Vitals Flashcards
Definition of Vital Signs?
- core nursing function
- key to recognising patient deterioration
- helps provide information about the r’ship between body systems
What are the 5 vital signs?
1) Temperature (°C)
2) Oxygen Saturation (SaO2)
3) Respiratory Rate (bpm - breaths)
4) Blood Pressure (Bp)
5) Pulse (bpm - beats)
When do you assess vital signs?
- on admission (a base for improvement/ deteriration)
- change in health status
- B/D/A surgery or invasive procedure
- B/ A surgery or invasive procedure
- B/ A administration of medication ( that could affect respiratory or circulatory systems)
- B/ A any nursing intervention (blood infusion/ moving around)
- after an accident/ injury
- timeliness (when allocated)
Define temperature?
reflects the balance between heat produced & heat lost
measured in degrees Celsius ( °C )
2 types of body temperature?
Core
- remains @ a constant temp to ensure organs are alive
Shell (surface)
- temp increases & decreases with the environment
Types of ways you can assess temperature
you want your temp to be F.E.A.R.O normal
F - forehead E - ear A - axilla / armpit R - rectum O - orally
How does the body regulate temperature?
sensors in the shell & core
\+
integrators in the hypothalamus
=
act as receptors to determine body tempWhat is the normal temperature range?
36-37 °C
T vocab - pyrexia
- when a person has a fever
- body temp. above normal
T vocab - hyperpyrexia
- very high temperature
- e.g. 41°C
T vocab - Febrile
- a person who has pyrexia/ fever
T vocab - Afebrile
- a person who has a normal temperature
T vocab - hyperthermia
- core temperature above 40.6°C
T vocab - hypothermia
- core temperature below normal (36°C)
What are some nursing interventions for adults with a fever?
- monitor vital signs
- assess skin colour & temp
- monitor lab reports (signs for dehydration & infection)
- feel warm = remove layers
- feel cold = add layers
- measure fluid intake & output
- rest = reduce physical activity
- give antipyrectic medication
Define oxygen saturation?
Is the measure of how much oxygen your red blood cells are carrying
How to assess oxygen saturation?
Using a pulse oximeter
- non-invasive device
- that estimates a client’s arterial blood oxygen
saturation (SaO2)
- by a sensor attached to the client’s
- finger,
- toe,
- nose,
- earlobe
- or forehead
- (or around the hand and foot of a newborn)
How does a pulse oximeter work?
1) Two, light-emitting diodes (LED’S) – red & infrared –
transmit light
2) A photodetector placed directly opposite the LED.
This measures the amount of red & infrared light
absorbed by oxygenated & deoxygenated
haemoglobin.
What are the different types of Oxygen saturation levels and what to do?
- Normal SaO2 is 95% - 100% room air (RA)
- If less than 95% = observe & give supplement oxygen
- If less than 90% = seek assistance/ medical emergency
if no underlying lung disease
- (such as Emphysema/ chronic obstructive lung
disease)
What are potential errors with a pulse oximeter?
- Circulation
- Activity – if they keep moving around
- Nail polish/ false nails
- Minimise motion
Define respiratory rate?
Respiration is the act of breathing, so therefore the respiratory rate is amount of breaths per minute
RR vocab - inhalation (inspiration)
Breathing in or intake of air into the lungs
RR vocab - exhalation (expiration)
Breathing out or the movement of gases from the lungs to the atmosphere
RR vocab - ventilation
Movement of air in and out of the lungs
What sections of the brain control respiration?
1) Pons respiratory system
2) Medullary respiratory system
these are in the brain stem
How can we assess respIrAtory rate?
INSPECTION
- Rate
- How many times are they breathing
- Depth
- Shallow or deep breaths
- Rhythm
- Regular or irregular
- Quality
- Measured using a pulse oximetry
- Effectiveness of respirations
AUSCULTATION
- Listening with a stethoscope
What is classified as normal respiration?
- Usually 10-16 breaths per minute
- Adult normal range = 10-19bpm
- Respiration should be
- Regular
- Quiet (no wheezing)
- All same size
RR vocab - Eupnoea
Breathing that is normal in rate and depth
RR vocab - Bradypnea
Abnormally slow respirations
RR vocab - Tachypnoea
Abnormally fast respirations, quick, shallow breaths
- E.g. anxiety attack
RR vocab - Apnoea
The absence of breath
- E.g. sleep apnoea
RR vocab - Dyspnoea
Difficult or laboured breathing
- noisy/ wheezing a lot
What happens to your body when you breathe?
