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HHA > Week three: vital signs > Flashcards

Week three: vital signs Flashcards

1
Q

what is a general survey?

A
  • describes the clients mental state and behaviours of the client
  • what the nurse notices during the initial encounter
  • provides a snap shot in time
  • used to make a timeline
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2
Q

what does ASEPTIC stand for?

A 
appearance and behaviour
speech
emotion
perception
thought process
insight
cognition
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3
Q

when do we assess vitals?

A
  • newly admitted
  • 3-4 hours per shift
  • if the patients status is changing
  • as per MD
  • pre/post surgery
  • pre/post procedures
  • before/during/after medications
  • as indicated by client condition/response
  • whenever you are in doubt
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4
Q

what is pulse? and what do we asses?

A

each ventricular contraction of blood a puse wave travels from the aorta through to the distal ends of the arteries

  • rate (bpm)
  • rhythm
  • strength
  • equality (symmetry)
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5
Q

what are the heart sounds?

A

S1- beginning of systole (loudest at apex or lower left

S2- beginning of diastole (loudest at the base

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6
Q

when is the apical pulse rate checked and how do you take it?

A

when: anytime the radial pulse is irregular, when its difficult to take a child’s pulse infants < 2yr, before administering drugs that can affect the heart

how to take it:auscultated with a stethoscope, placed over the apex of heart (between the 4th and 5th ribs MCL just below left nipple) the louder sound it counted

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7
Q

what are the expected values for pulse rates

A 
age               avg     range 
Newborn	120	70-190
Infant	120	80-160
Toddler	110	80-130
Child	95	70-115
Preteen	90	65-110
Teen	80	55-105
Adult	70-75	60-100
Elite athlete	50-60	50-100
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8
Q

list the different pulse rates

A
  1. temporal (above and towards outside of the eye
  2. brachial (inner side of the bicep)
  3. cartod (side of neck)
  4. radial (inner wrist under the line of thumb)
  5. femoral (near pelvic bone
  6. Popiteal (behind knee)
  7. posterior tibial (lower limb)
  8. dorsalis pedis (over the instep of the foot, big toe)
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9
Q

when do we take a radial pulse?

A
  • adults, children > 3yrs
  • most easily accessible
  • do not press too hard
  • if any unexpected findings, assess at radial for full 60 seconds, then listen to apical for 60 seconds
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10
Q

what factors influence heart rate?

A

-age
-gender
-exercise
-fever
-medications
-hemorrhage
-stress/emotions
-pain
other body conditions

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11
Q

how do we document heart rate and pulse?

A
  1. strength
    -amplitude of the pulse is described on a scale of 0-4
    4-bounding
    3-full, increased
    2-expected
    1-diminished
    0-absent
  2. rhythm
    -volume & rhythm
    -regularly irregular
    -irregularly irregular
  3. rate- in bpm
  4. symmetry and location
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12
Q

Define bradycardia/tachycardia

A

brady - slow heart rate <60 bpm

tachy - fast heart rate

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13
Q

define a pulse deficit/ asystole

A

pulse deficit - a rate difference between two pulses

asytole - absence of pulse

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14
Q

define dysrhythmia/arrhhythmia

A

dys - abnormality in the heart rhythm

arr - heart beats with an irregular or abnormal rhythm

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15
Q

define hyper/hypotension

A

hyper - too high BP

hypo - loo low BP

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16
Q

define orthostatic hypotension/postural hypotension

A

blood is in the feet = low BP

17
Q

what is pulse pressure

A

the difference between systolic and diastolic pressure, usually 30-40mmHg

18
Q

what is blood pressure?

A
  • the force exerted on the walls of an artery under pressure from the heart
  • peak of maximum pressure with ejection is systolic
  • minimum pressure exerted when the heart relaxes is the diastolic
  • arteries need to relax between pulses
19
Q

when/why do we assess blood pressure?

A

why:

  • an indicator of cardiovascular health
  • need to know the viscosity of the blood (dehydration)
  • the heart determines everything
    when:
  • newly admitted
  • whenever you are in doubt
20
Q

what are some key features the patient should be displaying while taking blood pressure

A
  1. be calm
  2. arm supported
  3. back supported
  4. feet on the floor and their legs crossed
  5. no talking
21
Q

describe the 2 step method

A
  1. palpate the brachial artery, inflate cuff until pulse disapears, continue to inflate to 30 mmHg above the estimated systolic, open valve slowly to deflate and feel for the pulse again
  2. place stethoscope diaphragm over the brachial artery and deflate at a rate of 2 mmHg/beat until you hear regular tapping sounds, when the sounds stop this is the diastolic
22
Q

describe the 5 korotkoff phases

A
  1. faint but clear tapping sounds that graduall increase in intensity - the first tap is the systolic
  2. muffled or swishing sounds -
  3. distinct loud sounds as blood is flowing freely
  4. a distinct, abrupt, muffling sound with a soft, blowing quality
  5. the last sound before continuous silence - the diastolic measurement
23
Q

describe the auscultatory gap

A

the disappearance of heart sounds at the end of phase one beginning of phase two, may cover a range of as much as 40mmHg

24
Q

expected values for BP

A 
Age						        BP (mmHg)
Newborn	73/55
Infant	85/37
Toddler	89/46
Child	95/57
Preteen	102/61
Teen	112/64
Adult	<120/80
Elite athlete	<120/80
25
Q

classification of blood pressure

A 
hyoptension = 90/60
hypertension = >140/>90
normotension = <120/<80
prehypertension = 120-139/80-90
26
Q

what are some factors that influence BP

A 
age
stress
ethnicity
gender
diurnal variations
medications
chronic conditions
27
Q

what are some reasons why an error in BP measurement might occur

A
  • stethoscope applied too firmly/loosely against antecubital fossa
  • Arm too high/low
  • Repeating measurements too quickly (should be 5 minutes at least)
  • Inflated too high/low
  • Cuff too wide/narrow
  • Cuff wrapped too loosely or unevenly
  • Cuff deflated too quickly/slowly
  • Arm held up isn’t supported
  • Examiner hearing/vision compromised

HHA (6 decks)

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