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Nursing Assessment Skills > Vital Observations > Flashcards

Vital Observations Flashcards

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1
Q

Patient observations are undertaken for the following three reasons…

A

1) they provide a baseline
2) they assist in the recognition of improving or deteriorating health
3) they assess the effectiveness of care

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2
Q

Why are observation charts important? (i.e. NEWS2)

A

The data plotted onto the chart can allow for trends and patterns to be seen - good and bad.

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3
Q

The abbreviations BD, TDS and QDS mean what?

A

BD - 2 times a day (every 12 hours)
TDS - 3 times a day (every 8 hours)
QDS - 4 times a day (every 6 hours)

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4
Q

What is the function of respiration?

A

To provide the tissues and cells of the body with sufficient oxygen to support aerobic metabolism and the removal of C02 (the waste product of metabolism)

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5
Q

Which vital observation is an early indicator of illness?

A

Respiratory Rate

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6
Q

What are the two classifications of respiration and what do they do?

A

External Respiration - the exchange of gases at alveolar and capillary level

Internal respiration - the metabolism of gases at a cellular level (where the body combines the oxygen with carbohydrates to create energy, resulting in C02 as a waste product)

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7
Q

Respiratory Rate is recorded in what form?

A

Breaths per minute (BPM)

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8
Q

What would you do to take a patients Respiratory Rate ?

A

Observe the chest rising (inspiration) and falling (expiration) over 60 seconds.

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9
Q

What is one breath counted as?

A

One breath is counted as one cycle of inspiration and expiration.

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10
Q

What three things are included when assessing a patients Respiratory Rate?

A

Rate, Depth and Pattern

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11
Q

What does ‘depth’ indicate when assessing respiratory rate?

A

Depth indicates the volume of air moving in and out of the lungs with each respiration.

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12
Q

What can a change in a respiratory pattern indicate?

A

It can indicate that there is a problem with the respiratory centre in the brain.

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13
Q

What other respiratory observations may a nurse use apart from RR (rate, depth and pattern)?

A

Look, listen and feel.

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14
Q

What does normal respiration sound like and what sounds could indicate respiratory distress?

A

Normal respiration = quiet

Respiratory distress = sounds such as grunting, snoring and gurgling.

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15
Q

What is chest asymmetry and what are the accessory muscles?

A

Chest asymmetry is when both sides of the chest do not take off at the same time.

Accessory muscles = anything that is NOT the diaphragm, external intercostal or scalene muscles (primary inspiration muscles).

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16
Q

What is cyanosis and what may it indicate?

A

Cyanosis refers to a bluish tinge/cast to a patients skin and mucus membrane (normally observed on fingers and lips).

It indicates low oxygen levels and is a late sign of respiratory deterioration.

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17
Q

What are the two levels of cyanosis?

A

Peripheral cyanosis (n the extremities and fingers), often seen in shock.

Central cyanosis (around the core, lips and tongue), indicates the patient is very ill and represents gross hypoxemia (low oxygen blood concentration)

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18
Q

When taking a patients respiratory rate they should ideally be _______.

A

Unaware - patient’s RR often changes when they are aware their breathing is being observed.

this can be achieved by taking a patients RR alongside other obs e.g. pulse

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19
Q

______ lips and _____ flaring can be another sign of respiratory distress / dysfunction.

A

Pursed lips and nasal flaring.

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20
Q

Assessing a patients level of a________ is also important as lack of a________ can indicate hypoxaemia.

A

Alertness.

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21
Q

What is a normal respiratory rate for an adult?

A

12 - 20 BPM

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22
Q

What is tachypnoea and what RR is it considered as?

A

Tachypnoea is known as hyperventilation and is a RR of >20 BPM.

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23
Q

What is bradypnoea and what RR is it considered as?

A

Bradypnoea is known as hypoventilation and is a RR of <12 BPM.

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24
Q

What is dyspnoea?

A

Dyspnoea is shortness of breath.

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25
Q

What is apnoea?

A

Apnoea is the absence of breathing.

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26
Q

What is hyperpnoea?

A

Hyperpnoea is abnormally deep and laboured breathing.

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27
Q

Name the steps you would take when observing a patient’s RR.

