Vital Signs/Respiration/Pain Flashcards
What are Vital Signs?
Measurements of the body’s most basic functions
Why are vital signs important?
Gives a glimpse of the patient’s well-being
What are baseline vital signs?
patient’s norm
What are textbook vital signs?
provides a gauge or clue
What is the first impending sign of distress involving vital signs/system? What are the signs?
Respiratory system
- increased RR/decreased RR
-O2 levels may drop
-SOB
-Anxiety
What is SBAR?
Interdisciplinary communication -
Situation: YOUR name first, state what floor you’re on, who the. pt’s doctor is
Background: patient’s info (dob, name, history)
Assessment: vital signs, etc
Recommendations: ex. pt needs a consult from physician
When do we use SBAR?
to report changes in patient status to the provider, update
What is HERO?
Hopkins Event Reporting Online
When do we use HERO?
to report adverse events, like medical errors or fall
What is a Sentinel Event?
an event that is life-changing or life-threatening.
How does circadian rhythm relate to body temperature?
fluctuate within 2 degrees throughout 24hrs
With circadian rhythm, when is body temp the lowest?
3am, sleeping, decreased metabolism, minimal activity
With circadian rhythm, when is body temp the highest?
4-6pm, active, moving, eating, increased metabolism
What are core body temp methods? (routes)
Rectal (one degree higher than oral), Tympanic (bc shares blood supply with hypothalamus), Temporal artery (bc shares blood supply as pulmonary artery)
Why is oral not a core body temp?
too many outside factors, such as the patient eating something hot/cold
What is the best method of taking an infant’s temp?
Temporal Artery - more accurate & non-invasive
What is the most common method of taking temp (not for infants)?
Oral
What are the characteristics of a pulse? (5)
-Strength
-Rhythm
-Regularity
-Quality
-Rate/Frequency
What is the average adult pulse?
60-100bpm
What would a newborn’s pulse rate be?
infants have increased BMR, so increased pulse - 130-160bpm
What is Tachycardia?
> 100bpm
what is Bradycardia?
<60bpm (except trained athletes would be 40-60bpm)
What does the quality of the pulse mean?
Strong: easily palpated
Weak: harder to palpate disappears when touched
Thready: hard to palpate
Bounding: overly strong
What is pulse deficit? What should the pulse deficit be?
difference b/w apical and peripheral pulse - there should NOT be a deficit (should be equal)
Where would you assess a pulse on a person with a shoulder injury?
Radial pulse - most distal pulse and to ensure there’s perfusion to the end of the limb
How long should you count a pulse and where is it typically in an adult?
30s multiple by 2 - at the radial artery
How long should you count an irregular pulse?
for a FULL minute
When do you auscultate a pulse?
- can’t palpate
- children under 5y/o
How/where should you auscultate an infant’s pulse?
with a stethoscope, apical, at 5th intercostal space, midclavicular line
What is Eupnea?
normal breathing - normal rate, rhythm and depth
What is normal RR in an adult?
12-20bpm
What is a newborn’s RR?
30-60bpm
What is the first response to hypoxia?
-increased RR
-depth of breathing increases
Do newborns have a higher or lower RR than adults? Why?
higher bc newborns have higher BMR
What is apnea?
stops breathing for 10-15s (true apnea)
What is dyspnea?
an increased effort to breathe
What is the range for a normal BP systolic?
100-119 systolic
What is the range for a normal BP diastolic?
60-79 diastolic
What is pulse pressure? What is the normal range?
difference b/w the systolic and diastolic - measures how hard the heart is working
- normal range: 40-60mmhg (>60mmHg = increased risk of CV disease)
What are the Korotkoff sounds?
Turbulence sound during a manual BP - first sound is systolic, last sound is diastolic (5th sound for an adult)
What is the 4th Korotkoff sound in children?
diastolic BP - up to age 13
What is the auscultatory gap? How do we find it?
is a period of diminished or absent Korotkofff sounds during manual measurement of BP
- Put the cuff on and find a radial pulse. Pump the cuff until we can no longer feel the pulse. For instance, if you no longer feel the pulse at 120mmHg, add 30mmHg to the number where the pulse disappears. That is the auscultatory gap. That number is where we pump the cuff to when we are taking a manual BP
What is orthostatic hypotension? When could this happen?
Patient suddenly stands up or has sudden change in movement - BP drops
- when the pt gets OOB
What are the parameters for orthostatic hypotension?
a change of at least 20mmHg systolic or at least 10mmHg diastolic
What is the best way to assess pain?
Verbal report/Self-report
What are some pain scales?
Numeric 0-10; Faces; CRIES; etc.
Who in the hospital manages the patient’s pain?
Care team
What are some pain interventions the nurse can employ?
medication, bathing, positioning, hygiene, deep breathing, relaxation, distraction, massage, hold/cold
