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Vital Signs Flashcards

1
Q

Description of Vital signs and name the 5

A

▪ Vital signs are a person’s
1. temperature (T)
2. pulse (P)
3. respiration (R)
4. blood pressure (BP)
5. Pain

Pulse oximetry, the noninvasive measurement of
arterial oxyhemoglobin saturation of arterial blood, is also often included with the measurement of vital signs.

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2
Q

Objective and Definition of Vital Sign

A

Objective: Measurement of one’s overall health status.

A change in vital signs may indicate a change in health.

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3
Q

What are the general guidelines when assessing vital signs?

A
  1. Measuring vital signs is your responsibility.
    • Healthcare provider 5 patients, you are responsible for 5 patients unless in your institution you have other modalities of care aside from general ruling
  2. Assess equipment to ensure that it is working correctly and provides accurate findings.
    - aneroid: gauge
    - if the manometer does not point to 0, you have to
    calibrate to achieve normal results
    - You need to calibrate it
    - They should have not have a defect
  3. Select equipment on the basis of the patient’s condition and characteristics
    - The BP cuff fit properly
  4. Know the patient’s usual range of vital signs
    - partial systolic pressure
    - range or baseline data of patient
  5. Know your patient’s medical history, therapies, and prescribed medications
    - Adverse effects: palpitation; : side effect of drug
    - PATHOLOGIC
    - What the patient has
    - Eg have hypertension they won’t have a normal BP
  6. Control or minimize environmental factors that affect vital signs
    - Temperature
    - Too hot too cold
  7. Use an organized, systematic approach when taking vital signs
    - assemble all materials that you need before doing the procedure
    - Follow procedural in making or doing vital signs
    - Organized - assemble all the materials
    - Systematic - Orderly manner
  8. On the basis of a patient’s condition, collaborate with health care providers to decide the frequency of vital sign assessment.
    - One parameter/order may have something to do
    with other interventions of other healthcare
    professional
    - Collaboration - You are a team working for one end goal
    - Physician, nurse, pharmacist
    - It may have other factors
    - Eg surgeon
  9. Use vital sign measurements to determine indications for medication administration
    - standard maintenance dose; backup medication
    - Eg anti hypersensitive tract
    - When BP shoots up you need to take this type of medication
    - You need to have your vital signs
    - You need to know first before you drink
  10. Verify and communicate significant changes in
    vital signs
    - not enough to know
    - denotes patient deterioration
    - You need to communicate with the physician
    - You don’t know if decrease or increase can
    cause a coma
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4
Q

State the 6 ways on when to assess vital signs

A
  1. Upon admission and before discharge of the
    client.
  2. At the start of every shift.
  3. Before, during and after an invasive procedure
  4. Before and after an intervention, therapy or
    treatment.
  5. Before and after medication administration
  6. Whenever a client’s condition changes
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5
Q

Description of Upon admission and before discharge of the client

A
  • ER
  • Ward
  • Admission (ER & Ward)
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6
Q

Description of At the start of every shift.

A
  • If you have 8 hour shift
  • At the start of every shift you take the vital signs
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7
Q

Description of Before, during and after an invasive procedure

A

What is an invasive procedure?
Anything that they insert, makes a cut and insert or an opening in the body and inserts

Ex: Catheterization, NGT insertion

Bedside procedures
- insertion

Diagnostic procedure
- endoscopy
- biopsy

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8
Q

Description of Before and after an intervention, therapy or treatment.

A

Therapy
- Physical
- Occupational

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9
Q

Description of Before and After medication administration

A

Just Before and After medication administration

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10
Q

Description of Whenever a client’s condition changes

A

Level of Consciousness
- conscious
- lethargic - Sleepy or fatigued and sluggish
- stupor - Near unconsciousness
- coma

For as long as the change or discrepancy is not significant, the standard vital signs table is credible

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11
Q

ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Temperature

A

Tympanic 36.5 - 38.1°C

Oral 36.4 - 37.6°C

Rectal 37 - 38.1°C

Axillary 35.9 - 37.0°C

Temporal 37 - 38°C

(NOTE: References may vary)

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12
Q

ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Pulse

A

60 - 100 bpm

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13
Q

ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Respiration

A

12 - 20 bpm

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14
Q

ACCEPTABLE RANGES OF VITAL SIGNS FOR ADULTS: Blood pressure

A

SBP <120 (less than)
DBP <80 mmHg (less than)

Pulse pressure
30 - 50 mmHg

SBP - Systolic (start)
DBP - Diastolic (end)

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15
Q

HOW TO CALCULATE FOR PULSE PRESSURE

A

Pulse pressure = Systolic - diastolic
(120 - 80 = 40)

30-50 is the normal pulse pressure
90 pulse = wide

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16
Q

ASSESSING BODY TEMP

A
  1. Oral temp
  2. Ear temp
  3. Rectal temp
  4. Axillary temp
  5. Temporal artery temp
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17
Q

Definition of Body Temperature

A

The result of the amount of heat produced and the amount of heat lost by the body.

