Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Fundamentals of Nursing Lab > Vital signs - Pulse & Respiration > Flashcards

Vital signs - Pulse & Respiration Flashcards

You may prefer our related Brainscape-certified flashcards:
Nursing Mental Health flashcards Nursing Management of Care flashcards NCLEX-PN® flashcards NCLEX-RN® flashcards Nursing Fundamentals flashcards Nursing Pediatrics flashcards Nursing Safety & Infection flashcards Nursing Pharmacology flashcards Nursing Maternity flashcards Family Nurse Practitioner (FNP) flashcards
1
Q

What is a pulse?

A

It is a wave of blood created by the contraction of the left ventricle of the heart.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is a peripheral pulse?

A

A pulse located away from the heart.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is an Apical pulse?

A

Central pulse, located at the apex of the heart.
Also referred to as maximal impulse (PMI)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the pulse sites?

A
  1. Temporal
  2. Carotid
  3. Apical
  4. Brachial
  5. Radial
  6. Femoral
  7. popliteal
  8. posterior tibial
  9. dorsalis pedis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

As a nurse, when you assess pulse, what should you be aware of?

A
  1. any medication that could affect heart rate
  2. if client has been physically active, so we wait 10-15 mins till it returns to normal.
  3. baseline data about normal heart rate for client
  4. whether client should assume a particular position, since rate change with position due to blood flow volume or autonomic nervous system activity for some clients.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the characteristics of pulse?

A
  1. Rate
  2. Pulse rhythm
  3. Pulse volume
  4. Elasticity of arterial wall
  5. presence or absence of bilateral equality / perfusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is pulse volume & how do we assess it?

A
  • Pulse strength or amplitude
  • force of blood with each beat
  • normal pulse can be felt with moderate pressure & pressure is equal with each beat
  • forceful pulse volume is full
  • easily obliterated pulse is weak
  • 0 = absent
  • 1+ = weak
  • 2+ = normal
  • 3+ = strong
  • 4+ = full & bounding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is pulse rhythm & how do we assess it?

A
  • the pattern of beats & intervals between beats
  • regular or irregular (arrhythmia)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How do we assess pulse rate?

A
  • normal range ( 60-100 bpm )
  • tachycardia ( above 100 bpm )
  • Bradycardia ( below 60 bpm )
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How do we assess the elasticity of the arterial wall?

A

Must feel straight, smooth, soft, & pliable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the purposes of assessing peripheral pulse?

A
  • to establish baseline data for subsequent evaluations
  • to identify whether pulse rate is within normal range
  • to determine pulse volume & whether pulse rhythm is regular
  • to determine equality of corresponding peripheral pulses on each side of the body
  • to monitor & asses changes in client’s health status
  • to monitor clients at risk of pulse alterations
  • to evaluate blood perfusion to extremities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What must nurses assess prior to measuring peripheral pulse?

A
  • clinical sign of cardiovascular alterations
  • factors that may alter pulse rate
  • which site is most appropriate for assessment based on purpose
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What causes pulse alterations?

A
  • history of heart disease
  • history of cardiac arrhythmia
  • hemorrhage
  • acute pain
  • infusion of large volumes of fluids
  • fever
  • emotional status
  • activity
  • beta blockers
  • calcium channel blockers
  • digoxin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the signs of cardiovascular alterations?

A
  • dysponoea ( difficult respirations )
  • fatigue
  • pallor ( pale )
  • cyanosis ( blush discoloration of skin & mucous membrane )
  • palpitations
  • syncope ( dizziness or fainting )
  • impaired peripheral tissue perfusion ( skin discoloration & cool temperature )
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What equipments do we need to measure peripheral pulse?

A
  • clock / timer / watch with a sweep second hand or digital seconds indicator
  • if using DUS ( doppler ultrasound )
  • transducer probe
  • Stethoscope headset
  • transmission gel
  • tissues or wipes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Mention the steps of assessing peripheral pulse

A
  1. select an appropriate pulse point
  2. assist client to a comfortable resting position
  3. place two or three middle fingertips lightly on pulse & count for a minute
  4. assess pulse rhythm & volume
  5. record/document all actions & results in client record, including pertinent related data
  6. compare to recent, baseline, or usual range etc…
  7. evaluate equality in corresponding extremities
  8. conduct appropriate follow-ups ( notify primary care provider or give medications )
17
Q

What is the method to measuring radial pulse?

