Week 1: Course Overview and Vital Signs

Question 1

CRAAP Criteria

Answer 1

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?

Question 2

Nursing Process

Answer 2

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

Question 3

Nursing Process: 5 Steps

Answer 3

1. Assessment
2. Diagnosis
3. Planning Intervention
4. Implementation of Intervention
5. Evaluation of Intervention effects

Question 4

2 Types of Assessment:

Answer 4

1. Focused: Problem-Oriented; “I have a cough”
   Based on pt’s concern and evaluates their progress & response to treatments/care
2. Comprehensive: Initial Assessment, every single part, from head-to-toe
   Detailed health history + physical examination, examines overall health status

Question 5

2 Types of Data:

Answer 5

1. Subjective Data: SYMPTOMS
   Not measurable, it’s what the patient tells us about their experience: health history
2. Objective Data: SIGNS
   Measurable, it’s what you find from physical exams

Question 6

Conducting an Assessment

Answer 6

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)

Question 7

Considerations for Developmental Stages: Infants

Answer 7

Will probably cry. Keep their parent close.

Question 8

Considerations for Developmental Stages: toddlers

Answer 8

Still keep them with their parents. They also like to say no; don’t give them choices

Question 9

Considerations for Developmental Stages: preschoolers

Answer 9

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

Question 10

Considerations for Developmental Stages: school age child

Answer 10

Choose the medical words you use carefully so they understand, speak to them like a person and not like a baby

Question 11

Considerations for Developmental Stages: adolescents

Answer 11

Want to be treated like mature individuals, parents not present, consider body image, don’t condescend but don’t talk like they’re adults

Question 12

Considerations for Developmental Stages: older adults

Answer 12

Consider their mental state, ability to see/hear/understand

Question 13

cultural considerations

Answer 13

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

Question 14

GENERAL SURVEY FOR ASSESSMENT (INSPECTION):

Answer 14

• physical appearance
• body structure
• mobility
• behaviour

Question 15

vital signs

Answer 15

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

Question 16

routine vital signs

Answer 16

Taken at the beginning of shifts/once per shift or with any change in clinical condition

Question 17

temperature

Answer 17

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

Question 18

how to take temperature

Answer 18

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

Question 19

Pulse

Answer 19

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

Question 20

what influences pulse

Answer 20

Exercise
Fever
Medications
Pain
Fear/Anxiety
Infection
Dehydration (increases as more blood needs to be pumped)

Question 21

how do you take pulse

Answer 21

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

Question 22

Respiration

Answer 22

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?

Question 23

what influences respiration

Answer 23

What influences it?:
Age
Exercise
Anxiety
Medications
Respiratory Distress/Infection
Head Injury

Question 24

how do you take respiration

Answer 24

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

Question 25

blood pressure

Answer 25

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

Question 26

what influences blood pressure

Answer 26

Age/gender/race
Diurnal Cycle
Weight
Exercise
Stress/emotion
Medications
Blood viscosity & volume (dehydration = less volume + pressure)
Vessel wall elasticity

Question 27

oxygen saturation

Answer 27

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

Question 28

pain

Answer 28

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.

Question 29

Hypothermia:

Answer 29

Low temperature from cold

Question 30

Hyperthermia:

Answer 30

High temperature from heat exposure

Question 31

Tachycardia

Answer 31

> 100bpm

Question 32

Bradycardia:

Answer 32

<60bpm

Question 33

Hypertension:

Answer 33

> 140 or 90 mmHg

Question 34

Hypotension:

Answer 34

<90 or 60 mmHg

Question 35

Normotensive:

Answer 35

around 120/80mmHg

Question 36

Orthostatic VS:

Answer 36

Taking VS when lying down and standing up

Question 37

Orthostatic Hypotension:

Answer 37

Drop in BP when going from lying down to standing up

Question 38

Afebrile:

Answer 38

No fever

Question 39

Febrile:

Answer 39

Fever (Above 37.3C due to immune response)