Inhalation = Chest expands & diaphragm contracts
Exhalation = Chest contracts & diaphragm relaxes
Define Blood Pressure?
is a measure of the pressure exerted by the blood as it flows through the arteries
What are the 2 types of blood pressure readings?
SYSTOLIC
- measures the pressure in your arteries when your heart beats
- measures the force of blood being pushed around your body when the heart contracts
DIASTOLIC
- measures the pressure in your arteries when your heart rests between beats.
- Is the pressure of the blood when the ventricles are at rest, lower pressure, present at all times within the arteries
How is blood pressure measured?
- Millimetres (mm) of mercury (Hg) = (mmHg) and
recorded as a fraction - E.g. (systolic pressure )/(diastolic pressure ) = 120/80
mmHg
What are the 2 ways we can assess BP and the equipment needed for it?
INVASIVE
- Canular needle into the radial artery
- hooked up to a monitor
NON-INVASIVE
- Auscultation (audio) - stethoscope
- Palpation - sphygnomanometer
What are the names of abnormal blood pressure?
Hypertension & hypotension
What is hypertension?
Hyper = high
Is generally classified as a blood pressure of greater than 140/90 mmHg
What is hypotension?
Hypo = low
Is generally classified as a blood pressure of less than 90/60 mmHg
When shouldn’t you take a person’s BP?
- when the arm/ shoulder has been injured
- arm/ shoulder has a disease
- there’s a cast or bandage on any part of the limb
- person has surgical removal of lymph nodes on that
side - Person has an intravenous infusion in that limb
- The person has an arteriovenous fistula
> E.g. renal dialysis
What is the correct procedure when taking BP manually or automatically?
- consent
- gather equipment
- prepare environment
- perform hand hygiene
- position & prepare patient – rested
> arm supported
> elbow extended
> palm upwards - apply the cuff (correct width) over the brachial artery 2.5cms above the bend
What is the process for manual BP?
- consent
- gather equipment
- prepare environment
- perform hand hygiene
- position & prepare patient – rested
> arm supported
> elbow extended
> palm upwards - apply the cuff (correct width) over the brachial artery 2.5cms above the bend
- First, perform a preliminary palpatory systolic estimation,
- position the stethoscope over the brachial pulse
- pump up the cuff
- auscultate (listen to) the patient’s blood pressure
- remove the cuff
- ensure the patient is comfortable
- clean & replace the equipment appropriately
- perform hand hygiene
- document & report relevant information
Describe each phase of the korotkoff sounds
Phase 1 - sharp tapping = systolic BP
Phase 2 - swishing or swooshing sound
Phase 3 - a light tapping compared to phase 1
Phase 4 - soft blowing sound that fades
Phase 5 - the last sound is heard followed by silence this
is the diastolic BP
Define what a pulse is?
- a wave of blood created by the contraction of the left ventricle of the heart
- Pulse waves represents the amount of blood that enters the arteries with each ventricular contraction
- The pulse reflects the heartbeat
- Heart rate control
How do you express the pulse measurement unit?
expressed as beats per minute (bpm)
What are the two types of pulse sites?
> Peripheral pulse
- Located away from the heart - E.g. wrist/ foot
> Apical pulse
- Is a central pulse, located at the apex of the heart
How do you assess the pulse?
PALPITATION (FEELING)
- Think you can feel “palp”
- Middle two/ three fingertips used for palpitating all pulses except the apex of the heart
- Apply moderate pressure
AUSCULTATION (AUDIO)
- Auscultation = audio
- The apex of the heart, auscultate with stethoscope
- Doppler ultrasound
What are normal pulse values?
- 60-80 beats per minute (bpm) at rest
- Adult normal pulse/ heart-rate range 60-100 bpm
What should the nurse be aware of before assessing the patient?
- Any medication that could affect the heart rate
- Whether the person has been physically active
- Any baseline data about the norm heart rate for the person
> Could be an athlete with a heart rate of 30 normally - If they should assume a particular position
> E.g. sitting/ lying down
Pulse vocab - Tachycardia
greater than 100bpm
Pulse vocab - Bradycardia
Less than 60bpm
Pulse vocab - Arrhythmia
An irregular pulse
What is peripheral vascular resistance?
> is the internal diameter/ capacity of the arterioles & capillaries this determines the peripheral resistance
can increase BP (especially diastolic BP)
Increased vasconstriction = raises BP
decreased vasconstriction = lowers BP
What is blood volume?
Blood volume decrease - BP decreases
> this is due to the decrease fluid in the arteries
> e.g. hemorrhage/ dehydration
Blood volume increases – BP increases
> because the greater fluid volume within the circulatory system
> e.g. rapid intravenous infusion
