Nurs 208 - Vital Signs and Pain Assessment Flashcards
1
Q
List the 5 Vital Signs
A
Pulse Respirations Temperature Blood Pressure SpO2
2
Q
Pulse
A
By palpating the peripheral pulse you can measure the rate and rhythm of the heartbeat, as well as obtain local data on the condition of the artery
3
Q
What is the average stroke volume in adults?
A
70 mL
4
Q
How to assess a pulse
A
Use the pads of your first 3 fingers
Palpate the radial pulse at the flexor of the aspect of the wrist laterally along the radius bone
Press until you feel the strongest pulsation
5
Q
If the rhythm of the pulse is regular…
A
count the number of beats in 30 seconds and multiply by 2
6
Q
If the rhythm of the pulse is irregular…
A
as in atrial fibrillation, always count for a full minute
7
Q
Why can’t we count the pulse for 15 seconds?
A
any one-beat error in counting results in a recorded error of 4 beats per minute
8
Q
Pulse: It is more important to establish the _______ so that you can accurately determine the _____
A
Rhythm
Rate
9
Q
4 Things to Assess for Pulse
A
Rate
Rhythm
Force
Equality (when comparing pulses bilaterally)
10
Q
All symmetrical pulses should be assessed bilaterally except for the ______ pulse
A
Carotid
11
Q
Normal Resting Heart Rate (Pulse)
A
50 to 96 beats/min
or
60 to 100 beats/kmin
12
Q
What is the name for a heart rate of less than 50 beats/min?
A
Bradycardia
13
Q
What is the name for a heart rate of more than 95 or 100 beats/min?
A
Tachycardia
14
Q
Heart rates in the 50s/min normally occur in? Why?
A
Well trained athletes because their heart muscle develops along with the skeletal muscles
15
Q
Rapid heart rates normally occur with _____ or with increased ______ to match the body’s demand for increased _______
A
Anxiety
Exercise
Metabolism
16
Q
Pulse: Rhythm
A
Normally has an even tempo
17
Q
What is the name for an irregularity in pulse that is common in children and young adults
A
Sinus Arrythmia
- in which the heart rate varies with the respiratory cycle
speeding up at peak of inspiration
slowing to normal with expiration
18
Q
If any irregularities are detected what do you do?
A
auscultate heart sounds for a more complete assessment
19
Q
Pulse: Force
A
Shows the strength of the heart’s stroke volume
20
Q
Pulse Force 3 Point Scale
A
3+ = Full Bounding 2+ = Normal 1+ = Weak, thread 0 = Absent
some agencies use a 4 point scale
21
Q
A “weak, thready” pulse reflects…
A
Decreased stroke volume
as occurs with hemorrhagic shock
22
Q
A “full, bounding” pulse reflects..
A
Increased stroke volume
as occurs with anxiety, exercise, and some abnormal conditions
23
Q
Respirations
A
Normally a patient’s breathing is relaxed, regular, automatic, and silent
Count for 30 seconds and multiply by 2
Count for a full minute if you suspect an irregularity
24
Q
Why can’t we count respirations for 15 seconds?
A
The result can vary by a factor of +/- 4 which is significant with such a small number
25
What is one full cycle for respirations
Inspiration and Expiration = 1 cycle
26
NORMAL RESPIRATORY RATES
| Neonate
30-40
27
NORMAL RESPIRATORY RATES
| 1 year
20-40
28
NORMAL RESPIRATORY RATES
| 2 years
25-32
29
NORMAL RESPIRATORY RATES
| 4 years
25-30
30
NORMAL RESPIRATORY RATES
| 8-10 years
20-26
31
NORMAL RESPIRATORY RATES
| 12-14 years
18-22
32
NORMAL RESPIRATORY RATES
| 16 years
12-20
33
NORMAL RESPIRATORY RATES
| Adult
10-20
34
What is blood pressure?
