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Health Across the Lifespan 1 > Vitals > Flashcards

Vitals Flashcards

1
Q

What is respiration, inhalation, exhalation and ventilation?

A

Respiration - the act of breathing
Inhalation - aka inspiration - intake of air into the lungs
Exhalation - aka expiration - breathing out, expelling gases from the lungs into the atmosphere
Ventilation - movement of air in and out of the lungs

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2
Q

What happens during inhalation?

A

The diaphragm contracts (flattens)
The ribs move upwards and outwards and the sternum moves outwards, enlarging the thorax and permitting the lungs to expand

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3
Q

What happens during exhalation?

A

The diaphragm relaxes, the ribs move downward and inward, the sternum moves inward, thus decreasing the size of the thorax and the lungs are compressed

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4
Q

What is assessed when assessing respiration?

A 
rate (breaths per minute)
depth
rhythm
quality
effectiveness
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5
Q

What is eupnoea, bradypnoea, tachypnoea and apnoea?

A

Eupnoea - normal breathing
Bradypnoea - abnormally slow respiration
Tachypnoea - abnormally fast respiration
Apnoea - absence of breathing

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6
Q

Factors affecting respiration

A
  • exercise
  • stress
  • environmental factors (temperature, oxygen concentration)
  • medications such as narcotics
  • increased inter-cranial pressure
  • body position
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7
Q

What is Cheyne-Stokes breathing?

A
  • waxing and waning respiration from deep to shallow, including temporary apnoea
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8
Q

What are dyspnoea and orthopnoea?

A

Dyspnoea - difficult and laboured breathing

Orthopnoea - ability to breathe only in upright or standing positions

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9
Q

What are 4 common abnormal breathing sounds?

A

Stridor - shrill, harsh sound during inspiration due to laryngeal obstruction
Stertor - snoring or sonorous respiration, usually due to partial obstruction of upper airway
Wheeze - continuous high-pitched whistling sound
Bubbling - gurgling sounds from air passing through moist secretions in the respiratory tract

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10
Q

What does SaO2 stand for?

A

Saturation of arterial oxygen - ration of the oxygen bound to haemoglobin compared with the oxygen-carrying capacity of the haemoglobin

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11
Q

Average (A) and normal pulse ranges (R)

A 
Newborn: A- 130, R- 80-180
1 year: A-120, R- 80-140
5-8 years: A-100, R- 75-120
10 years: A-70, R-50-90
Teen: A-75 R- 50-90
Adult: A-80, R-60-100
Older adult: A-70, R-60-100
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12
Q

Average (A) and normal respiration ranges (R)

A 
Newborn: A- 35, R- 30-80
1 year: A-30, R-20-40
5-8 years: A-20, R-15-25
10 years: A-19 R- 15-25
Teen: A-18, R- 15-20
Adult: A-16, R- 12-20
Older adult: A-16, R- 15-20
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13
Q

What are the 9 pulse sites?

A
  1. Temporal (forehead) (used when radial not accessible)
  2. Carotid (neck) (used during cardiac shock and to determine circulation to the brain)
  3. Apical (chest) (used for infants and young children, also used to determine discrepancies with radial pulse)
  4. Brachial (inner elbow) (used to measure blood pressure)
  5. Radial (wrist) (readily accessible)
  6. Femoral (inner thigh) (used in cases of cardiac arrest and to determine circulation to leg)
  7. Popliteal (inner knee) (used to determine circulation to lower leg)
  8. Posterior tibial (inner foot, along heel) (used to determine circulation to foot)
  9. Dorsalis pedis (top of foot) (used to determine circulation to foot)
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14
Q

What does the nurse need to know when assessing pulse?

A
  • any medication that may impact pulse
  • whether the person has been physically active recently (if so, wait ~15 min before taking reading)
  • any baseline data that my impact what is normal for the patient (e.g. - elite athletes’ pulse may be well below 60bpm)
  • whether the person should be in a particular position for the reading
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15
Q

What is tachycardia, bradycardia and dysrhythmia (arrhythmia)?

A

Tachycardia - abnormally fast pulse (over 100 for an adult)
Bradycardia - abnormally slow pulse (under 60 for an adult)
dysrhythmia (arrhythmia) - pulse with irregular rhythm

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16
Q

Temperature ranges for adults

A 
Normal - between 36 and 38
Hypothermia - below 36 (death occurs ~34
Pyrexia (fever) - between 38 and 41
Hyperpyrexia - above 41 (death occurs ~ 43
Hyperthermia - over 40.6 - often fatal
17
Q

4 common types of fever

A

Intermittent fever - alternates at regular intervals between periods or fever and periods of normal or below normal temps - eg malaria
remittent fever - cold or flu - wide range of above-normal temp fluctuations
relapsing fever - short febrile periods interspersed with periods of normal temp
constant fever - body temp remains above normal, eg during typhoid fever

18
Q

When to assess vital signs

A
  • on admission to obtain baseline
  • when a person has a change in health status
  • before, during and after surgery/invasive procedure
  • before and/or after administration of medication that affects respiratory or cardiovascular systems
  • before and after nursing interventions that could affect the vital signs
  • following an incident, accident or injury
19
Q

Signs of breathlessness

A
  • nasal flaring
  • tensing neck muscles
  • use of intercostal muscles
  • anxious look
  • cyanosis (blue lips)
  • tracheal tug
  • paradoxical breathing and abdominal movements
20
Q

How does the average adult temperature vary during the day?

