per second. Note the point on the manometer at which you hear the first clear sound. This is the first Korotkoff sound, which reflects the systolic pressure.
Continue to deflate the cuff slowly, and when the sound disappears, note the pressure to the nearest 2 mmHg. This is the fifth Korotkoff sound, which reflects the diastolic pressure.
Listen for 10 to 20 mmHg after the last sound, and then let the remaining air escape quickly.
Discuss the findings with the patient. Remove the cuff.
- For greater accuracy, take the patient’s blood pressure again in 2 minutes. Use the
second set of measurements as the baseline. - Remove the cuff from the patient’s arm. If this is the first assessment, repeat the
process on the other arm, if possible. - To complete the procedure, help the patient into a comfortable position, cover the
upper arm again, and discuss your findings. - Perform hand hygiene.
- Clean the earpieces, diaphragm, and bell of the stethoscope with alcohol swabs.
- Compare your findings with the classification of blood pressure for adults
- As part of your follow-up care, compare this BP measurement to the patient’s
baseline readings. - As part of your follow-up care, teach the patient ways in which to prevent
hypertension, such as exercising every day, losing weight, stopping smoking,
reducing sodium and saturated fat intake, and maintaining an adequate intake of
dietary potassium and calcium. - Document and report the patient’s response and expected or unexpected outcomes