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18
Q

Purposes of Body Temperature

A
  1. To obtain baseline information
  2. To assess the progression of an illness
    - Eg Dengue
    - Infection UTI
  3. To monitor a response to therapy
    - Progression
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19
Q

2 TYPES OF BODY TEMP

A
  1. Core temperature
    - Inside the body
  • Rectal
  • Oral cavity
  • Tympanic membrane
  1. Surface temperature
    - Skin & axillae
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20
Q

WHAT IS THE DIFFERENCE BETWEEN THE 2 CONTROL CENTERS?

(Anterior & Posterior hypothalamus)

A

Compensatory Mechanism to achieve HOMEOSTASIS

They need to work hand in hand for us to be able to have homeostasis

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21
Q

Description of anterior hypothalamus

A
  • Control heat loss; nerve sensors send out signals that initiate sweating, peripheral vasodilation and inhibition of heat production
  • Too hot we want to stay cool
  • Sweating
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22
Q

Description of Posterior hypothalamus

A
  • Controls heat productions; nervous sensors send out signals that initiate shivering, vasoconstriction (increases BP), release of epinephrine
  • compensatory mechanism
  • Super cool want to stay warm
  • Shivering
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23
Q

FACTORS THAT PROMOTE HEAT PRODUCTION

A
  1. Basal metabolic rate
  2. Muscle activity
  3. Thyroxine production
  4. Epinephrine, norepinephrine, and sympathetic
    stimulation stress response
  5. Fever.
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24
Q

Description of BASAL METABOLIC RATE (BMR)

A

Number of calories burned performing basic life sustaining functions

  • Different metabolic rates that affects heat
    production
  • Eg laying in bed we have resting metabolic rate
  • It has a link to heat production
  • Higher metabolic rate = More heat production
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25
Q

Description of MUSCLE ACTIVITY

A

Ranges from internal substance movement to exterior muscle locomotion

  • Internal substance movements
  • Controls body heat
  • Contraction of skeletal muscle
  • Metabolism increases and released as heat
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26
Q

Description of THYROXINE PRODUCTION

A

Thyroxine is a thyroid hormone
- Hyperthyroidism
- Hypothyroidism

Stimulated neurological system affects heat production

Hyperthyroidism (hotter) - Thyroid glands produces too much hormone thyroxine causing unintentional weight loss and rapid or irregular heartbeat

Hypothyroidism (cooler) - Thyroid gland doesn’t produce enough hormones

  • Blood vessels
  • Secrete different hormones to aid different production
  • Thyroid hormones
  • If you have too much thyroxine they always feel hot
  • Hypothyroid - to make the ppl cooler
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27
Q

Description of EPINEPHRINE, NOREPINEPHRINE, AND SYMPATHETIC STIMULATION STRESS RESPONSE

A

neurotransmitter and hormone also known as adrenaline “fight or flight response”

Stress - Epinephrine body responses
- Flight or flight response
- Adrenal glands give epinephrine which causes an increase in body temperature

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28
Q

Description of FEVER

A

our body’s attempt to fight an infection, produces more White Blood Cells that affects hypothalamus that increases body temperature (heat production)

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29
Q

FACTORS THAT PROMOTE HEAT LOSS

A
  1. Conduction
  2. Radiation
  3. Convection
  4. Vaporization
    (evaporation
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30
Q

Description of conduction

A

The process of losing heat through physical contact with another object or body. For example, if you were to sit on a metal chair, the heat from your body would transfer to the cold your body would transfer to the cold metal chair

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31
Q

Description of radiation

A

Form of heat loss through infrared rays.

This involves the transfer of heat from one object to another, with no physical contact involved. For example, the sun transfers heat to the earth through radiation

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32
Q

Description of convection

A

The transfer of heat from a body to moving molecules such as air or liquid

Convection is the process of losing heat through the movement of air or water molecules across the skin.