A

1) Decontaminate hands, apply PPE if required and gain consent.
2) Position the patient so the chest can be observed (maintaining dignity).
3) Count each time the chest raises for 60 seconds.
4) Decontaminate hands, remove PPE if applied and document the reading according to hospital/trust policy.

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28
Q

What is the pulse?

A

The pulse is a pressure wave of blood caused by the alternating expansion and recoil of the elastic arteries during each cardiac cycle (heartbeat).

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29
Q

In what form is pulse rate recorded?

A

BPM (beats per minute)

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30
Q

What is the most commonly used pulse point when taking a patients pulse?

A

Radial pulse (wrist)

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31
Q

How many pulse points are there on the body that can be palpitated with fingers?

A

8

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32
Q

Where is the temporal artery pulse point located?

A

It is located in the head, above the zygomatic arch as well as above and in front of the tragus.

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33
Q

Where is the carotid artery pulse point located?

A

It is located at the neck, between the larynx and the sternocleidomastoid muscle in the neck. Present bilaterally.

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34
Q

Where is the brachial artery pulse point located?

A

It is located near the elbow crease (antecubital fossa), 2-3cm above it.

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35
Q

Where is the radial artery pulse point located?

A

It is located on the inside of the wrist, near the side of the thumb.

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36
Q

Where is the femoral artery pulse point located?

A

It is located in the femoral triangle, can be found bilaterally.

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37
Q

Where is the popliteal artery pulse point located?

A

It is located at the back of both knees. (One of the more challenging pulse points to palpitate)

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38
Q

Where is the posterior tibial artery pulse point located?

A

It is located near the medial malleolus (bony projection on the inside of each ankle), near the Achilles tendon’s insertion point.

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39
Q

Where is the dorsalis pedis artery pulse point located?

A

It is located on top of the foot, in the first intermetatarsal space, above the extensor tendon of the great big toe.

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40
Q

When calculating and assessing a patients pulse (HRT), the r___, r_____ and a________ should be taken into account.

A

Rate (BPM), rhythm (sequence of beats i.e. regular or irregular) and amplitude (strength).

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41
Q

Name 3 factors that can affect an individuals heart rate.

A
  • Talking
  • Age
  • Temperature
  • Medication
  • Sex
  • Posture
  • Illness
  • Stress and/or anxiety
42
Q

What is a normal BPM for an adult?

A

55 - 90 BPM

43
Q

What is tachycardia?

A

Tachycardia is a heart rate that is >100BPM

44
Q

What is Bradycardia?

A

Bradycardia is a heart rate that is <60BPM

45
Q

Before recording a pulse, what signs should you look for in a patient? Name 3.

A

1) If they are hot/flushed (temperature)
2) If they are red or pale (colour)
3) If they are sweaty or clammy

46
Q

Name the steps you would take when observing a patient’s BPM.

A

1) Decontaminate hands, apply PPE if required and gain consent.
2) Locate a pulse point and palpitate using 2-3 fingers (index and middle finger preferably).
3) Count the pulse for 60 seconds, taking note of rate, pattern and amplitude.
4) Decontaminate hands, remove PPE if applied and document the reading according to hospital/trust policy.

47
Q

Why is it important to not use the thumb when palpitating a patients pulse?

A

The thumb has its own pulse beat, this may cause an inaccurate or muddled reading.

48
Q

What is the definition of temperature?

A

Temperature is the ‘degree’ of the internal heat of the body.

49
Q

Why is it important to place the numerical value of the temperature reading alongside the patients presenting condition and symptoms?

A

It allows us to gain greater insight into the patient’s current condition and allows more appropriate treatment and care to be given.

50
Q

Temperature monitoring can also be used to measure the e____________ of, and track the s___ e______ arising from any intervention delivered to the patient.

A

Effectiveness and side effects.

51
Q

How many ways can temperature be taken?

A

7.

52
Q

What is and how is a tympanic temperature taken?

A

Tympanic temperature is done via the tympanic membrane (ear) and is the most commonly used method.

53
Q

What is and how is a nasopharyngeal temperature taken?

A

It is a nasal measurement, a probe is placed in the nasal cavity.

54
Q

What is and how is an oesophageal temperature taken?

A

It is a core temperature measurement, a probed is inserted into the oesophagus. This method is often used to monitor anaesthetised patients.

55
Q

What is and how is a rectal temperature taken?

