Vital Observations Flashcards
What are the 6 vital observations?
- respiratory rate
- pulse
- CRT (capillary refill time)
- blood pressure
- temperature
- oxygen saturation levels (Sp02%)
Which vital observation can be an early indicator of acute illness?
respiratory rate
in terms of breathing, what does bradypnoea mean?
abnormally slow
what does tachypnoea mean?
elevated and rapid
what does dyspnoea mean?
shortness of breath
what does hyperpnoea mean?
abnormally deep and laboured
what does apnoea mean?
absence of breathing
what is the normal respiratory rate for an adult?
12-20bpm
what rate does hypoventilation occur?
RR<12
what rate does hyperventilation occur?
RR>20
what does the pulse measure?
pressure wave of blood caused by the arteries of each heart beat
what is the normal pulse for an adult?
55-90
what are the 10 steps of taking a pulse reading?
- wash hands, apply PPE
- gain consent
- locate the radial artery
- ensure the patient is rested when recording the pulse
- using 2/3 fingers, palate the radial artery
- ensure enough pressure is applied
- count the pulse for 60 seconds
- take note of the rate, rhythm and amplitude
- wash hands, remove PPE
- document the reading
what is the normal CRT rate?
normal CRT should return within 2-3 seconds
what is the target oxygen saturation levels for a healthy individual?
95-100%
what is the target sp02% for an acutely ill patient?
94-98%
what is the optimal body temperature?
36.0 - 37.5
How is blood pressure written?
120/70 mmHg
What is systolic pressure? x/00
this is when the arteries contain maximum pressure
what is diastolic pressure? 00/x
this is when the arteries contain the least pressure
what value indicates hypertension?
BP systolic>140
what value indicates hypotension?
BP systolic <100
How would the Korotkoff sounds be during taking BP?
- tapping/thudding sound
- sound changes to a murmur/ swishing sound
- sound changes to knocking sounds louder than stage 1
- sound is muffled as pressure decreases
- silence
what are the tips in taking manual blood pressure?
- ensure equipment is clean and working
- wash hands, apply PPE
- ensure patient is rested
- ask patient not to eat or speak while taking the observation
- ensure legs are uncrossed
- take an estimated systolic reading
- ensure the stethoscope is in your ear correctly
- ask for help if needed
What are the main key points when taking vital observations?
- introduce yourself
- gain consent
- maintain privacy and dignity
- PPE
- documentation
- handover information
What is the response when the NEWS2 score is 1-4?
- inform nurse, who then must assess the patient
- 4-6 hourly monitoring
what is the response when the NEWS2 score is 5+
- inform nurse, urgent assessment
- minimum 1 hour monitoring
what is the response when the NEWS2 score is 7 or more?
- emergency assessment, taken to higher dependency unit
- continuous monitoring