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33
Q

Description of Vaporization (evaporation)

A

Loss of heat that occurs when a liquid is converted to a vapor

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34
Q

FACTORS AFFECTING TEMPERATURE

A
  1. Age
  2. Diurnal variations
  3. Environment
  4. Exercise
  5. Hormones
  6. Stress
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35
Q

Description of age

A

Influenced by the environment
extreme ages due to thermoregulation functions
- young - not fully developed
- old - easily deteriorated

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36
Q

Description of Diurnal variations

A

Changes throughout the day

Diurnal Cycle: vital signs can change due to metabolic rate
Changes through out the day
- Urinal cycles
- Vital signs can change

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37
Q

Description of Environment

A
  • Too hot and too cold
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38
Q

Description of exercise

A

the more you engage in strenuous activity, the more you increase body temperature

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39
Q

Description of hormones

A

Progesterone rises body temperature
Synthetic production system

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40
Q

Description of stress

A

stimulation of the sympathetic nervous system can increase the production of epinephrine and norepinephrine thereby increasing metabolic rate and heat production

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41
Q

TYPES OF THERMOMETER

A
  • Digital and paper strip thermometer
    • Temperature Sensitive Skin Tape

Tympanic thermometer

Temporal Artery thermometer

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42
Q

ROUTES OF TEMPERATURE ASSESSMENT

A
  1. Oral
  2. Rectal
  3. Axillary
  4. Tympanic
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43
Q

Where is the oral route?

A

In the mouth

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44
Q

Advantages of the Oral Route

A

▪ most accessible and convenient
▪ reflects rapid change in core temperature

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45
Q

Disadvantages of the Oral Route

A

▪ contraindicated in children below 3 y/o
- chew/play/remove

▪ Seizure-prone client
- jaw tightening causing injury as paced under the tongue, hypervascularized which is very fragile

▪ Confused irrational and unconscious clients

▪ clients who experience nausea and vomiting

▪ contraindicated after oral and nasal surgery.

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46
Q

Client Care Considerations for Oral Route

A

1.Ensure that the client has not smoke or
ingested hot or cold foods or liquids for 9
minutes before measurement and capable
of sealing the lips around the
thermometer.

2.Insert the thermometer under the tongue
in the posterior sublingual pocket.

  1. Hold the thermometer in place until
    temperature is obtained.; 3-5 minutes for a
    glass or plastic thermometer.
  2. Wash the thermometer
    a. Bulb to stem (before use) - tip to body
    b. Stem to bulb (after use) - body to tip
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47
Q

Where is the rectal route?

A

In the rectal

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48
Q

Advantages of Rectal Route

A

▪most accurate and reliable measurement of temperature

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49
Q

Disadvantages of Rectal Route

A

▪inconvenient and difficult to clients who are unable to turn to sides
- Bedridden
- Stroke patients
- Impacted stool

▪ presence of stool may interfere with thermometer placement

▪ may cause ulcerations and rectal perforations in children and infants

▪ contraindicated to client with diarrhea, after rectal and/or prostatic surgery or injury, recent myocardial infarction and post head injury
- May stimulate subnoval maneuver (pagire)
- Increased workload on the heart
- Increased ICP (Increased Intracranial Pressure)

▪ may embarrass the client; requires
privacy

▪ contraindicated for newborns; clients with hemorrhoids, or a fragile rectal mucosa and those underwent colon and rectal surgery, clients with heart conditions
- Imperforate anus
- Newborn - There is a procedure where we get
the temperature per anus
- Check if there is an anal opening
- Some may have imperforiated anus (no hole)

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50
Q

Client Care Considerations for Rectal

A
  1. Draw the curtain and position the client
    properly.
  2. Wash hands and don gloves.
  3. Lubricate the tip of the thermometer.
  4. Raise the upper buttock with one hand,
    instruct the client to take a deep breath
    while inserting the thermometer into the
    anus.

▪ 1 – 1.5 inches = adult
▪ 0.5 - 0.9 inches = child
▪ 0.5 inches = infant

  1. Hold the thermometer in place until it is time of
    removal; 2 minutes (adult) & 5 minutes (infants).
  2. Remove, clean and read the thermometer.
  3. Remove any gel from perianal area after
    the removal.
  4. Remove and discard your gloves in an
    appropriate receptacle; wash your hands.
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51
Q

Where is the axillary route?

A

Armpit

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52
Q

Advantages of Axillary route

A

▪ Safest and non-invasive; accessible

▪ Can be used for newborns and uncooperative clients

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53
Q

Disadvantages of Axillary route

A

▪ Thermometer must remain in place for long periods; approx. 8 minutes.

▪ Not as accurate as rectal route

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54
Q

Client Care Considerations for axillary route

A
  1. Pat dry the axilla if moist.
  2. Place the thermometer in the middle of the axilla and instruct to position the arms across the chest.
  3. Leave the thermometer for 8-10 minutes.
  4. Remove the thermometer and wipe with
    rotating motion from stem to bulb.
  5. Hold the thermometer at eye level.
  6. Read the temperature.
  7. Clean the thermometer with soap and water (if
    mercurial glass).
  8. Use same thermometer for repeat temperature
    taking to ensure accuracy.
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55
Q

Where is the tympanic route?