A

Rectal temperature is measured by inserting a probe into the anus.

56
Q

What is and how is an axillary temperature taken?

A

Axillary temperature is taken from the armpit.

57
Q

What is and how is a sublingual/buccal temperature taken?

A

It is an oral measurement which can be taken as a sublingual measurement (under the tongue) or a buccal measurement (in the cheek).

58
Q

What is and how is a temporal artery temperature taken?

A

It is a measurement taken from the forehead, by measuring infrared heat waves from the skin above the tympanic artery.

59
Q

What is the normal temperature range?

A

35.1c - 37.9c

However, the optimal range is 36.5c - 37.5c

60
Q

What is hypothermia and what temperature is it classed as?

A

Hypothermia is a low body temperature and is <35c

61
Q

What is pyrexia and what temperature is it classed as?

A

Pyrexia is a high temperature >37c which is associated with infection (fever).

Low-grade pyrexia = 37-38c
Moderate to high-grade pyrexia = 38-40c
Hyperpyrexia = >40c

62
Q

What is hyperthermia and what temperature is it classed as?

A

Hyperthermia refers to an elevation in core body temperature due to thermoregulation failure. Not necessarily caused by infection. It is >37c.

63
Q

Name the steps you would take when observing a patient’s temperature.

A

1) Decontaminate hands, apply PPE if required and gain consent.
2) Choose and locate a temperature point.
3) Ensure the device used is clean and in good working order.
4) Make sure there are no signs of swelling, injuries or infection before inserting or using the equipment.
5) Take reading, dispose of any single-use apparatus used and clean device.
6) Decontaminate hands, remove PPE if applied and document the reading according to hospital/trust policy.

64
Q

What is blood pressure (BP)?

A

It is a measure of the force that your heart uses to pump blood around your body.

65
Q

What is systolic pressure?

A

Systolic pressure is the peak force of your blood as it pushes against the walls of the arteries, as the heart contacts.

66
Q

What is diastolic pressure?

A

Diastolic pressure is the force exerted on the walls of the arteries as the heart relaxes and refills.

67
Q

What unit is BP measured in?

A

Millimetres of mercury (mmHg)

68
Q

What are some factors that can influence BP readings?

A
  • Sleep
  • Activity
  • Stress/emotions
  • Medication
69
Q

Which artery is most commonly used to measure BP?

A

The brachial artery.

70
Q

What is generally considered a normal systolic BP at rest in adults?

A

110 - 140 mmHg

71
Q

What is generally considered a normal diastolic BP at rest in adults?

A

70 - 80 mmHg

72
Q

What is hypertension and what reading would it be considered as?

A

Hypertension is BP reading that falls above the normal range, it is considered as a reading above 140/90 mmHg.

73
Q

What is hypotension and what reading would it be considered as?

A

Hypotension is BP reading that falls below the normal range, it is considered as a reading that falls below 90/60 mmHg.

74
Q

What equipment would you need to take a manual BP?

A
  • Aneroid sphygmomanometer

- Stethoscope

75
Q

What is the name of the sound you ear when taking a manual BP?

A

Korotkoff.

described as a faint tapping, ticking or thudding sound

76
Q

What is advised when taking a pregnant patient’s BP?

A

When taking blood pressure it is advised that pregnant patients are sat up instead of lying down.

77
Q

What steps would you take when taking a patient’s BP?

A

1) Decontaminate hands, apply PPE if required and gain consent.
2) Select an arm and remove any clothing that is covering it, check for any broken skin, infections, mastectomy sites etc.
3) Check the equipment is in good order and clean/decontaminated.
4) Locate the brachial artery, wrap and fix the cuff securely 2-3cm above it.
5) Ensure the patient is rested, does not talk when taking and legs are uncrossed.
6) To calculate the estimated systolic pressure relocate the brachial artery and palpate while inflating the cuff. When the brachial artery can no longer be felt, inflate the cuff a further 20- 30 mmHg. Slowly deflate the cuff and note the point at which the pulse becomes detectable again. (this is the estimated systolic pressure)
7) Deflate the cuff and wait 15-30 seconds then lace the stethoscope in your ears (earbuds facing forward). and place the diaphragm over the brachial artery.
8) Inflate the cuff 20-30 mmHg above the estimated systolic pressure.
9) Slowly deflate the cuff by 2-3 mmHg per second. and listen for Korotkoff sounds. The first Korotkoff sound is the systolic reading and the diastolic reading is the point in which the sound completely disappears.
10) Once the Korotkoff sounds disappear, deflate the cuff and remove.
11) Decontaminate hands, remove PPE if applied and document the reading according to hospital/trust policy.

