Week 2 Health Assessment Flashcards
Inspiration
Ribcage ___ as rib muscles____
Ribcage expands as rib muscles contract
Things to assess in airway and respiratory
Rate
Depth
Pattern
Effort
Normal average breaths per minute for adult
12 - 20 per minute
Normal average oxygen saturation
95 - 100%
Process of oxygen saturation
Blood flows through pulmonary capillaries where O2 attaches to BRCs, after O2 diffuses from alveoli into pulmonary blood, where most O2 attaches to haemoglobin.
Definition of < 90% SpO2
Hypoxemia
Pulse Oximeter
Non invasive method for monitoring SpO2
Where can a pulse oximeter be attached?
Finger
Toe
Nose
Earlobe
Forehead
Things to assess in pulse
Rate
Rhythm
Strength (amplitude)
Normal pulse rate
60 - 100bpm
Tachycardia
> 100bpm
Bradycardia
<60bpm
Blood pressure
Measure of pressure exerted by blood as it flows through arteries
Systolic pressure
Pressure as a result of constriction of ventricles
Diastolic pressure
Pressure when ventricles relax
Normal blood pressure
90-140 / 60-90
Should you use a limb with an IV for assessing blood pressure?
No
Hypertension
High blood pressure
As a result of ___
- Thickening and loss of resistance of heart walls
- Heart pumps with greater resistance
- Decreased blood flow to brain, lungs, and kidneys
Hypertensions (High BP)
Hypotension
Low blood pressure
As a result of___
- Dilation of vessels
- Blood leaves central organs and moves into periphery
Hypotension
Blood pressure is ____ in adolescents
Lower
Normal body temperature
36-37.4
Temperature <35
Hypothermia
Temperature >37.9 to 40
febrile
Temperature > 40.6
Hyperthermia
Sudden changes in vital signs can indicate___
Life threatening problems
Why do we assess vital signs?
- To detect abnormal body system functions
- Give baseline
- Assess effects of medication
When do we assess vital signs?
- Start of shift
- Department change
- Pt deteriorations
- Admission
- Medication
- When you are concerned
Nurses role in vital sign assessment
- Systematically assesses
- Understand and interpret
- Appropriate early interventions
- Communicate
Hyper (Prefix)
Increase
Hypo (Prefix)
Decrease
A (Prefix)
Without
Tachy (Prefix)
Fast
Brady (Prefix)
Slow
Eu (Prefix)
Normal
Dys (Prefix)
Difficult
Olig (Prefix)
Few
Poly (Prefix)
Many
Haem (Prefix)
Blood
tension (Suffix)
Pressure
apnoea (Suffix)
Breathing
cardia (Suffix)
Heart
rythmia (Suffix)
Heart Rhythm
uria (Suffix)
Urine
volaemia (Suffix)
Blood volume
Vital signs are assessed regularly to:
- Determine the adequacy of oxygenation of the tissues.
- Reassure the person that you are monitoring their health.
- Determine the overall status of well-being for the person.
- Enable escalation of care.
When assessing a person’s peripheral pulse, the nurse is also assessing which of the following?
Rhythm
When assesing the temperature of older adults, the nurse needs to be aware that:
It is not a reliable indicator of serious infection.
The measurement of blood that enters the aorta with each ventricular contraction is called the
Stroke volume
When assessing respiratory rates, you should
Place you hand lightly on the chest and feel the rise and fall.
When considering the factors that influence activities of living, stress and anxiety is likely to ___ a person’s heart rate (pulse) and blood pressure.
Increase
What role does hand hygiene patient care while in the emergency department?
Preventing nurses from contracting or infecting other patients with HCV
Patient is seropositive status for hepatitis C, is there any special personal protective equipment the nursing staff should be using
Standard precautions as only blood is infectious
