WEEK 2- VITAL SIGNS Flashcards
Outline components included in the general survey.
Physical appearance
body structure
mobility
behavior
Outline equipment required to complete a general survey
physical appearance:
- age
- sex
- LOC
- skin colour
- facial features
body structure
- stature
- nutrition
- symmetry
- posture
- position
- contour
mobility
- gait
- range of motion
behavior
- facial expression
- mood and affect
- speech
- dress
- personal hygiene
measurement
- weight, height, BMI
Identify measurement components related to height, weight, Body Mass Index (BMI), & waist-to-hip ratio.
Weight in kg
Height in cm
BMI
Normal 18.5 to 24.9
***Note: Ensure the BMI formula includes the denominators being squared (Jarvis p. 156)
Weight in Kg
Height in metres²
Waist-to-hip ratio = waist circumference
Hip circumference
Waist circumference > 88 cm in women and > 102 places individuals at risk for diabetes, heart disease and hypertension
Distinguish approaches & techniques of general survey when examining clients across the lifespan.
Outline relationship between health promotion & objective data gathered during general survey.
Describe assessment findings in the following growth & development abnormalities of hypopituitary Dwarfism,
insufficient growth hormone in pituitary gland
gigantism
too much growth hormone
acromegaly (hyperpituitarism),
too much growth hormone
a-chondro-plastic Dwarfism,
abnormal bone growth in face, hands, etc
anorexia nervosa
BMI below 18, fear of gaining weight
Endogenous obesity: Cushing’s Syndrome.
chronic exposure to excessive levels of cortisol
Outline equipment required to complete a vital signs assessment
Identify strategies to maintain infection prevention & control safety principles.
Overview different methods of obtaining a temperature.
- rectal (most invasive, infants)
- oral (least invasive, common)
- axillary
- tympanic
Outline range of normal temperatures via different routes
oral- 35.8-37.3
rectal- 36-37/38
Differentiate between expected findings and abnormal findings (hyperthermia & hypothermia) and identify potential physiologic causes
Outline developmental differences related to technique & findings.
Range of Afebrile – 35.8-37.4C
Febrile 37.5 C and >
Pediatric population
Canadian Paediatric Society (2011) recommendations for rectal temperatures
Older Population
With age less likely to be febrile, but great risk for hypothermia
Document findings in narrative and graphic form.
Outline methods of obtaining a peripheral pulse.
Radial pulse
Pads of your 3 fingers
Place on flexor of wrist along the radius bone
Identify findings of rate, rhythm, force & expected findings when assessing a peripheral pulse.
Rate
Normal, bradycardia & tachycardia
Rhythm
Sinus arrhythmia
Force (0- 3+)
0- absent pulse
1+ weak
2+ normal
3+ bounding
Differentiate between expected findings and abnormal findings (bradycardia & tachycardia) and identify potential physiologic causes.
normal findings
50-95
bradycardia- less than 50
tachycardia- more than 100
Outline developmental differences related to technique & findings.
Outline method of assessing respirations.
maintain position for counting pulse
- assess, rate, rhythm, quality (relaxed, quiet, automatic)
Identify findings of rate & rhythm & expected findings.
infants (30-40)
2yr old (25-32)
adults (10-20)
less respirations
Differentiate between expected findings and abnormal findings (bradypnea & tachypnea ) and identify potential physiologic causes.
bradypnea- slow respirations (less) less than 10.
tachypnea- fast respirations (more) more than 20 in a adult.
Outline developmental differences related to technique & findings.
Outline method of obtaining a blood pressure using the one step & two step methods.
Wait 5 minutes
Heart level
Palpate brachial artery
Medial to biceps tendon
Above antecubital fossa
Wrap cuff 1 inch above brachial artery
Ausculatory Gap
*abnormal finding
Palpate brachial artery
Inflate cuff until pulsation is obliterated
And then, 20-30mm Hg above
Deflate cuff quickly
Wait 15-30 seconds
Begin BP
Identify findings of Korotkoff’s sounds.
Inflate cuff to maximum inflation level
Deflate slowly 2 mm Hg per heartbeat
Note Korotkoff sounds I & V
Differentiate between expected findings & abnormal findings (hypotension & hypertension) & identify potential physiologic causes.
Hypertension
Contextual
140/90
Hypotension
<95/60
Outline common technique errors that lead to false results.
- cuff too narrow or to big (can yield falsely high or low results)
Outline technique & potential findings of orthostatic hypotension.
Specific change in pulse and BP observed through a series of position changes
Supine, sitting with feet dangling, and standing
2 minutes in between so that venous congestion subsides
Orthostatic hypotension is a drop in systolic BP of more than 20mmHg or increase of pulse of more than 20 bpm
Reason for taking: hypertension, volume depletion, or reports of syncope
Prolonged bedrest, older age
Outline developmental differences related to technique & findings.
Outline method of obtaining an oxygen saturation.
Pulse Oximetry is measured with a pulse oximeter
This will provide both a pulse and an oxygen saturation reading
What reading is expected for within normal range for Oxygen Saturation?
Identify expected findings and abnormal findings
95 or more is expected
abnormal would be less than 95.
Outline developmental differences related to technique.
Outline the use of electronic vital signs monitoring system.
Review physiologic process of the pain sensation. Including sources & types of pain.
