Vitals Flashcards
Tachycardia
Faster than 100 beats per min ( adult ) eg: shock , hemorrhage , drugs .
Bradycardia
Slower than 60 beats per minutes (resting in supine position )
Bradypnea
Slow Breathing below 10 per min
Tachypnea
Fast breathing
Dyspnea
Difficulty breathing
Eupnea
Normal breathing
Apnea
Absence of breathing
Pyrexia
Elevated temperature , above normal body temp
Febrile
FEVER ! Way above normal body temperature
Hyperthermia
High body temperature
Hypothermia
Low body temperature
Receiver
The person to whom the message is conveyed
Sender
The person conveying the message or the one that create the message
Othopnea
Shortness of breath /Difficult breathing when lying down
Pulse normal range
60-100 bpm
Temperature normal range
Healthy adults 98.6
Normal blood pressure range
In adult less than 120/80measured in (MMHG) millimeter of mercury …… B/P is veins and chambers of the heart , volume of the arterial wall
Respiration normal range
Adult 12-20per min
Active listening
full attention to what the patient is saying , open posture , allow the speaker to validate you recieved the message , to give feedback , restating or paraphrasing , clarifying , focusing
Close ended question
Question that has a YES OR NO ANSWER
Open ended question
How , what , can you tell me about or in what way questions , cannot be answered with a yes or no
How a tympanic temperature obtained for children under 3 years ? And adults ?
Pull ear Down and back for child under 3yrs …. Pull ear For adults up and back
The systolic pressure and diastolic pressure
The top number , the heart contracts ….. The bottom number relaxing/filling
What is cardiac output
The amount if blood pumped in 1 minute …….The amount of blood discharged from left to right ventricle … CO=HR X
What is pulse pressure
The difference between the two reading of the diastolic and systolic pressure eg:120-80=40
What is the formula for B/P
BP=COxSVR…. CO-cardiac output -the amount of blood pumped in 1 min ….SVR-systemic vascular resistance -the diameter of your blood vessel
What is the most common arterial site to obtain B/P ?
Brachial pulse
What are various types of breathing patterns ? Which is common near death ?
Eupnea - normal breathing , apnea - absence of breathing , Dyspnea - difficulty breathing , Bradyapnea - slow breathing , tachyapnea - fast breathing , othropnea -difficult breathing laying down Chyene-stroke - near death , abnormal breathing , stop and grasp ….
How are respirations assessed ?
Without the pt noticing …… One inhalation plus one exhalation equals one respiration , PLACE ONE HAD ON CHEST OR OBSERVE RISE AND FALL OF CHEST
What is a radial/ apical pulse measurement ? What is a pulse deficit ?
Two nurses readings at the same time ….. Pulse deficit is the difference between the radial and apical pulse , it can be a sign of vascular disease or cardiac dysrhthmia
What factor influence the pulse rate ?
Smoking , stress , sex , age , pain , blood pressure , emotions , medication, excersize , fever,postural changes - sitting , lying , standing
Where is the stethoscope placed to assess the apical pulse ? How long should the nurse listen ?
Over the apex of the heart -left fifth intercostal space , mid clavicular space …..the nurse listens for 1 minute
What sites may the pulse be checked ?
Temporal , carotid , apical , radial , brachial , femoral , popliteal ,dorsalis pedis or pedal pulse ,posterial tibial
How is strength of the pulse assessed ?
+1- tready - difficult to breath… +2-weak- cannot be palpated with light pressure ….+3-normal - moderate pressure cannot feel +4- can still be palpated with moderate pressure
How do you insure the patient understood your message ?
Feedback Letting them repeat it , explain in their words
What is non verbal communication ? How is eye contact used ?
Message transmitted without words … Use of touch , eye contact or physical appearance , posture , gesture … 2-6 sec to not be threathing or intimidating , diff cultures interpret eyecontact different .
How does the nurse initiate the nurse -client relationship ?
Introduce self eg: hi my name is____ and I will be ur nurse today and will be doing …
How is silence used ?