A

Ear

56
Q

Advantages of tympanic route

A

▪ Easily accessible

▪ Reflects results within seconds

▪ Unaltered by eating, smoking, drinking, and
oxygen administration

▪ Can be used for infants, unconscious and
dyspneic clients.

57
Q

Disadvantages for tympanic route

A

▪ Equipment is expensive

▪ Can be uncomfortable

▪ Contraindicated for clients with ear infection and
those who underwent ear surgery

▪ Earwax may result to inaccurately low result

58
Q

Client Care Considerations for Tympanic route

A
  1. Clean the lens under the probe before use.
  2. Straighten the ear canal.
    ▪ Pull the pinna UP and BACK (adult).
    ▪ Pull the pinna DOWN and BACK (children 3
    years and younger).
  3. Insert the probe into the ear canal firmly but
    gently towards tympanic membrane.
  4. Push the button to take the temperature.
  5. Remove the device when it beeps.
  6. Eject the probe cover into an appropriate trash receptacle.
  7. Repeat procedure for the other ear using a new
    probe cover.
59
Q

Where is the temporal artery?

A

Head

60
Q

Advantages of Temporal Artery

A

▪ Easily accessible

▪ Reflects results within seconds

▪ Unaltered by eating, smoking, drinking, and
oxygen administration

▪ Can be used for infants, unconscious and
dyspneic clients.

61
Q

Disadvantages of Temporal Artery

A

▪ Head covering, hair or temporal area against a
pillow or mattress can cause inaccurately high
results.

▪ Influenced by perspiration

62
Q

Client Care Considerations for Temporal Artery

A
  1. Determine that the site is not influenced by hair, a hat or lying on a pillow or mattress.
  2. Dry the site if there is perspiration.
  3. Ensure the device is charged.
  4. Remove the protective cap & clean the probe
    following the manufacturer’s instructions.
  5. Place probe with gentle pressure on the center
    of the forehead, halfway between the hairline and eyebrows.
  6. Depress and hold the start button while dragging the probe laterally across the forehead to the opposite hairline.
  7. Continue to depress the start button and touch the probe behind the ear lobe on the soft area below the mastoid process.
  8. Release the button and read the result.
  9. Clean the probe.
63
Q

Alterations in Body Temperature

A

A. Decreased body temperature
1. Hypothermia - Body temperature < 36°C (less than)

  1. Severe hypothermia - Body temperature < 28°C (less than)

B. Increased body temperature
1. Hyperthermia - Temperature >40.5°C

a. Heat exhaustion - Caused by excessive environmental heat and dehydration

Clinical indicators: Weakness, muscle aches,
headache, syncope, N/V, pallor, dizziness,
diaphoresis.

b. Heat stroke - caused by exercise in hot
weather

Clinical indicators: Flushed, hot & dry skin;
throbbing headache; rapid, strong pulse;

Watch Out For: Impaired judgment, delirium,
unconsciousness & seizure

64
Q

10 Clinical indicators

A
  • Shivering initially
  • Decreased, irregular pulse
  • Decreased respirations
  • Hypotension
  • Pale, cool skin
  • Oliguria
  • Reduced muscle coordination
  • Disorientation
  • Decreased level of consciousness
  • WOF (watch out for): Coma
65
Q

Fever (pyrexia, febrile)

A

Temperature 37.8°C (orally) or 38.3°C (rectally).

NOTE: Fever up to 38.9°C enhances immune response, promote phagocytosis, hinder reproduction of pathogens.

66
Q

Hyperpyrexia

A

temperature of 41°C or more.

Clinical indicators: agitation, confusion, stupor (unconsciousness) and may progress to coma.

67
Q

Definition of Pulse

A

⮚ wave of blood created by contraction of the left
ventricles of the heart.

⮚ regulated by autonomic nervous system (involuntary)

68
Q

What are the related terms of pulse?

A
  • Stroke volume
  • Cardiac output
69
Q

Definition of Stroke Volume

A

Amount of blood that enters the aorta with each ventricular contraction.

70
Q

Definition of Cardiac Output

A

Amount of blood pumped by the heart in one full minute.