The force of blood pushing against the side of the vessel wall
35
Systolic Pressure
The maximum pressure felt on the artery during left ventricular contraction or systole
36
Diastolic Pressure
The elastic recoil, or resting, pressure that the blood exerts constantly between each contraction
37
Pulse Pressure
The difference between the systolic and diastolic pressures and reflects the stroke volume
38
Mean Arterial Pressure (MAP)
the pressure forcing the blood into the tissues, averaged over the cardiac cycle
A value closer to diastolic pressure plus 1/3 of the pulse pressure
39
Influences on Blood Pressure (8)
Age - rises
Sex - Before puberty, no difference. After puberty, girls have lower BP than males. After menopause, BP higher in women than males
Ethnocultural Considerations - African decent have higher than European descent
Dirunal Rhythm - BP highest in late afternoon or early evening, declines to an early morning low
Weight - BP higher in obese
Exercise - Increases, Within 5 minutes of terminating exercise it normally returns to baseline
Emotions - momentarily rises with fear, anger, and pain as a result of the Sympathetic nervous system
Medications
40
Width of BP Cuff
Should equal 40% of the circumference of the patient's arm
```
6 sizes (from newborn to extra large adult)
Match the appropriate size cuff to the patient's arm size and shape not to the patient's age
```
41
What happens if you use a cuff size that is too narrow?
| Why?
it will yield a falsely high BP because it takes extra pressure to compress the artery
42
The aneroid gage is subject to drift; it must be recalibrated at least _____ each year and it must rest at _____
once
| zero
43
BP Recommended Procedure
Allow at least a 5-minute rest before measuring BP
Take 3 BP measurements separated by 2 minutes, discard the first, average the second 2
Center the deflated cuff 2.5 cm (1 inch) above the brachial artery
Palpate brachial artery, inflate cuff until pulse is obliterated and then 20-30mmHg beyond to prevent an auscultatory gap
Deflate cuff completely, then wait 15 to 30 seconds before reinflating so that the blood trapped in the veins can dissipate
Reinflate cuff
deflate cuff slowly and evenly, about 2mmHg per heartbeat
44
When do we verify BP in both arms?
On admission or for first complete physical examination
45
True or False. On occasion, a 5 to 10 mmHg difference may occur in BP in the two arms (if values are different, record the higher value)
True
46
A difference in the two arms of more than 10 to 15 mmHg may indicate...
a renal obstruction on the side with the lower reading
47
BP is falsely ____ when the legs are crossed
High
48
Auscultatory gap
a period when Korotkoff's sounds disappear during auscultation
occurs in about 5% of people, most often in those with hypertension caused by a noncompliant arterial system
49
Common errors in Blood Pressure Measurement
| Falsely High
Taking BP when patient is anxious/angry/ has just been active
Faulty arm positon: Below level of heart
Patient supports own arm (falsely high diastolic)
Faulty Leg position (legs crossed)
Examiners eyes are not level with meniscus of mercury column: looking up at meniscus
Inaccurate Cuff size (most common error); cuff too narrow for extremity
Deflating cuff too quickly: falsely high diastolic or falsely low systolic
Deflating cuff too slowly: falsely high diastolic
Halting during descent and reinflating cuff to recheck systolic: falsely high diastolic
Failure to wait 1-2 min before repeating entire reading: falsely high diastolic
50
Common errors in Blood Pressure Measurement
| Falsely Low
Faulty arm position: Above level of heart
Examiners eyes are not level with meniscus of mercury column: looking down on meniscus
Cuff wrap is too loose or uneven
Failure to palpate radial artery while cuff is inflated: falsely low systolic
Poor inflation of the cuff
Pushing stethoscope too hard on brachial artery: falsely low diastolic
Deflating cuff to quickly: Falsely low systolic or falsely high diastolic
51
Temperature: mean stable core ("deep body") temp.
37.2 (99)
52
Normal Oral Temp vs Rectal Temp
Oral = 37 (98.6)
| Rectal measures 0.4 C to 0.5 C (0.7 F to 1 F) higher
53
Influences on temp
Dirunal Cycle of 1 to 1.5 C - lowest (trough) in morning, peak in late afternoon to early evening
Menstruation Cycle - Progesterone secretion (ovulation), causes a 0.5 to 1.0 C rise in temperature until menses
Exercise - increases
Age - Wider normal variations occur in infants and young children as a result of less effective heat control mechanisms. Temp usually lower in older adults (mean of 36.2 C (97.2 F)
54
Oral Temp
Shake mercery-free glass thermometer down to a reading of 35.5
Place thermometer at base of tongue in either of the posterior sublingual pockets
Instruct patient to keep lips closed
Leave thermometer in place 3-4 minutes if patient is afebrile. Up to 8 minutes if febrile
55
How long do you wait to take an oral temperature if the patient has just taken hot or iced liquids?
20 minutes
56
How long do you wait to take an oral temperature if the patient has just smoked?
2 minutes
57
Hyperthermia
above 40 degrees
or fever, is caused by pyrogens secreted by toxic bacteria during infections or as a result of tissue breakdown such as that after myocardial infarction, trauma, surgery, or malignancy. Also neurological disorders
58
Hypothermia
below 35 degrees
Usually caused by accidental, prolonged exposure to cold.
Also may be purposefully induced to lower the body's oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage
59
Axillary Temperature
Safe and accurate for infants and young children
| Not the method of choice in adults, as it is highly insensitive
60
Rectal Temperature
Only when other routes are not practical
Wear gloves
Insert lubricated probe cover on an electronic thermometer, insert 2 to 3 cm (1 in) into the adult rectum
61
Disadvantages of Rectal Temperature
patient discomfort
| time consuming
62
Temporal Artery Temperature (TAT)
Takes multiple readings, provides an average
Takes approximately 6 seconds
More accurate than TMT
63
Tympanic Membrane Temperature (TMT)
The tympanic membrane shares the same vascular supply that perfuses the hypothalamus thus making it an accurate measurement of core temperature
64
Measurement of Oxygen Saturation (SpO2)
pulse oximeter
a sensor attached to patient's finger or earlobe has a diode that emits light and a detector that measures the relative amount of light absorbed by hemoglobin
65
Normal SpO2
97% to 99%
value of >95% is acceptable for an individual with normal hemoglobin
66
SpO2 in infants
Tape probe to large toe
67
If you are using a finger, make sure the hand is ____
warm
68
At lower oxygen saturation, the _______ probe is more accurate
earlobe
69
When do we use thigh pressure?
When BP measured in the arm is excessively high, particularly in adolescents and young adults, compare it with the thigh pressure to check for coarctation of the aorta
70
Normally, blood pressure of the thigh is ______ than the pressure in the arm
higher
71
Coarctation of the aorta
a congenital form of narrowing
arm pressures high
thigh pressure is lower because the blood supply to the thigh is below the constriction
72
What artery is used for thigh pressure?