Demonstrates caring and concern Not always good , sometimes good …asian not too much touching , USED IN CONJUNCTION WITH TOUCH
How does the nurse communicate with older adults
Being patient with them , askin about their history , asking questions
Orthostatic hypotension
Drop in blood pressure , falls when you stand up too quickly … Eg:dizziness , disoriented , feeling weak , nausea , blurred vision
What is othrostatic blood pressure checks ?
Select arm with highest systolic reading from previous measurement and take B/P … Assist the pt to standing position , after 1-3 mins take B/P AGAIN if pt is dizzy/faint , assist pt back to lying down , leave cuff in place assist pt to stand and take B\P
What factors can affect blood pressure ?
Age ,sex , excersize , hormonal influence eg:birthcintrol daily variation : lowest when sleep , medication ,stress - elevated tempeature , enviorment -eg: AC , hot/cold liquids , smoking , talking , temperature , emotional state , , full bladder , too big b/p cuff or too small
Compare the sites that might be used to measure temperature ?
Oral - 98.6 not for unconscious pt or pt that had oral surgery (blue probe ) has to be assessible / comfortable …..tympanic - 98.6 (A)non invasive accurate lessens heat loss … Rectal -LEAST ACCURATE - 99.5 reiable … Not for rectal surgery disorder , for pt who cannot be postion properly , reliable ….Anxillary -97.6 LEAST ACCURATE .. Non invasive … Excessive cerumen may interfere with reading
How does the nurse communicate with older adult ?
Being patient with them , low pitch voice , , face the client ! So they can read lips and hear better , asking them questions , asking about their history
Sp02 normal range
A normal range of 93-100% !! saturation of hemoglobin , carries oxygen in red blood cell , ……….A device intended for the non-invasive measurement of arterial blood oxygen saturation and pulse rate
Channel/mode
How the information is carried out ! Auditory , visual , kinesthetic
What is asculatory gap ? How does the nurse ensure and accurate reading when the patient has asculatory gap ?
Between the first and second korotkoff sound …… korotkoff sound sometimes the sound disappear temporarily and reappear ……. By inflating the blood pressure cuff 30mmhg higher than the pressure requires to occlude the brachial pulse
Stoke volume
The amount of blood pushed into the aorta with each heart beat
Othrostatic hypotension
From lying to sitting or standing … A drop of 25mmhg in systolic pressure and a drop of 10mmhg in diastolic pressure … When the pt rises too quickly .
Aphasia
Without speech , after stroke cannot get the word out
What part of the body regulates temperature ? How does the body cool itself off if it starts overheating ? How does the body warm up if it’s too cold
Hypothalamus …. Sweating -blood vessel dialates , shivering it vaso-constrict because the blood is further away from the skin
What is the procedure for obtaining weight / height ?
Set the scale to zero , place paper on the base if pt does not have on shoe , keep pt upright to obtain height , assist pt back to bed or wheelchair if necessary and document
Feedback
The importance of communication ! To determine if the message has been recieved and understood , Nurse to nurse , nurse to doctor , nurse to pt , nurse to pt family
Korotkoff sound
Pulsating sounds heard during auscultation of blood pressure …. These go through 5 phases
Hypotension
Low blood pressure , considered healthy to have low BP if no I’ll effects ….eg:vertigo or syncope (fainting )
Hypertension
High blood pressure 140/90mmhg
Pain
The fifth vital sign
Message
What you say to the pt , communication in writing, speech , or by signal
What is the goal of therapuetic communication ? What technique are used ?
Build trust and meet patients needs … Active listening techniques - restating , clarifying , focusing , reflecting
How does the nurse communicate with an unresponsive patient ? Or assess if and unresponsive patient can communicate
Talk to them like they are responsive …. Squeezing of the hand or blinking of the eye
Kussmal Breathing
Deep , rapid ef: pt with diabetes
What is stethoscope ?
Instrument used for listening
What are the vital signs?
Temperature , respiration , pulse , pain , blood pressure
Palpation
Touching
Percussion
Tapping
Auscultation
Listening
