Respirations and Pulse

Question 1

What are you assessing with a pulse?

Answer 1

1. the rate- fast=tachycardia slow=bradycardia
2. the rhythm- normal or arrythmic= irregular beats
3. the volume

Question 2

How long would you assess the pulse?

Answer 2

One minute on an initial assessment, a paediatric patient or if the pulse is irregular.
30 seconds then x by 2 if the pulse is regular, not the first assessment

Question 3

What is an apical pulse?

Answer 3

This refers to the pulsations at the apex of the heart.

sometime referred to as the point of maximum impulse (PMI)

Question 4

what is a normal pulse rate?

Answer 4

Anywhere from 60-100 beats per minute

Question 5

What are the 3 processes of respiration?

Answer 5

1. gas movement in and out of the lungs - VENTILATION
2. O2 and CO2 between the lungs and blood- DIFFUSION
3. Distribution of RBC to and from the lungs - PERFUSSION

Question 6

What are you assessing when measuring respiration?

Answer 6

1. respiratory rate
2. depth - degree of movement of chest wall (deep/shallow/normal)
3. Rhythm
4. Quality
5. pattern- checking for regular cycle (normal or irregular)
   laboured inspiration (forgein body)-accessory muscles
   extended expiration (asthma)

Question 7

What is respiration?

Answer 7

It is the mechanism the body uses to exchange gases between the atmosphere and the blood; and then the body cells.

Question 8

what is a normal range for respirations for an adult?

Answer 8

Anywhere from 12-20 breaths per minute

Question 9

What is pulse saturation (SpO2)?

Answer 9

the % of haemoglobin (hb) carrying oxygen within the arteries

Question 10

What is the normal range for pulse saturation (SpO2) levels?

Answer 10

A normal range is anywhere from 95-100% however some people with chronic respiratory conditions live with “normal”SpO2 of below 95% sometimes down to 85%

Question 11

What are the indications for assessing the pulse?

Answer 11

determining that the pulse rate, rhythm, quality and volume are within normal limits for the patient.
Establishing a baseline for subsequent comparison.
Monitoring the patient’s health status.
Monitoring patients who are at risk for alterations in their pulse.

Question 12

What are the indications for assessing respiration?

Answer 12

• Determining that the respiratory rate, rhythm, quality and depth are within normal limits for the patient.
• establishing a baseline for subsequent comparison
• monitoring the patients health status (assessing them prior to or after medication like morphine, ventolin, anaesthesia)
• monitoring patients who are at risk for alterations in their respiratory status.

Question 13

Remember TPR should be monitored any time the nurse feels that the health status of the patient warrants the assessment.

Answer 13

Remember TPR should be monitored any time the nurse feels that the health status of the patient warrants the assessment.

Question 14

What does the pulse oximeter do?

Answer 14

Measures the oxygen saturation in the arteriole blood (haemoglobin)

Question 15

When shouldn’t oral temperature readings be done?

Answer 15

It should not be done on patients that are:

• confused
• unconscious
• have active convulsive disorders
• have an infection in the oral cavity
• had recent oral surgery
• are mouth breathers