78
Q

What other type of BP measurement may be taken apart from a manual BP?

A

Electronic.

79
Q

What is oxygen saturation?

A

Oxygen saturation is the fraction of oxygen-saturated haemoglobin relative to total haemoglobin in the blood.

80
Q

What is used to measure oxygen saturation?

A

Oxygen saturation is measured by using a pulse oximeter.

81
Q

What unit is oxygen saturation measure in?

A

%

82
Q

What can a pulse oximeter device be used to identify?

A

Early hypoxia (deprivation of oxygen)

83
Q

What colour is deoxygenated blood and what colour is oxygenated blood?

A
  • Venous blood (deoxygenated blood) is dark red.

- Arterial blood (oxygenated blood) is bright red.

84
Q

How do pulse oximeters measure blood oxygen saturation?

A

Pulse oximeters measure the blood oxygen levels via red and infrared light.

Oxygenated blood absorbs infrared light and deoxygenated blood absorbs red light. A pulse oximeter measures and calculates the ratio of red and infrared light in the blood giving a SpO2 % reading.

85
Q

What is considered a normal Sp02 in an adult with no respiratory disorders?

A

95 - 100%

86
Q

What is considered a normal Sp02 in an adult with a respiratory disorder?

A

> 88%.

87
Q

Where is the most common place to place a pulse oximeter?

A

The fingers (excluding thumbs).

88
Q

Where else may a pulse oximeter be placed on the body?

A
  • Nose
  • Ear lobes
  • Toes
  • Forehead
89
Q

Name some medical conditions which can affect an Sp02.

A
  • Anaemia

- Raynaud’s syndrome

90
Q

Name some non-medical factors that can affect an Sp02 reading.

A
  • False nails and nail varnish
  • Cold peripheries
  • Pressure damage from continuous Sp02 readings
  • Dirty hands/skin
  • Unclean Sp02 probe
91
Q

How often should the pulse oximeter site be changed if it is in continuous use?

A

Every 4 hours.

92
Q

What steps would you take when taking a patient’s Sp02 reading?

A

1) Decontaminate hands, apply PPE if required and gain consent.
2) Ensure the probe site and equipment is clean (and nails are varnish/false nail-free if using fingers)
3) Check the probe light is working and place on the patient, asking them to remain still.
4) Wait for up to 60 seconds for the oximeter to record
5) Decontaminate hands, remove PPE if applied and document the reading according to hospital/trust policy.

be careful to take note as to whether the patient is receiving 02 therapy

93
Q

What is capillary refill time (CRT)?

A

Capillary refill time is a visual assessment. It is defined as the time taken for a distal capillary bed (nail bed) to regain its colour after it is drained from applying pressure.

94
Q

What unit is CRT measured in?

A

/ seconds

95
Q

How long should pressure be applied when taking a patient’s CRT?

A

5 seconds

96
Q

What does CRT assess?

A

It assesses peripheral perfusion (the arterial blood flow to the tissues in the extremities).

97
Q

What is considered a normal CRT?

A

≤ 2 seconds

98
Q

What does a prolonged CRT indicate?

A
  • Poor circulation

- A sign of dehydration and shock.

99
Q

Name some factors can cause a prolonged CRT reading.

A
  • Age
  • Cold surroundings
  • Poor lighting
100
Q

What steps would you take when taking a patient’s Sp02 reading?

A

1) Decontaminate hands, apply PPE if required and gain consent.
2) Ensure the patient’s nails are free from varnish or fake nails and are clean.
3) Check for any injury, trauma or pain to the nail bed and finger (use a different site if so)
4) Use firm pressure to press on the nail bed for 5 seconds, then release (the nail bed will appear white at first).
5) Count how long it takes for the blood to return to the nail bed.
6) Decontaminate hands, remove PPE if applied and document the reading according to hospital/trust policy.

Nursing Assessment Skills (2 decks)

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