Week three: vital signs Flashcards
what is a general survey?
- 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
what does ASEPTIC stand for?
appearance and behaviour speech emotion perception thought process insight cognition
when do we assess vitals?
- 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
what is pulse? and what do we asses?
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)
what are the heart sounds?
S1- beginning of systole (loudest at apex or lower left
S2- beginning of diastole (loudest at the base
when is the apical pulse rate checked and how do you take it?
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
what are the expected values for pulse rates
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
list the different pulse rates
- temporal (above and towards outside of the eye
- brachial (inner side of the bicep)
- cartod (side of neck)
- radial (inner wrist under the line of thumb)
- femoral (near pelvic bone
- Popiteal (behind knee)
- posterior tibial (lower limb)
- dorsalis pedis (over the instep of the foot, big toe)
when do we take a radial pulse?
- 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
what factors influence heart rate?
-age
-gender
-exercise
-fever
-medications
-hemorrhage
-stress/emotions
-pain
other body conditions
how do we document heart rate and pulse?
- strength
-amplitude of the pulse is described on a scale of 0-4
4-bounding
3-full, increased
2-expected
1-diminished
0-absent - rhythm
-volume & rhythm
-regularly irregular
-irregularly irregular - rate- in bpm
- symmetry and location
Define bradycardia/tachycardia
brady - slow heart rate <60 bpm
tachy - fast heart rate
define a pulse deficit/ asystole
pulse deficit - a rate difference between two pulses
asytole - absence of pulse
define dysrhythmia/arrhhythmia
dys - abnormality in the heart rhythm
arr - heart beats with an irregular or abnormal rhythm
define hyper/hypotension
hyper - too high BP
hypo - loo low BP
define orthostatic hypotension/postural hypotension
blood is in the feet = low BP
what is pulse pressure
the difference between systolic and diastolic pressure, usually 30-40mmHg
what is blood pressure?
- 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
when/why do we assess blood pressure?
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
what are some key features the patient should be displaying while taking blood pressure
- be calm
- arm supported
- back supported
- feet on the floor and their legs crossed
- no talking
describe the 2 step method
- 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
- 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
describe the 5 korotkoff phases
- faint but clear tapping sounds that graduall increase in intensity - the first tap is the systolic
- muffled or swishing sounds -
- distinct loud sounds as blood is flowing freely
- a distinct, abrupt, muffling sound with a soft, blowing quality
- the last sound before continuous silence - the diastolic measurement
describe the auscultatory gap
the disappearance of heart sounds at the end of phase one beginning of phase two, may cover a range of as much as 40mmHg
expected values for BP
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
classification of blood pressure
hyoptension = 90/60 hypertension = >140/>90 normotension = <120/<80 prehypertension = 120-139/80-90
what are some factors that influence BP
age stress ethnicity gender diurnal variations medications chronic conditions
what are some reasons why an error in BP measurement might occur
- 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