Nociceptive;
Caused by tissue injury; well localized
Described as “aching” or “throbbing”
Somatic
Superficial from skin and subcutaneous tissue (cutaneous pain)
Deep from joints, tendons, muscles, or bone
Visceral
From direct injury or stretching of large interior organs
Result of tumour, ischemia, distension, or contraction
Neuropathtic
Caused by lesion or disease affecting somatosensory nervous system
Results from damage to nerve pathway
Caused by direct nerve trauma, infections, metabolic problems; may be drug induced
Described as “burning” or “shooting”
Manifestations vary among patients
Referred
Originates in one location but is felt in another site
Innervated by same spinal nerve
Discuss developmental & social determinants of health considerations that relate to pain.
Describe the factors of a complete pain assessment.
Describe the use of standardized tools for assessing pain.
face pain chart (non verbal pain expressions)
Outline the components of objective pain assessment.
Outline developmental differences related to techniques, tools, & findings.
Neonates
Dependent on behaviour and physiological cues
More than one assessment approach
There is no increase in pain as one ages
Pain is always associated with pathology and not aging
Identify reasons for validating assessment findings of pain with the client.
vital signs
Temperature
Pulse
Respiratory Rate
Blood pressure
Pain Assessment
pulse
With every heart beat:
Stroke volume (SV)
approximately 70ml
Pressure wave is generated
results in a peripheral pulse
beats per minute (bpm)
8 factors affecting BP
age, gender, ethnocultural background, diurnal rhythm, weight, exercise, stress/emotions.
Blood pressure
Force of blood pushing against side of vessel wall
Changes with cardiac cycle
Two cycles
Systole
Diastole
systole
Systole
left ventricle contraction
pushes blood out into arterial blood stream
Systolic - maximum force on artery wall
Systolic ~ 120mm Hg
Levels of BP (5)
Cardiac Output (CO) –volume pumped per minute CO = SV x R
Peripheral Vascular Resistance (PVR)
Opposition to blood flow
Viscosity
Volume of Circulating Blood
Elasticity of Vessel Walls
equipment- BP
Stethoscope and aneroid sphygmomanometer
Width of BP cuff should equal 40% of the circumference of patient’s arm
A cuff that is too narrow yields a falsely high BP
subjective data- pain
Pain is whatever the experiencing person says it is, existing whenever he/she says it does” (McCaffery, 1968)
We have pain assessment questions we can ask
And assessment tools
OPQRSTU
Initial pain assessment (PQRSTU)
Onset : when did the pain start
Provocative or palliative: Relieved with rest? Previous treatments effective?
Quality of pain: Words to describe pain?
Region of body: Where? Radiates?
Severity: How patient would rate on intensity scale?
Timing and onset of pain: When started? Constant, dull, or intermittent? Changed over time? Pain-free periods?
Understanding of pain: What patient believes is causing the pain? Goal for comfort? Medications used?
2 TYPES OF PAIN
ACUTE AND CHORNIC
The young and the old are the most sensitive to environmental temperature fluctuations. True or False
TRUE
For an accurate oral temperature the thermometer should be left in place for 10 minutes . True or False
FALSE
Normally the apical pulse is greater than the radial pulse. True or False
FALSE
Arterial pressure is a result of the interaction between pumping action of the heart, peripheral vascular resistance, blood volume and viscosity. True or False
TRUE
Nursing goals and interventions for the client who is febrile are designed to determine the etiology of the fever. True or False
FALSE
Identify the 8 factors that significantly affect blood pressure:
Age. Blood pressure tends to increase with age. …
Family history and genetics. High blood pressure often runs in families. …
Lifestyle habits. …
Medicines. …
Other medical conditions. …
Race or ethnicity. …
Sex. …
Social and economic factors.
Pulse rate is affected by
amount of time since the last meal
degree of involvement in health care
developmental level
stress
Which of the following temperature readings is considered to be most accurate?
RECTAL
Your client’s vital signs are BP=80/50, T= 38.9C, P=112, RR=26. Your client is:
Hypotensive, tachycardic, tachypneic, and febrile
Your client’s vital signs are BP= 130/78, T=36.9C, P=84, RR=16. Your client is :
within normal range for all vital signs
The systolic pressure is ausculatated at 140 mm Hg, the point of muffling is heard at 80mm Hg and the last sound that you auscultate is at 70 mm Hg. Document the appropriate Blood pressure measurement of? ___140/70________
140/70
The normal respiration for an adult is _____10______to ______20_______
10/20
Bradycardia___pulse below 60__
BELOW 60
Orthostatic Hypotension-
fall in systolic blood pressure greater than 20 millimeters of mercury (mmHg) or a fall of in diastolic pressure greater than 10 mmHg
Systolic pressure
– pressure in the heart when the heart is at work
Pulse pressure
the difference between the systolic and diastolic pressure
Symptoms, such as pain, are often influenced by a person’s cultural heritage. Which of the following is a true statement in regard to pain?
The ethnic background of a patient is important in a nurse’s assessment of that patient’s pain.
Which of the following statements is true regarding pain?
Just as patients vary in their perception of pain, so will they vary in their expression of it.
A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. You would:
consider this a normal finding for a 1-month-old infant.
Which of the following statements is true regarding vital sign measurements in aging adults?
An increased respiratory rate and a shallower inspiratory phase are expected findings.
Which of the following is an example of acute pain?
Kidney stones
Which question would best assess the quality of the patient’s pain
What does your pain feel like?
Pain signals are carried to the central nervous system by way of:
afferent sensory fibers
Deep somatic pain originates from sources in which of the following locations?
Bone and joints
Which of the following has been found to influence pain sensitivity in women
Hormonal changes
Which of the following types is short, self-limiting pain that dissipates after injury?
acute
normal temp
37.2
temp is affected by
hormonal changes
diurnal cycle
mensuration cycle
exercise
older adults - 36.2
yes
