Week 1: Course Overview and Vital Signs Flashcards
CRAAP Criteria
Currency: When was it made/revised? Are old sources okay (historical research)?
Relevance: Is it important for your needs? Is the intended audience yourself as a HCP?
IMPORTANT: If it’s for patients, pull the references used by the website
Authority: Who wrote this? Authors/publishers/sources/sponsors?
Qualifications? Contact info? URL (.com, .org, .edu, .gov …)
Accuracy: Where is it coming from? Is evidence cited? Peer reviewed? Verifiable?
Bias/Emotional Tone? Spelling/Grammar/Typos?
Purpose: Why was this page made? Inform/Teach? Sell/Entertain? Clickbait? Intentions?
Fact/Opinion/Propaganda? Any biases whatsoever?
Nursing Process
A five-step problem-solving approach to identify, diagnose and treat health issues
- A nursing diagnosis is made, not a medical one; it analyzes what we as a nurse can do independently, though it is complementary to the medical approach
- Medical Assessments treat disease
- Nursing Assessments treat human responses to actual/potential health problems
Nursing Process: 5 Steps
- Assessment
- Diagnosis
- Planning Intervention
- Implementation of Intervention
- Evaluation of Intervention effects
2 Types of Assessment:
- Focused: Problem-Oriented; “I have a cough”
Based on pt’s concern and evaluates their progress & response to treatments/care - Comprehensive: Initial Assessment, every single part, from head-to-toe
Detailed health history + physical examination, examines overall health status
2 Types of Data:
- Subjective Data: SYMPTOMS
Not measurable, it’s what the patient tells us about their experience: health history - Objective Data: SIGNS
Measurable, it’s what you find from physical exams
Conducting an Assessment
There are many steps, and it starts with TALKING
1. Inspection (Concentrated looking/searching, examining)
2. Palpation (Lightly touching for lumps, bumps, bruises, abnormalities)
3. Percussion (Placing outstretched middle finger on body part and tapping finger with dominant hand to hear what type of noise it makes; hollow, dull — i.e., a healthy lung should be hollow)
4. Auscultation (Listening with stethoscopes)
Considerations for Developmental Stages: Infants
Will probably cry. Keep their parent close.
Considerations for Developmental Stages: toddlers
Still keep them with their parents. They also like to say no; don’t give them choices
Considerations for Developmental Stages: preschoolers
They probably won’t pay attention to you, you have to engage them but distinguish playing and treating. They may want to be on the “big kid table” or their parent’s lap
Considerations for Developmental Stages: school age child
Choose the medical words you use carefully so they understand, speak to them like a person and not like a baby
Considerations for Developmental Stages: adolescents
Want to be treated like mature individuals, parents not present, consider body image, don’t condescend but don’t talk like they’re adults
Considerations for Developmental Stages: older adults
Consider their mental state, ability to see/hear/understand
cultural considerations
Some cultures don’t like eye contact, touching, hugging, opposite sex
Information they disclose is different, there could be a language barrier (and relatives may bias information translated)
Use slang and phrasings with caution
GENERAL SURVEY FOR ASSESSMENT (INSPECTION):
- physical appearance
- body structure
- mobility
- behaviour
vital signs
There are 4 of them (excl. Oxygen saturation and Pain). You take them to establish a baseline for their physiological functions/to see how it may deviate from normal
1. Temperature
2. Pulse
3. Respiratory Rate
4. Blood Pressure
routine vital signs
Taken at the beginning of shifts/once per shift or with any change in clinical condition
temperature
TEMPERATURE: Range for optimal physiological function; too high can mean fever, low = cold
What’s Normal?: 35.8 to 37.3 C
What Influences It:
Diurnal (Day/Night) Cycle (Coolest in morning)
Menstrual Cycle
Exercise
Gender/Age
Cold/Heat Exposure
Surgery
Infection
Neurological Disease
how to take temperature
Orally: Under the tongue, common and accurate, fast if electric, otherwise for 3-4 minutes (no fever) or 8 minutes (fever)
Axillary: Under armpit (done if uncooperative, ex., children), can be 0.5C lower than oral
Tympanic: In the ear, reads quickly but requires special ear thermometer
Rectal: Uncommon and Uncomfortable, 0.5C higher than oral
Pulse
Measures heart function + ability to circulate blood
What’s Normal?:
Rate:
Newborns: 70-190bpm
Children: 70-110bpm
Adults: 60-100bpm
Rhythm: Regular or Irregular? (Steady vs. Irregular)
Elasticity: Is it straight/resilient?
Force: Graded from 0-3
0: Absent
1+: Weak, Thready
2+: Normal
3+: Full, bounding
what influences pulse
Exercise
Fever
Medications
Pain
Fear/Anxiety
Infection
Dehydration (increases as more blood needs to be pumped)
how do you take pulse
Palpate the radial artery (under the thumb) or carotid artery (under neck) with 2-3 fingers
Count for 30 seconds if regular (*2 for BPM), 60 seconds if irregular
Respiration
Measures intake of air/oxygen
What’s normal?:
Rate:
Adults: 10-20 breaths/minute
Children: 20-30 breaths/minute
Infants: Up to 40 breaths/minute
Rhythm: Regular or irregular?
Depth: Shallow or deep?
what influences respiration
What influences it?:
Age
Exercise
Anxiety
Medications
Respiratory Distress/Infection
Head Injury
how do you take respiration
DON’T tell them you’re taking it; while you’re taking the pulse, continue counting their breaths
You can hold their arm to their chest to feel breathing
If regular: 30 seconds, if irregular: 60 seconds
blood pressure
DON’T tell them you’re taking it; while you’re taking the pulse, continue counting their breaths
You can hold their arm to their chest to feel breathing
If regular: 30 seconds, if irregular: 60 seconds
what influences blood pressure
Age/gender/race
Diurnal Cycle
Weight
Exercise
Stress/emotion
Medications
Blood viscosity & volume (dehydration = less volume + pressure)
Vessel wall elasticity
oxygen saturation
Oxygen Saturation: Measures amount of oxygen binding to hemoglobin in the blood as a %, generally 92% and above is acceptable. Attach oximeter to left finger, light side pointing to nail capillary
pain
Pain: Measures amount of discomfort. Ask patient how they’d rate their pain when lying down and when moving (1-10, 1 = no pain at all, 10 is the worst pain imaginable — or sad-happy scale). Can be highly subjective.
Hypothermia:
Low temperature from cold
Hyperthermia:
High temperature from heat exposure
Tachycardia
> 100bpm
Bradycardia:
<60bpm
Hypertension:
> 140 or 90 mmHg
Hypotension:
<90 or 60 mmHg
Normotensive:
around 120/80mmHg
Orthostatic VS:
Taking VS when lying down and standing up
Orthostatic Hypotension:
Drop in BP when going from lying down to standing up
Afebrile:
No fever
Febrile:
Fever (Above 37.3C due to immune response)