71
Q

FACTORS AFFECTING PULSE RATE

A
  1. Age
  2. Sex
  3. Exercise
  4. Fever
  5. Medications
  6. Stress and hormones
  7. Blood volume
  8. Position
72
Q

Description of age - Pulse rate

A

As age increases the pulse rate gradually decreases

73
Q

Description of sex - Pulse rate

A

After puberty the average male’s pulse rate is slightly lower than the female

74
Q

Description of Exercise - Pulse rate

A

The pulse rate increases with activity especially if it’s vigorous. When engaged in very strenuous exercise

75
Q

Description of Fever - Pulse rate

A
  • The pulse rate increases due to response due to the lowered blood pressure that results from peripheral vasodilation because when there is fever there is vasodilation & increased metabolic rate
  • Increased BMR. It is one factor which in charge of heat production
76
Q

Description of Medications - Pulse rate

A
  • Decreases the pulse rate and other increases the pulse rate
  • Eg cardiac tracts, cardiotonics, bronchodilators (people who have asthma. One effect is increase in pulse rate)
77
Q

Description of Stress and Hormones - Pulse rate

A
  • Increase your pulse rate
78
Q

Description of Blood volume - Pulse rate

A
  • Decrease in blood volume it can affect the pulse rate
79
Q

Description of Position - Pulse rate

A

Check your pulse in a supine position (lying position) and during standing assume different positions and check your pulse, there is a little difference.

80
Q

Name the Pulse Sites

A
  1. Head - Temporal
  2. Carotid pulse - Side of the neck
  3. Apical - Apex of the heart
  4. Brachial - Arm
  5. Radial - Along the radial bone
  6. Femoral
  7. Popliteal - Behind the knee
  8. Posterior tibial
  9. Dorsalis pedis
81
Q

Description of Head - Temporal = Pulse site

A
  • Temporary artery passes over the temporal bone of the head
  • Superior & lateral to the eye
  • We use this when the radial pulse is not accessible
82
Q

Description of Carotid pulse - Side of the neck = Pulse site

A
  • Where the carotid artery runs between the trachea & the sternocleidomastoid muscle
  • We use this during cardiac arrest, shock in adults, used to determine the circulation to the brain
  • Used for emergency situations.
83
Q

Description of Apical - Apex of the heart = Pulse site

A
  • Adult - Located on the left side of the chest
  • 8cm to the left of the sternum (breastbone)
  • Fifth intercostal space between the ribs
  • Use for infants to children up to 3 years of age to observe during assessment when you take the heart rate
  • Used to determine discrepancy in radial pulse
  • During consultations with a doctor
84
Q

Description of Brachial - Arm = Pulse Site

A
  • Used for palpating in BP taking
  • Inner aspect of your bicep muscles of the arm or medially in the antecubital space
  • Used for cardiac arrest for infants
85
Q

Description of Radial Along the radial bone = Pulse site

A
  • Common site wherein you get the pulse of an adult patient
  • Radial artery along the radial bone on the thumb side of the inner aspect of the wrist
86
Q

Description of Femoral = Pulse site

A
  • Where the femoral artery is along the inguinal ligament
  • We use incase of cardiac arrest or shock
  • Used to determine the circulation of the leg
87
Q

Description of Popliteal - Behind the knee = Pulse site

A
  • Used to determine the circulation of the lower leg
88
Q

Description of Posterior tibial = Pulse site

A
  • Used to determine the circulation of the foot
89
Q

Description of Dorsalis pedis = Pulse site

A
  • Used to determine the circulation of the foot
  • Artery passes of the bones of the foot
  • From the middle of the angle to the middle of the big toe and second toe.
90
Q

State the 2 Techniques in Pulse Assessment

A
  1. Palpation
  2. Auscultation
91
Q

Description of Palpation

A

⮚ Select the pulse site.

⮚ Place the client in a comfortable resting position.

⮚ Place two or three fingertips and apply moderate pressure. Do not use thumb to palpate arterial pulsation.

⮚ Count for 1 full minute to obtain accurate picture of rate and irregularities.

92
Q

Description of Auscultation

A

⮚ Use the diaphragm of the stethoscope to count the
apical pulse at Left 5th ICS MCL for adult and Left 4th ICS MCL for children.

⮚ Make sure the tubing extends straight as kinks can
distort sound transmission.

ICS = Intercoastal space
MCL - Midclavical

93
Q

APICAL-RADIAL PULSE ASSESSMENT

A
  • An apical-radial pulse may need to be assessed for clients with certain cardiovascular disorders.
  • Normally, the apical and radial rates are identical.
    If there is a significant deviation (difference) then it
    needs to be evaluated or the patient needs to undergo
    more diagnostic procedure (cardiovascular procedures)
    Eg ECG, Treadmill

PULSE DEFICIT- significant deviation/ discrepancy between the two pulse rates

94
Q

STATE THE PULSE SCALE

A

0 = Pulse is Absent
1+ = Pulse is weak
2+ = Pulse is normal
3+ = Pulse is bounding

95
Q

Definition of Respiration - Act of breathing

A

⮚ movement of gases into and out of the lungs, promoting an exchange of gases between the atmosphere and the capillary beds in the alveoli.
- Take note of the rate, depth, rhythm, quality &
effectiveness of respiration
- Described “in breathes per minute”

⮚ involves inhalation and exhalation.