A

Lying down :
- palm facing downward
- arm can rest alongside body
or forearm can rest at 90-degree angle across the chest
sitting :
- forearm rest across thigh
- palm facing downward

18
Q

What are the purposes of assessing the apical pulse?

A
  1. to obtain the heart rate of an adult with an irregular peripheral pulse
  2. to establish baseline data for subsequent evaluations
  3. to determine whether the cardiac rate is within the normal range and the rhythm is regular
  4. to monitor clients with cardiac, pulmonary, or renal disease & those receiving medications to improve heart health
19
Q

What equipment is required to assess apical pulse?

A
  1. clock, timer, watch with sweep second hand, or digital seconds indicator
  2. stethoscope
  3. antiseptic wipes
20
Q

What are the steps of assessing apical pulse?

A
  1. position client appropriately in comfortable position - supine or sitting
  2. expose area of the chest over the apex of the heart
  3. locate the apical impulse - middle of clavicle, down 5 intercostal spaces, 4 if below age of 4
  4. use antiseptic wipes to clean earpieces & diaphragm of stethoscope
  5. warm the diaphragm by holding it in your palm for a moment to not startle client
  6. insert earpieces & tap lightly on diaphragm to ensure active side of the head
  7. place diaphragm over apical impulse 7 listen for normal s1 & s2 sounds, ‘lub-dub’. Each lub dub is counted as one heart beat
  8. if you face difficulty hearing the apical pulse, ask the patient to turn to their side if in supine position, or ask them to lean slightly forward if sitting.
  9. if regular rhythm count for 30 seconds multiplied by 2
    if irregular rhythm, count for 60 seconds
  10. Assess the rhythm and strength of the heart beat
  11. document the pulse rate, rhythm, nursing actions & pertinent related data in clients record.
  12. evaluate by relating the pulse rate to other vital signs, and the pulse rhythm to baseline data & health status
  13. report to primary care provider any abnormal findings
  14. conduct appropriate follow up, such as administering medication ordered.
21
Q

What are the types of abnormal findings in the apical pulse?

A
  1. irregular rhythm
  2. reduced ability to hear heartbeat
  3. pallor
  4. cyanosis
  5. dyspnea
  6. tachycardia
  7. bradycardia
22
Q

What is the purpose of assessing the apical-radial pulse?

A

It is to determine the adequacy of peripheral circulation or the presence of a pulse deficit.

23
Q

What are the steps to assessing apical radial pulse for two nurses?

A
  1. position client appropriately. if previous measures were taken, use the same position.
  2. one nurse locates the apical pulse with either stethoscope or palpation, the other nurse palpates the radial pulse site
  3. if a clock or timer is not visible, the nurse taking the radial pulse needs to have a watch
  4. nurse taking radial pulse decides when to begin and says start, to ensure simultaneous counts are begun
  5. each nurse counts pulse rate for 60 seconds. Both nurses end the count when the nurse taking the radial pulse says ‘stop’.
  6. nurse assessing apical pulse also assess apical pulse rhythm & volume
    nurse assessing radial pulse also assess radial pulse rhythm and volume
24
Q

What is the one nurse technique for assessing apical radial pulse?

A
  1. feel radial pulse & listen to apical pulse at the same time
  2. you will be able to detect if it’s not synchronized
  3. if two pulses aren’t the same, to determine pulse deficit assess apical pulse for 60 seconds then immediately assess radial pulse for 60 seconds.
  4. document apical & radial (AR) pulse rates, rhythm, volume and data such as variation in pulse rate compared to normal for client & other pertinent observations.
  5. relate pulse rate & rhythm to other vital signs, baseline data & to general health status
  6. report to primary care provider any changes from previous measurements or any discrepancy between two pulse rates
25
Q

Prior to assessing respiration, the nurse should be aware of :

A
  • clients normal breathing pattern
  • influence of clients health problems on respiration
  • any medications or therapies that might affect respirations
  • the relationship of the clients respirations to the cardiovascular function
26
Q

What are the characteristics of respiratory assessment?