popiliteal artery
73
Systolic vs Diastolic values in thigh vs arm
Normally the systolic value is 10 to 40 mmHg higher than in the arm, diastolic pressures are the same
74
List the 5 Types of Pain
```
Nociceptive
Neuropathic
Referred
Acute
Chronic
```
75
Nocioceptive Pain
Pain caused by tissue injury
Well localized
often described as aching or throbbing
Can be further classified as Somatic or Visceral
76
Nocioceptive Pain: Somatic
can be superficial, derived from the skin surface, or deep, derived from joints, tendons, muscle, or bone
77
Nocioceptive Pain: Visceral
originates from the larger interior organs (ie. kidney, intestine, gall bladder, pancreas)
can be constant/intermittent
may be poorly localized
78
Neuropathic Pain
caused directly by a lesion or a disease affecting the somatosensory nervous system
can result from damage to the nerve pathway at any point along the nerve, from the terminals of the peripheral nociceptors to the cortical neurons in the bran
described as burning, shooting, or lancinating
often intensifying at night
79
Examples of Neuropathic pain
spinal cord injury, herpes zoster/HIV/diabetes
may be medication-induced
chemotherapy, antiretroviral therapy, sciatic pain
80
Referred Pain
originates at one location but is felt at another site - both sites are innervated by the same spinal nerve and it is difficult for the brain to differentiate the point of origin
81
Example of referred pain
appendicitis
82
Acute Pain
Short Term and Slef-limiting
Follows a predictable trajectory and dissipates after an injury heals
It warms the actual or potential tissue damage
ex. pain caused by surgery, trauma, and kidney stones
83
Chronic Pain/Persistent Pain
Pain that has been persistent for 6 months or longer than the time of expected tissue healing
Can be Categorized as Malignant or Nonmalignant
84
Chronic Pain: Malignant
cancer-related pain
pain induced by tissue necrosis or stretching of an organ by the growing tumour
severity fluctuates
85
Chronic Pain: Nonmalignant
often associated with Musco-skeletal conditions such as arthritis, low back pain, and fibromyalgia
86
Acute pain can lead to chronic pain through 2 processes:
Peripheral Sensitization - reduction of pain threshold and an increased response of the peripheral end of the nociceptors
Central Sensitization - increase in the excitability of neurons within the CNS
87
True or False. Pain is a normal process of ageing
FALSE. Pain is NOT a normal process of ageing
88
Initial Pain Assessment (OPQRSTUV)
```
O - Onset
P - Provocative/Palliative
Q - Quality of Pain
R - Region of the body/radiation
S - Severity of Pain
T - Treatment/Timing
U - Understanding of pain
V - Values
```
89
Questions to ask:
| Onset
When did the pain start?
90
Questions to ask:
| Provocative/Palliative
Does your pain increase with movement or activity?
Are the symptoms relieved with rest?
Were any previous treatments effective?
91
Questions to ask:
| Quality of Pain
What does your pain feel like?
| What words describe your pain?
92
Questions to ask:
| Region of the body/radiation
Where is your pain?
| Does the pain radiate, or move to other areas?
93
Questions to ask:
| Severity of pain
How would you rate your pain on an intensity scale?
94
Questions to ask:
| Treatment/Timing
What treatments have worked for you in the past?
| Is it a constant, dull, or intermittent pain?
95
Questions to ask:
| Understanding of pain
What do you believe is causing the pain?
96
Questions to ask:
| Values
What is your acceptable level for this pain?
Is there anything else you would like to say about your pain?
Are there any other symptoms related to the pain?
97
True or False. Pain is a subjective experience
True
98
What is the most reliable indicator that an individual is experiencing pain?
The self-report of pain
Pain is whatever the experiencing person says it is, existing whenever he/she says it does
99
True or False. Those who are unable to report pain are at high risk for the undertreatment of pain
True
100
How to assess pain in an unconscious individual
The Critical Care Pain Observation tool
-behaviours assessed include facial expression, body movement, muscle tension, vocalizations, and degree of compliance with ventilation
They still can feel pain!
