Red Flags, vitals and lines Flashcards
What are vital signs
*Heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen saturation (O2) all give vital information of a person’s cardio/pulmonary system and status as well as how other systems are working.
*Observation alone of a patient will not tell you cardio/pulmonary status
*Assessing vital signs can also give you information of how a person is responding to exercise and therapy
what are Normal vital ranges for adults
BP 120/80 mmHg
RR 12-20 breaths per minute
HR 60-100 beats per minute, average 60
O2 sats 100 %
***Many stroke patient suffer from cardiovascular disease which caused CVA. A fib #1 risk factor for ishemic stroke
what is blood pressure
*The force that blood exerts on an vessel wall
*Pressure is highest in arteries (top number) than veins (bottom number)
*Control center is lower pons and upper medulla
what are Factors that influence blood pressure:
-Blood volume
-Diameter and elasticity of the arteries
-Cardiac output
-Age
-Physical activity
-Valsalva maneuver
-Orthostatic hypotension
Blood pressure values
Hypertension: > 140/90
Prehypertension: 120-139/80-89
Hypotension: systolic < 100
Medical emergency: > 180/110
what is respiratory rate
Function is to supply the body and organs with oxygen and remove carbon dioxide
what are factors that influence RR
-Age
-Body size and structure
-Exercise
-Body position
-Environment
-Stress
-Pharmacology
what is heart rate?
*Wave of blood in the artery created by contraction of the left ventricle during a cardiac cycle
*Pulse is when the blood is forced out of the heart into systemic system
*Bradycardia: slow heart rate, below 60 bpm
*Tachycardia: fast heart rate, greater than 100 bpm
what are factors that influence HR
Age
Gender
Stress
Exercise
Medications
Heat and fever
-Fetal 120-160 bpm
-Newborn 70-170
-Adults 60-100
-Male and boys typically lower than females
-Stress can increase HR
-Hr increases with exercise to provide additional blood flow to muscles
Intracranial Pressue (ICP) is
-Pressure exerted by fluids (CSF) inside the skull and on the brain tissue
-If pressure is too high, the brain can herniate
signs of Pressure ICP
Vomiting
Headache
What are ICP values
Normal: 4-15 mmHg
Mild hypertension: 20-30 mmHg
Sever hypertension: > 39 mmHg
what is Hemoglobin (Hb)
Amount of hemoglobin in RBCs that transports O2 throughout the body
what are Hemoglobin values
Male: 14-17 g/dL
Female: 12-16 g/dL
< 8 g/dL no exercise
8-10 g/dL light exercise
> 10 g/dL resistive exercise
what is Hematocrit (Hct)
% of RBCs throughout the body
what are values of Hematocrit (Hct)
Male: 40-51%
Female: 36-47%
< 25% no exercise
> 25% light exercise
> 35% resistive exercise
what is International Normalizing Ratio (INR) and values?
How well your blood clots
Normal: .8-1.2
4: no increase in intensity
4-5: no resistance
5-6: no exercise
> 6: bed rest
what are red flags values
BP >180/90 mmHg
Labored breathing
O2 less than 90 %
ICP > 39 mmHg
Anemia: hemoglobin < 8 g/dL
INR: > 5
When in doubt ALWAYS ask and seek MD guidance
what is a Arterial catheter (Art line)
-Measures arterial blood pressure in real time
-Goes directly into the artery
-More accurate than BP
-If it is pulled, there will be heavy bleeding
-Physician has to replace it
Depending on placement (hip or wrist) limit ROM
—In hip, limit to 60-80 degrees of hip flexion which may limit ability to sit
what is External Ventricular Drains
-Measures ICP
-Drains CSF
-Consult with healthcare before mobilizing patient with EVD
what is Bolt
-Real time measure of ICP
-Hole drilled into the skull to measure
-Typically seen in TBI
-Typically these patients are too unstable to mobilize so PROM may be only option
normally have low GCS cant move
what are Central venous catheters (Central lines)
*Swan-Ganz catheter: inserted into the neck and goes down large vein through the vena cava into the right atrium
*Can deliver medication directly into the circulatory system
directly in heart, cause arrhythmias or pneumothorax
what is Peripherally inserted central catheter (PICC)
Peripherally inserted into the vein and goes directly into the heart. Used with longer course antibiotics
directly in heart, cause arrhythmias or pneumothorax
what is a ventilator
*Used for people who cannot breath on their own
*Usually and endotracheal tube
*If on vent more than 14-21 days, patients usually get a tracheostomy where the tube goes to a hole in their neck directly into the trachea
*Ventilators are not very portable, so may need respiratory therapy to assist
*Increased likelihood to de sat so watch O2
*High risk of barotrauma if vent settings are high
Consider how much buffer room with settings and how much they are safely be moved on settings
a high flow nasal cannula
*A way to give high amounts of oxygen to a patient without needing to intubate
*Consider how much buffer room they: can mobilize if they are not near maximum settings that would tax cardiopulmonary system
*Next step after this is intubation so you do not want to push too much
what is a fecal management system
Collects fecal matter into a bag and often used with c-diff
a foley is?
*Urine collection and gravity dependent
*Can be foley, external, or suprapubic
*In SCI can often be noxious and cause autonomic dysreflexia
*Bags are easy to pull and very messy so be aware
*Hurt a lot when accidentally pulled
*Keep below waistline as they are gravity dependent
what is Nasogastric tube (NG):
through the nose to stomach and short term solution
If someone has a feeding tube, they are most likely NPO so do not give them water or food
Easy to pull when patients are agitated
Percutaneous Endoscopic Gastrostomy (PEG): is
directly into the abdomen and a long term solution, common in patients with more severe injuries