A
  1. Rate
  2. Depth
  3. Rhythm
  4. Quality
  5. the effectiveness of respirations
27
Q

What do the different rates of respiration indicate & what are they called?

A
  1. 12-20 breaths per minutes is eupnoea which is normal
  2. more than 20 breaths per minute is tachypnea, which is fast respiration
  3. less than 20 breaths per minutes is bradypnea, which is slow respiration
  4. absence of breath is apnoea
28
Q

What are the purposes of assessing respiration?

A
  • to acquire baseline data against which future measurements can be compared
  • to monitor abnormal respirations, respiratory patterns & identify changes
  • to monitor respirations before & after the administration of a general anesthetic or any medication affecting respirations
  • to monitor clients at risk of respiratory alterations
29
Q

What causes respiratory alterations?

A
  • fever
  • pain
  • acute anxiety
  • chronic obstructive pulmonary disease
  • asthma
  • respiratory infection
  • pulmonary edema or emboli
  • chest trauma or constriction
  • Brain stem injury
30
Q

How do we assess respiration?

A
  1. assess skin & mucous membrane color
  2. position assumed for breathing
  3. signs of cerebral anoxia
  4. chest movements
  5. chest pain
  6. dyspnea
  7. activity tolerance
  8. medications affecting respiratory rate
31
Q

What are the implementation steps of assessing respiration?

A
  1. check client’s activity level & make sure they’re well rested before monitoring
  2. place hand against the chest of the client to feel the movement of respiration or place client’s arm across their chest & observe movements while supposedly taking redial pulse
  3. an inhalation & exhalation count as one respiration
  4. observe respirations for depth by watching movement of chest.
    Deep respiration = large volume is exchanged
    shallow respiration = small volume is exchanged
  5. observe respiration for regular or irregular rhythms
  6. observe the character of respirations, the sound they produce & effort they require
  7. document the respiratory rate, depth, rhythm & character on the appropriate record
  8. relate respiratory rate to other vitals signs, baseline & health status
  9. report to primary care provider any abnormality in respiratory rate
    10.collaborate with other health care team members such as the respiratory therapist regarding the care plan to address any respiratory issues
32
Q

What is ventilation ?

A

It is the process of moving air in & out of the lungs, essential for gas exchange

33
Q

What are the two types of respiration?

A
  • costal / thoracic breathing
    involving contraction & relaxation of intercostal muscles
  • diaphragmatic / abdominal breathing
    the contraction & downward movement of the diaphragm during inhalation & relaxation of diaphragm during exhalation
34
Q

Describe what occurs during inhalation & exhalation

A

Inhalation - diaphragm contracts/flattens
ribs move upward & outward
sternum moves outward
size of thorax enlarged

Exhalation - diaphragm relaxes
ribs move downward & inward
sternum moves inward
size of thorax decreases

35
Q

What are the respiratory control mechanisms?

A
  • Respiratory centers ( Medulla oblongata , the pons )
  • Chemoreceptors ( medulla , carotid & aortic bodies )
36
Q

What factors affect respiration?

A

Increase : Exercise
stress
high environmental temperature
low O2 conc.

Decrease : low environmental temperature
some medications
increased intracranial pressure

37
Q

What components must we assess during respiratory assessment?

A
  1. Depth
    - Normal
    - Shallow
    - Deep
  2. Tidal Volume
    - Normal = 500 mL of air during inhalation for adults
    - Hyperventilation = very deep, rapid resp.
    - Hypoventilation = very shallow resp.
  3. Rhythm
    - Regular or irregular
    - cheyne-stokes breathing ( very deep to shallow to temporary apnea breathing )
  4. Quality or character
    - effort to breathe ( dyspnea/labored, orthopnea )
    - sound of breathing ( stridor, stretor, wheeze, bubbling )
  5. Effectiveness
    - uptake & transport of O2
    - O2 Saturation using pulse oximeter
    - Release of CO2 from blood into expired air
  6. Chest movement
    - retraction ( intercostal, substernal, superasternal )
  7. Secretions & coughing
    - Hemoptysis
    - Productive/nonproductive cough

Fundamentals of Nursing Lab (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions