Vital observations Flashcards
Patient observations are usually undertaken for the following 3 reasons:
- To act as a baseline
- To assist in the recognition of improving or deteriorating health
- to assess the effectiveness of care
(Carvalho et al., 2020)
The 6 vital signs and 3 others:
The 6 vital signs: • Respiratory rate (RR) • Pulse/Heart rate (HRT) • Temperature • Manual Auscultation of Blood Pressure (BP) • Oxygen Saturation Levels (Sp02%) • Capillary Refill Time (CRT)
Others include:
• Conscious level
• Urine output
• GCS - Glasgow Coma Scale
why are vitals so important?
Why are taking vitals important?
• Reliable indicator of deteriorating and improving health.
Measuring each of the vital obs means data is collected therefore plotted onobservations chart (i.e NEWS2, PEWS), allowing for trends and patterns to be seen (Park, Allen & Hill, 2019).
The findings and results plotted will then help determine the level of care a patient requires (Carvalho et al., 2020).
• Inadequate recording of vitals// inappropriate responses to abnormal values (Brekke et al, 2019) can lead to clinical deterioration or it being detected far too late.
• All patients should have vitals checked once every 12 hours unless specified otherwise by Senior (Dougherty and Lister, 2015).
-Frequency depends on condition, diagnosis and location (ITU).
What are frquent abbreviations in taking vitals?
- BD- Bis and die 2x a day aka every 12 hr
- TDS-3X a day aka every 8 hours
- QDS-4X a day aka every 6 hours
what is respiration? why is taking respiration rate valuable?
- Respiration: ensure tissues and cells have sufficient oxygen to support process of aerobic metabolism and the removal of carbon dioxide, the waste of metabolism.
- Respiration changes are one of the early indicators of acute illness or deterioration and account for one of the main reasons for admission to critical care units (Rolfe, 2019).
- Most freq, missed though (Flenady et al., 2017; Park, Allan & Hill, 2019)
what are the 2 types of respiration?
2 types:
• Internal respiration-Metabolism of gases at CELLULAR LEVEL, WHERE BODY COMBINES OXYGEN+ CARBS= ENERGY + CO2(WASTE)
External respiration- the exchange of gases at an ALVEOLAR AND CAPILLARY level
How do you calc the respiration rate?
• Involves calculation of breaths per min
Observe the chest rise (inspiration) and fall (expiration) over 60 seconds. One breath is counted when one cycle of inspiration and expiration has been observed.
Describe the mechanisms of breathing:
inspiration and exhalation
- Changes in volume in respiratory system lead to changes in pressure lead to flow of gases to equalise this pressure. BOYLE’S LAW
- Inspiration-
- the pressure in the alveoli must be lower then the air pressure in the atmosphere:
- so need to expand lungs via contraction of the diaphragm and external intercostal muscles so chest cavity to expands , - alveolar pressure to drop below atmospheric pressure. Air then flows into .
• Expiration:
- the pressure gradient in the lungs needs to be greater then the pressure in the atmosphere.
- During expiration the diaphragm and the external intercoastal muscles relax.
how does respiratory rate in children under 7 change?
Predom abdominal breathers therefore abdominal movements should be counted over 60 sec, instead of chest rising.
How to assess resp rate?
• Rate -BPM
• Depth- volume of air moving in and out of the lungs with each respiration
• Pattern -changes in pattern are often due to problems with the respiratory centre in the brain
•
What is the look,listen, feel approach to assessing a patients’s resp rate?
Look, listen and feel2 approach:
- AKA “see and treat” to prevent deterioration which focuses on assessing a patient’s respiratory rate.
1. SOUND/NOISE - Normal= quiet
- Unusual= grunting, snoring and gurgling could indicate etc
- CHEST SYMMETRY
- Shape and expansion of chest.
- Do both side of the chest rise to the same extent and at the same time? Anything else is abnormal unless has smthn diagnosed in history.
- Must stand directly when assessing. - USE OF ACCESSORY MUSCLES
- Important muscles : diaphragme, external intercostal and scalene muscles
- Accessory muscles are the extra and so if these are being used this means the person needs extra help with lung expansion so could show resp distress. - COLOUR
-Look for central or peripheral cyanosis (bluish tint to skin and mucous membrane, normally on fingers and lips which indicates low O2 levels which could be due to resp failure).
-Cyanosis seen as late sign for deterioration and CAN BE HARD TO DETECT IN ARTIFICAL LIGHTING
-2 levels:
Peripheral cyanosis: adequate oxygenation of the circulating blood but abnormalities of local circulation are present- SLUGGISH PERIPHERAL CIRCULATION.
Visible in nail beds, fingertips and toes.
Central cynanosis: indicates gross hypoxaemia indicating that the patient is very ill.
- PURSED LIPS AND NASAL FLARING
- Pursed lip is a technique used yo slow down breathing in patients experiencing shortness of breath (SOB). - CONSCIOUS LEVEL
-Reduced level or confusion often presents in hypoxaemia
-Does the patient look alert?
Is the patient orientated to the time and place?
Speak and ask simple questions in relation to time, location and their identity.
what are the normal resp rates?
Newborn - 1 year: 30-60 bpm 1-3 years: 24-40 bpm 4-5 years: 22-34 bpm 6-12 years: 18-30 bpm Adolescent: 12-16 bpm Adult: 12-20 bpm
• Tachypnoea
aka Hyperventilation. This a respiration rate above levels considered to be normal >20bpm
• Bradypnea
aka Hypoventilation. RR <12 bpm
• Dyspnoea
shortness of breath with an elevated, normal or decreased respiratory rate.
