Vital Observations Flashcards
What are vital observations?
Vital signs are measurements of the body’s most basic functions. The four main vital signs routinely monitored by medical professionals and health care providers.
Why are vital observations so vital?
- Recognising the deteriorating patient (RCP, 2017, BTS, 2017)
- Complete the procedure as per best evidence based practice (NMC 2018, HCPC 2012)
- Referral if needed
- Ensure any equipment used is properly serviced and maintained
What is the purpose of respiration?
Respiration supplies the body with oxygen and removes carbon dioxide
Why measure respiration?
- To determine per minute the rate, depth and pattern of respiration as a base measurement for future comparison
- To monitor fluctuations in respiration
- To evaluate the patients response to medications or treatments
What are the observations for respiration?
Rate: The rate and depth will together determine the type/quality of respiration
Depth: Indicates the 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 terminology for irregular respiratory rates?
- Bradypnoea
- Tachypnoea
- Dyspnoea
- Hyperpnoea
- Apnoea
What is Bradypnoea?
Abnormally slow
What is Tachypnoea?
Elevated and rapid
What is Dyspnoea?
Shortness of breath with an elevated, normal or decreased respiratory rate
What is Hyperpnoea?
Abnormally deep and laboured- it may occur with or without rapid breathing
what is Apnoea?
Absence of breathing
What is the average respiratory rate of a Newborn?
30-60 breaths per minute
What is the average respiratory rate of a 1-3 year old?
24-40 breaths per minute
What is the average respiratory rate of a 4-5 year old?
22-34 breaths per minute
What is the average respiratory rate of a 6-12 year old?
18-30 breaths per minute
What is the average respiratory rate of an adolescent?
12-16 breaths per minute
What is the average respiratory rate of an adult?
12-20 breaths per minute
What is hypoventilation (bradypnoea)?
Below levels considered to be normal (RR<12)
What is hyperventilation (Tachypnoea)?
Above levels considered to be normal (RR>90)
What is a pulse?
The pulse is a pressure wave of blood caused by the alternating expansion and recoil of the elastic arteries during each cardiac cycle.
What is the purpose of measuring a pulse?
- To obtain a base measurement for future comparison
- To monitor fluctuations in pulse
- To determine per minute information regarding heart rate, pattern (rhythm), and amplitude (strength)
How do you observe a pulse?
- Felt anywhere an artery can be palpated against something firm
- Rhythm: Normally regular, contained by contraction of the heart muscle in response to specific nerve stimulus
- Amplitude: The reflection of the pulse strength and arterial elasticity
What is the average pulse rate of a 1 week-3 month old?
100-160 beats per minute
What is the average pulse rate of a 3 month-2 year old?
80-150 beats per minute
What is the average pulse rate of a 2-10 year old?
70-110 beats per minute
What is the average pulse rate of a 10 year old-adulthood?
50-90 beats per minute
What is Tachycardia? (pulse)
Above levels considered to be normal (>100 BPM)
What is Bradycardia? (pulse)
Below levels considered to be normals(<60 BPM)
What is a normal Capillary Refill Rate?
- Normal CFT is considered to be shown to return within 2-3 seconds
- A delay in this return may be a sign of reduced skin perfusion, hypovolemic shock, circulatory diseases
What is blood pressure?
The force exerted by blood on the walls of the vessel in which it is contained.
What is the purpose of measuring blood pressure?
- To determine the patient’s blood pressure as a base for comparing future measurements
- To monitor fluctuations in blood pressure
What is the measurement of blood pressure?
-mmHg (millimetres of mercury) is the unit of measurement
What is systolic pressure (blood pressure)?
Pressure exerted on the blood vessel walls following ventricular systole, when the arteries contain maximum pressure.
What is diastolic pressure (blood pressure)?
Pressure exerted on blood vessel walls during ventricular diastole, when the arteries contain least pressure.
What is hypertension (blood pressure)?
A BP above levels considered to be normal (BPS>140)
What is hypotension (blood pressure)?
A BP below levels considered to be normal (BPS<90)
What is body temperature?
Is the balance between heat gain and heat loss
What controls body temperature?
Hypothalamus- heat loss- heat conservation/ production
What is the body temperature range?
36-37.5 degrees- optimum core temp is 37 degrees
What are the temperature values?
- Hypothermia 35 degrees
- Normal range in accordance with definitions: 35.1-37.9 degrees
- Optimal range for homeostasis: 36.5-37.5 degrees
What are the 6 ways to measure core temperature?
- Tympanic
- Nasalpharyngeal
- Oesophageal
- Rectal
- Axillary
- Sublingual
What is hyperthermia (pyrexia)?
Above levels considered to be normal (Above 38 degrees)
What is hypothermia?
Below 35 degrees
How do you measure oxygen saturation levels (SP02%)?
- Using a probe attached to the finger, ear or toe (depending on age or the patient)
- Photodetector and light-emitting diodes (LED) on probe
What is considered a normal oxygen saturation level?
Normal pulse oximeter reading 94-98%. Below 94% requires investigation
What is NEWS?
National Early Warning Scores- National early warning system to identify “at risk” patients at an early age
What is MEWS?
Modified Early Warning Scores
What is PEWS?
Paediatric Early Warning Scores
What is a PAR score?
Patient at risk scoring
What should you do for all procedures?
- Gain consent
- Decontaminate hands
- Clean equipment
- Dispose equipment safely
- Record, report and act on results