101
Pain Developmental Considerations
| Neonates
because neonates and young infants are preverbal and incapable of self-report, pain assessment is dependent on behavioural and physiological cues
102
Pain Developmental Considerations
| Infants and Young Children
By 20 weeks gestation, infants have the same capacity for pain as do adults
Infants are more sensitive to pain because the inhibitory neurotransmitters are in insufficient supply until birth at full term
Toddlers and children older than 2 years of age can report pain and point to its location but are unable to rate pain intensity
It is helpful to ask the parent/caregiver what words their child uses to report pain (boo-boo, owie)
Be aware that some children will try to act "grown up and brave" and often deny having pain in the presence of a stranger, or if they are fearful of receiving a shot
103
Pain Developmental Considerations
| Older Adults
NO evidence suggests that older adults perceive pain to a lesser degree or that sensitivity is diminished with age
Although a common experience, pain is NOT a normal process of ageing
Older adults may express fears about becoming dependent or perceive that they are taking an excessive number of medications
May need more time to respond to assessment questions
The incidence of chronic pain conditions is higher in the adult population: such conditions include diseases such as arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, peripheral neuropathies, and angina
104
Pain Gender Differences
Women are more likely to experience migraines with aura, fibromyalgia, irritable bowel syndrome, rheumatoid arthritis
Men are more likely to experience cluster headaches, gout, coronary artery disease, and duodenal ulcers
Pharmacological treatments for pain and the related adverse effects may not be the same for both genders
105
Pain Ethnocultural Considerations
Pain can have different meanings for different cultures
Indigenous children tend not to express pain outwardly: often manage it and silently suffer. This response to pain is thought to be a result of cultural traditions and the effects of the residential school system
Indigenous have higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis
106
Pain Assessment Tools
| Unidimensional Aspects vs Multidimensional Components
Unidimensional Aspects: eg. Intensity
Multidimensional Components: eg. effect on ADL's and quality of life
107
Selection of pain assessment tool is based on:
Its purpose
Time involved in administration
patients ability to comprehend and complete the tool
108
Pain Assessment Tools
| Visual Analogue Scale/Numeric Scale (from 0 to 10) - Where do we want them to be?
Want them to be a 4 or lower
109
Pain Assessment Tools
The Faces Pain Skill - Revised (FPS-R)
Why was it revised?
To remove the tears because we do not want children to associate pain with fear/tears
6 drawings of faces that show pain intensity
110
Pain Assessment Tools
| Descriptor Scale
Lists words that describe different levels of pain intensity, such as no pain, mild pain, moderate pain, and severe pain
Older adults may find the number scale too abstract and may respond better to this scale
111
Pain Scales for those with intellectual/cognitive disability
PAINAD Scale
(Pain Assessment in Advanced Dementia)
Abbey scale
112
Order of Vital Signs
| Infant
Reverse the order of vital sign measurement
| Respiration first, then pulse and temperature
113
Developmental Considerations
| Temperature: Tympanic/Temporal
TMT and TAT are useful with toddlers who sqiurm at the restraint needed for rectal route and it is useful for preschoolers who are not yet able to cooperate for an oral temperature measurement but fear the rectal route
114
Developmental Considerations
| Temperature: Axillary
Safer and more accessible than the rectal. Accuracy and reliability have been questioned.
115
Developmental Considerations
| Temperature: Oral
Use the oral route when the child is old enough to keep the mouth closed
- usually at age 5 or 6 years but some 4 year olds can cooperate
- Use electronic thermometer when one is available
116
Recommended Temp. Technique based on age
| Birth to 2 years
1. Rectal (definitive)
| 2. Axillary (screening low risk children)
117
Recommended Temp. Technique based on age
| From 2 to 5 years of age
1. Rectal (definitive)
2. Axillary, tympanic (or temporal artery if in hospital)
(screening)
118
Recommended Temp. Technique based on age
| Older than 5 years
1. Oral (definitive)
2. Axillary, tympanic (or temporal if in hospital)
(screening)
119
Developmental Considerations
| Pulse - Infants
In children older than 2 years, use the radial site
Count the pulse for a full minute to take into account normal irregularities, such as sinus arrhythmia
Heart rate normally fluctuates more in infants and children than in adults in response to exercise, emotion, and illness
120
Developmental Considerations
| Respirations - Infants
Watch infants abdomen for movement (respirations are more diaphragmatic than thoracic
Count for a full minute because the pattern varies from rapid breaths to short periods of apnea
Faster
121
Developmental Considerations
| Blood pressure - infants
In children aged 3 years and older and in younger children at risk, take a routine BP measurement at least annually
Cuff width must be over 2/3 of upper arm, cuff bladder must encircle it completely
