Week 4: Basic Observations Flashcards
Why do we take basic obs?
A baseline so abnormal changes can be identified and to make a plan for immediate treatment
What is heart rate/pulse?
The rise and fall of pressure associated with the contraction and relaxation of the heart, can be felt palpating an artery
How do you measure a pulse?
-measure for 1 minute ( or 30s X2)
- check for regularity, volume and character
How long should you take a paediatrics pulse for?
1 whole minute
What are some common sites for palpating arterial pulses?
- carotid
- brachial
- femoral
- radial
- popliteal
- posterior tibia
- dorsalis pedis
What does tachycardia mean?
Rapid resting heart rate <100bpm
What does bradycardia mean?
Slow heart rate >60bpm
What are some factors that affect heart rate?
- exercise
- stress
- illness
- overdose/drugs/intoxicated
- anxiety
- excitement
- cardiac related issues
- pain
What is first vital observation to alter in a patient whose condition is deteriorating?
Respiratory Rate
What can resp rate be influenced by?
- pain
- stress
- emotion
Define tachypnoea
A raised respiratory rate
Define hyperventilation
When breathing removes more CO2 than is produced
Define dyspnea
Difficulty breathing/SOB
Define orthopnea
Difficulty in breathing when laying flat
Define apnea
No resp rate
What are the two ways oxygen is transported to the tissues?
-98.5% bound to haemoglobin
-1.5% dissolved in the plasmas
What is pulse oximetry?
A measure of the amount of heamoglobin saturated with oxygen by projecting 2 pulsating beams of light through the peripheral blood vessel, a portion is absorbed by the HB and converted to saturation
What is a normal value of SPO2?
> 95%
When should you be mindful when taking SPO2?
Nail polish or cold peripherals
When resting where generates the most heat?
Heart, liver, brain and endocrine glands
What is a normal range for temperature?
36.5-37.2 C
What is blood pressure?
A measure of the pressure exerted by the blood against the walls of the blood vessels. The most simple indicator of haemodynamic well-being
Why is blood pressure important?
- oxygen transport
- tissue perfusion
What are the two numbers associated with blood pressure?
- systolic (the highest pressure when the heart beats)
- diastolic (the lowest pressure in between beats)
What is the average blood pressure for a health adult?
120/80mmHg
What are some physiological factors that affect blood pressure?
- vol of blood
- viscosity of blood
- elasticity of arteries
- pumping action of the heart
- amount of resistance in the circulation
What factors cause hypertension?
- physical activity
- strong emotion
- obesity
- heart disease
- arteriosclerosis
- vasoconstriction
- circulatory overload
- polycythemia
What factors cause hypotension?
- hypovolemia
- lack of sympathetic tone-vasodilation
- cardiac arryhthmias
- anemia
Define hypertension
- systolic >140mmHg
- diastolic >90mmHg
Define hypotension
- systolic <90mmHg
- diastolic <60mmHg
What do we use to measure blood pressure?
A sphygmomanometer and a stephoscope
What are the three types of sphygmomanometers?
- mercury
- aneroid
- automatic
What is heard in phase 1 of Korotkoffs sounds?
First appearance of faint clear tapping sounds which gradually increase in intensity
What is heard in phase 2 of korotkoffs sounds?
The softening of sounds which may be swishing
What is heard in phase 3 of korotkoffs sounds?
The return of sharper sounds which become crisper but never fully regain then intensity of phase 1 sounds
What is heard in phase 4 of korotkoffs sounds?
The distinct abrupt muffling of sounds, which become soft and blowing
What is heard in phase 5 of korotkoffs sounds?
The point at which all sounds disappear completely
In what order should we record obs?
- resp rate
- SPO2
- temp
- BP
- pulse rate
- level of consciousness
- blood glucose levels
- cap refill <2 seconds
What does a low NEWS score (1-4) prompt?
An assessment from a registered nurse
What does a medium NEWS score (5-6) prompt?
Urgent review by a clinical skilled with competencies in the assessment of acute illness
What does a high NEWS score (7 or more) prompt?
The emergency assessment by a clinical team/critical care outreach team
What are some red flags obs on adults?
- NEWS 2 greater or equal to % and or look well with a Hx of infection
- systolic is <90
- HR > 130 bpm
- RR > 35 bpm
- oxygen is >925 and they require supplementary oxygen
ACVPU is either VPU