96
Q

2 TYPES OF BREATHING:

A
  1. Coastal breathing
  2. Diaphragmatic breathing
97
Q

Description of Coastal Breathing

A

External intercostal muscles (shoulder blade) and other accessory muscles, such as the sternocleidomastoid muscles

  • You can observe the rise and fall during breathing
  • For patients who have difficulty of breathing
  • Eg patients suffering abnormalities of the respiratory
    system (pateints with emphysema, copd)
  • The shoulder blades, torso it is widened because of the
    lots of use
98
Q

Description of Diaphragmatic breathing

A

The contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen

  • Normal breathing for adults
99
Q

FACTORS AFFECTING RESPIRATION:
Increases respiratory rate

A
  1. Exercise (increases metabolism)
    • The more strenuous exercise the more it increases our
      respiration
  2. Stress (readies the body for “fight or flight”)
  3. Increased environmental temperature
  4. Lowered oxygen concentration at increased altitudes.
    • If you go to high lands (baguio, tagaytay) you have a
      difficult time breathing due to low oxygen levels
100
Q

FACTORS AFFECTING RESPIRATION
Decreases respiratory rate

A
  1. Decreased environmental temperature
    • When it is hot it affects
  2. Certain medications (e.g., narcotics)
    • Given to patients who have pain
    • In the hospital recovery room if the patient is given
      narcotics there is always an order to monitor since it
      can cause respiratory depression. (regulated drugs)
  3. Increased intracranial pressure
    • If the patient sustained head injury and all of the
      sudden heart rate decreases there is a problem there
      might be an increase in your ICP
    • 1 parameter
101
Q

ASSESSING RESPIRATIONS

A

A. Count respiration with client in comfortable position. Place client’s arm in relaxed position across abdomen or lower chest

B. Discreetly observe the rise and fall of the chest
- Assume you are not done taking the pulse rate of the
patient but in reality you are already done
- So the patient will not be conscious since the patient
can increase or decrease their heart rate
- Do not tell them you are getting respiratory rate
assume you are still getting their pulse rate

C. Observe the character of respirations

102
Q

STATE RATE OF RESPIRATIONS

A

A. Eupnea
B. Tachypnea
C. Bradypnea
D. Apnea
E. Hyperpnea

103
Q

Definition of Eupnea

A

Normal

104
Q

Definition of Tachypnea

A

Fast

105
Q

Definition of Bradypnea

A

Slow

106
Q

Definition of Apnea

A

Absence of breathing

107
Q

Definition of Hyperpnea

A

labored respiration normally occurring during exercise

You are trying to catch up with your breathing

108
Q

STATE EFFORT OF RESPIRATIONS

A
  1. Dyspnea
  2. Orthopnea
109
Q

Definition of Dyspnea

A

Difficulty in breathing

110
Q

Definition of Orthopnea

A

Ability to breathe only in upright, sitting or standing position.

111
Q

Definition of Blood Pressure

A

Pressure exerted by blood against the walls of the
arteries.

Blood moves in waves

112
Q

3 TYPES OF BLOOD PRESSURE

A
  1. Systolic pressure
    Ventricular contraction
    1st beat
  2. Diastolic pressure
    Ventricular relaxation
    last beat
  3. Pulse pressure
    Difference between systolic and diastolic pressure
113
Q

4 PHYSIOLOGICAL DETERMINANTS OF BLOOD PRESSURE

A
  1. PUMPING ACTION OF THE HEART
  2. BLOOD VOLUME
  3. PERIPHERAL VASCULAR RESISTANCE
  4. BLOOD VISCOSITY
114
Q

Description of Pumping action of the heart

A

When the pumping action of the heart is weak, less blood is pumped into arteries (lower cardiac output), and the blood pressure decreases.

When the heart’s pumping action is strong and the volume of blood pumped into the circulation increases (higher cardiac output), the blood pressure increases.

For example:
If you have an old patient and their pumping action of the heart is weak they will have lower cardiac output and sometimes the blood pressure is decreased

For an adult the pumping action is strong so there is a higher cardiac output.

115
Q

Description of Blood volume

A

When the blood volume decreases (for example, as a result of a hemorrhage or dehydration), the blood pressure decreases because of decreased fluid in the arteries.
- Hemorrhage - severe breathing

Conversely, when the volume increases (for example, as a result of a rapid intravenous infusion), the blood pressure increases because of the greater fluid volume within the circulatory system.
- Reason why we need to regulat our IV fluid diligently
and check every now and then since the patient can
manipulate

116
Q

Description of Peripheral vascular resistance

A

Something to do with blood vessels

The internal diameter or capacity of the arterioles and the capillaries determines in great part the peripheral resistance to the blood in the body.
- The elederly are usally more affected, chronic
illnesses especially with cardiac abnormalities

The smaller the space within a vessel, the greater the resistance. Normally, the arterioles are in a state of partial constriction.
- Eg you have a patient with an unhealthy lifestyle that
inhinders the person so their arterioles get narrow
especially with smoking as it can cause
vasoconstriction.