A

drops to ~ 36.2 around 5am.

steadily rises to ~37.1 around 8pm, then drops again

21
Q

What are the stages of fever?

A

Chill phase

  • temp rises from ~37.1 - ~39.5
  • increased heart rate
  • increased respiratory rate and depth
  • shivering
  • pallid, cold skin
  • feels cold
  • cyanotic nail beds
  • ‘goosebumps’
  • cessation of sweating

Plateau phase

  • temp fluctuates but stays around 39.5
  • absence of chills- skin feels warm
  • photosensitivity
  • glassy-eyed
  • increased pulse and resps
  • thirst
  • mild to severe dehydration
  • drowsiness, restlessness, delirium or convulsions
  • herpetic lesions of the mouth
  • loss of appetite
  • malaise, lethargy, weakness, aching muscles

Defervescence phase

  • temp returns to normal
  • skin that appears flushed and feels warm
  • sweating (diaphoresis)
  • decreased shivering
  • possible dehydration
22
Q

Symptoms of heat stroke (aka sunstroke or thermic fever)

A
  • temp above 40.5
  • life-threatening
  • red, hot, dry skin
  • dry, swollen tongue
  • rapid pulse
  • shallow, rapid breathing
  • throbbing headache
  • confusion
  • nausea
  • possible loss of consciousness
  • children, the elderly, and those with cardiovascular and respiratory diseases are vulnerable
  • treated with cool environment (fans, cool baths and showers), hydration
23
Q

Treating adults with fever

A

Monitor vital signs.

Assess skin colour and temperature.

Monitor white blood cell count, haematocrit value and other pertinent laboratory reports for indications of infection or dehydration.

Remove excess blankets when the person feels warm, but provide extra warmth when the person feels chilled.

Provide adequate nutrition and fluids (e.g. 2500–3000 mL per day) to meet the increased metabolic demands and prevent dehydration.

Measure fluid intake and output.

Reduce physical activity to limit heat production, especially during the defervescent phase.

Administer antipyretics (medications that may reduce the signs and symptoms of fever, such as pain, discomfort and elevated body temperature) only as indicated or ordered. This intervention should be considered on the basis of maintaining the person’s level of comfort rather than simply reducing an elevated body temperature.

Provide oral hygiene to keep the mucous membranes moist.

Provide dry clothing and bed linen

24
Q

Treating children with fever

A

Axillary measurement of temperature is recommended for routine clinical use, but staff should be aware that axillary temperatures are up to 1ºC lower than rectal temperatures. Rectal and oral temperatures are not recommended because of safety concerns and problems with acceptability. There is also a lack of data for oral temperatures. Tympanic temperatures are not recommended as they are unreliable.

All febrile neonates should have a full septic work-up and be admitted for parenteral antibiotics. Infants aged 1–3 months will generally be managed in a similar fashion, but there may be a place for outpatient management in carefully selected infants who are non-toxic, clinically stable over a period of observation, have reassuring pathology investigations and in whom close follow-up is assured.

Any child assessed as being at risk of sepsis should be admitted to hospital for investigation and, under most circumstances, parenteral antibiotics should be administered.

The possibility of urinary tract infection needs to be considered in all febrile children who do not have an obvious source of infection. Although urinalysis is a useful screening investigation in these children, urine culture is essential prior to the commencement of antibiotics for suspected urinary tract infection.

The response to antipyretics should not be used as a diagnostic tool to try to differentiate bacterial from viral infection

25
Q

Treating hypothermia

A

Provide a warm environment.

Remove wet clothing and provide dry clothing.

Apply warm blankets (a space blanket may also be used).

Keep limbs close to body.

Cover the person’s scalp with a cap or beanie.

Supply warm oral or intravenous fluids.

Apply warming pads

26
Q

Signs of hypothermia

A

Decreased body temperature and decreased pulse and respiration rates.

Severe shivering (initially).

Feelings of cold and chills.

Pale, cool, waxy skin.

Frostbite (nose, fingers, toes).

Hypotension.

Decreased urinary output (oliguria).

Lack of muscle coordination.

Disorientation.

Drowsiness progressing to coma

27
Q

What is the process for taking TPR?

A 
Introduce yourself
Confirm patient ID
Explain procedure
Gain consent
Brakes on
Gather equipment
Patient comfort and privacy
Hand hygiene
Before taking vitals:
  - has the patient recently consumed hot or cold drink?
  - recently exercised?
  - recently smoked or had caffeine?

Before taking temp via ear:
- does the patient have a history of ear pain, recent surgery or trauma?
Insert the probe of the tympanic thermometer into the plastic cover, which turns the thermometer on
Gently pull the top of the ear up and back to expose the tympanic membrane
Insert the probe of the thermometer and press the “thermometer” button
Dispose of the cover
Record result

Taking the pulse
Find the radial pulse with two fingers (NOT the thumb)
Rest the patient’s arm across their chest so you can feel their respirations more easily
Count beats for 60 secs if first time or previous result wasn’t normal, 30 secs if repeat and x 2 for bpm

Resps
Count respirations for 60 secs if first time or previous result wasn’t normal, 30 secs if repeat and x 2 for breaths per minute
Note if the respirations are irregular, shallow, or noisy, as these can be signs of a problem

SaO2
Attach oximeter to the finger

Record pulse, respiration and SaO2 results

Health Across the Lifespan 1 (17 decks)

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