Increased vasoconstriction, such as occurs with smoking, raises the blood pressure, whereas decreased vasoconstriction lowers the blood pressure
- The more blood vessel constricted the higher the
pressure

117
Q

Description of Blood viscosity

A

Blood pressure is higher when the blood is highly viscous (thick),that is, when the proportion of red blood cells to the blood plasma is high.
- When the proportion of blood cells to the blood plasma
is high
- The more viscous = pressure increases
- Eg patients suffering from diabetes the patients due to
the glucose the blood become viscous. Most of them
are hypertensive
- Proportion is referred to as the hematocrit. The
viscosity increases markedly when the hematocrit is
more than 60% to 65%.

118
Q

STATE THE PERSONAL DETERMINANTS OF BLOOD PRESSURE

A
  1. Age
  2. Exercise
  3. Stress
  4. Race
  5. Sex
  6. Medications
  7. Obesity
  8. Dinural variations
  9. Medical conditions
119
Q

Description of Age - Personal Determinants
of Blood Pressure

A

Older people have higher blood pressure due to decreased elasticity of blood vessels

120
Q

Description of Exercise - Personal Determinants
of Blood Pressure

A

Physical activity increases the cardiac output and hence the blood pressure.

121
Q

Description of Stress - Personal Determinants
of Blood Pressure

A

Stimulation of the sympathetic nervous system increases the blood pressure reading;

122
Q

Description of race - Personal Determinants
of Blood Pressure

A

African Americans over 35 years tend to have higher blood pressures than European Americans of the same age

123
Q

Description of Sex - Personal Determinants
of Blood Pressure

A

After puberty, females usually have lower blood pressures
than males of the same age; this difference is thought to be due to hormonal variations. After menopause, women generally have higher blood pressures than before.

124
Q

Description of Medications - Personal Determinants
of Blood Pressure

A

Many medications, including caffeine, may increase or decrease the blood pressure.

125
Q

Description of Obesity - Personal Determinants
of Blood Pressure

A

Both childhood and adult obesity predispose to
hypertension.

126
Q

Description of Diurnal variations - Personal Determinants
of Blood Pressure

A

Pressure is usually lowest early in the morning, when the metabolic rate is lowest, then rises throughout the day and peaks in the late afternoon or early evening.

127
Q

Description of Medical conditions - Personal Determinants of Blood Pressure

A

Any condition affecting the cardiac output, blood volume, blood viscosity, and/or compliance of the arteries has a direct effect on the blood pressure.

128
Q

Client Care Considerations - Personal Determinants of Blood Pressure

A
  1. Ensure that the client is rested
  2. Allow 30 minutes to pass if the client had engaged
    in exercise or had smoked or ingested caffeine
    before taking the BP.
  3. Use appropriate size of the BP cuff. Too narrow
    cuff causes false high reading. Too wide cuff
    causes false low reading.
  4. Position the client in sitting or supine position
  5. Position the arm at the level of the heart, with the
    palm of the hand facing up. The left arm is
    preferably used because it is nearer the heart
  6. Apply BP cuff snugly, 1 inches above the
    antecubital space
  7. Use the bell of the stethoscope since the BP is a
    low-frequency sound
  8. Inflate and deflate BP cuff slowly, 2-3 mmHg at a
    time
129
Q

ASSESSING BLOOD PRESSURE

A
  • The blood pressure is usually assessed in the client’s
    upper arm using the brachial artery and a standard
    stethoscope.

Assessing the blood pressure on a client’s thigh is
indicated in these situations:

  • The blood pressure cannot be measured on either arm
    (e.g., because of burns or other trauma).
  • The blood pressure in one thigh is to be compared with
    the blood pressure in the other thigh.

Blood pressure is not measured on a particular
client’s limb in the following situations:

  • The shoulder, arm, or hand (or the hip, knee, or
    ankle) is injured or diseased.
  • A cast or bulky bandage is on any part of the
    limb.
  • The client has had surgical removal of breast or axillary (or inguinal) lymph nodes on that side.

*The client has an intravenous infusion or blood transfusion in that limb.

*The client has an arteriovenous fistula (e.g., for renal dialysis) in that limb.

130
Q

WHAT ARE THE OTHER VITAL SIGNS

A
  • Pain assessment
  • Oxygen Saturation
131
Q

DESCRIPTION OF PAIN

A

⮚ an unpleasant and highly personal experience
that maybe imperceptible to others, while
consuming all parts of the person’s life.

⮚ subjective data; “what & where the client says
it is.”

⮚ Pain Assessment Scale: 0-10
* Zero-No pain
* 10-Worst Possible scale

132
Q

ASSESSING PAIN

A
  1. Check the temperature, pulse rate, respiration,
    and blood pressure. If the client is in pain, proceed to
    the succeeding steps.
  2. Ask the patient to point to the pain (location).
  3. Determine the severity. Three scales are
    commonly used:
    a. Visual Analog scale
    b. Numeric rating scale (1-10)
    c. Faces pain scale
  4. Ask the patient to describe the pain and how it started
    (associated features). Pursue the seven (7) features/attributes of pain, as you would with any symptom:
    a. Location. Where is it? Does it radiate?
    b. Quality. What is it like?
    c. Quantity or severity. How bad is it? (For pain, ask for a
    rating on a scale of 1 to 10.)
    d. Timing. When did (does) it start? How long did (does) it
    last? How often did (does) it occur?
    e. Setting in which it occurs. Include environmental
    factors, personal activities, emotional reactions, or other
    circumstances that may have contributed to the illness.
    f. Remitting or exacerbating factors. Does anything
    make it better or worse?
    g. Associated manifestations. Have you noticed anything
    else that accompanies it

5.Refer to the primary care provider as necessary.

133
Q

DESCRIPTION OF OXYGEN SATURATION

A
  • A pulse oximeter is a noninvasive device that estimates a client’s arterial blood oxygen saturation (SaO2) by means of a sensor attached to the client’s finger
  • The oxygen saturation value is the percent of all hemoglobin binding sites that are occupied by oxygen.
134
Q

WHAT IS THE NORMAL OXYGEN SATURATION

A

Normal oxygen saturation is 95% to 100%, and below 70% is life threatening

135
Q

MEASURING OXYGEN SATURATION

A

ASSESS
a. The best location for a pulse oximeter sensor based on
the client’s age and physical condition. Unless
contraindicated, the finger is usually selected for adults.

b. The client’s overall condition including risk factors for
development of hypoxemia (e.g., respiratory or cardiac
disease) and hemoglobin level

c. Vital signs, skin color and temperature, nail bed color,
and tissue perfusion of extremities as baseline data

d. Adhesive allergy

  1. Assemble the necessary equipment:
    a. Nail polish remover as needed
    b. Alcohol wipe
    c. Sheet or towel
    d. Pulse oximeter
  2. Check if the pulse oximeter is functioning
    normally

IMPLEMENTATION
1. Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments.

  1. Perform hand hygiene and observe appropriate infection control procedures.
  2. Provide for client privacy.
  3. Prepare the site. Remove nail polish with acetone or polish remover if there is, as it may interfere with accurate
    measurement.
136
Q

MEASURING OXYGEN SATURATION
Clinical Decision Point:

A

a. Do not attach sensor to finger, ear, forehead, or bridge
of nose if area is edematous or skin integrity is
compromised.

b. Do not attach sensor to fingers that are hypothermic.
Select forehead, ear, or bridge of nose if adult patient has
history of peripheral vascular disease

c. Do not use earlobe and bridge of nose sensors for
infants and toddlers because of skin fragility.

d. Do not use disposable adhesive sensors if patient has
latex allergy.

e. Do not place sensor on same extremity as electronic
blood pressure cuff because blood flow to finger is
temporarily interrupted when cuff inflates and causes
inaccurate readings that trigger alarm

  1. Once sensor is in place, turn on oximeter by
    activating power. Observe pulse
    waveform/intensity display and audible beep.

Correlate oximeter pulse rate with patient’s radial
pulse.

Differences require reevaluation of oximeter sensor
placement and may require reassessment of pulse
rates

  1. Leave sensor in place until oximeter
    readout reaches constant value and pulse
    display reaches full strength during each
    cardiac cycle. Inform patient that oximeter
    alarm will sound if sensor falls off or patient
    moves sensor. Read SpO2 on digital
    display.
  2. Assess skin integrity every 2 hours under sensor.
    Routinely relocate sensor at least every 24 hours or more
    frequently. This is especially important if skin integrity is
    altered or tissue perfusion is compromised. Use care
    during removal to avoid damage to skin.
  3. Clean the surface of a reusable sensor between patients with 70% Isopropyl alcohol solution or solution
    recommended by manufacturer.
  4. Discuss findings with patient as needed.
  5. Perform hand hygiene.
  6. Record SpO2 on vital signs flow sheet

Health (3 decks)

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