Basic Observations Flashcards
(62 cards)
What are baseline observations? (8)
Respiratory rate, rhythm and depth
Pulse rate, rhythm and volume
Capillary Bed Refill (CBR)
Pulse oximetry
Blood pressure
Blood glucose
3 lead ECG
Conscious Level (AVPU)
What does AVPU stand for?
Alert
Verbal
Pain
Unresponsive
What should be done if a patient has reduced level of consciousness?
Do a baseline observation including a head to toe assessment
When should baseline obs be taken earlier on?
If the primary survey was positive
When would a baseline obs be taken later on?
If the primary survey was negative meaning the results fall into normal range for he patient, we would do history taking before conducting baselines obs.
What is an adults normal respiratory rate?
12-20 breaths per minute
What is the normal respiratory rate for birth to 1 year?
30-40 breaths per minute (bpm)
What is the normal respiratory rate for a 1 year old?
25-35 bpm
What is the normal respiratory rate of a child 2-5 years old?
25-30
What is the normal respiratory rate for a child 5-12 years old?
20-25 bpm
What factors increase the respiratory rate? (5)
Exercise Stress/anxiety Fever Hypoxia (lack of oxygen in the tissues) Pain
What is tachypnoea?
Abnormally fast respiratory ate above 20 breaths per minute (bpm)
What factors decrease the respiratory rate? (4)
Opiates (eg. Morphine and heroin)
Hypothermia (cold temp)
Depression of CNS
Severe fatigue
What is bradypnoea?
Abnormally slow respiratory rate less than 12 breaths per minute
What else would you have to document other than breaths per minute in terms of respiration?
Where respiration is normal, shallow or deep
When would a pulse oximetry be used?
If the patient is presenting with a respiratory problem or appears short of breath
It can also be used before and after oxygen therapy as a baseline and indicator of efficacy of treatment
What is a pulse oximetry? (4)
A device that uses a red and infrared light to measure the peripheral ratio of oxyhaemoglobin (haemoglobin with oxygen attached) to haemoglobin (a protein in erythrocytes(RBCs) that can carry oxygen and other gases).
The device shines the red and infrared light through the tissues with oxyhaemoglobin absorbing more infrared light and haemoglobin more red light.
The sensor detects the amount of absorbed light and displays the result as a percentage on the machine.
It also measures pulse rate, although this should not replace an actual pulse check because it does not give an indicator of rhythm or volume
What is normal oxygen saturations?
94-98%
What is oxygen saturation documented as?
SPO2
Saturation Potential of Oxygen
How do you use a pulse oximeter? (5)
Turn on the machine
Place probe into the area to be measured (usually a finger, but could be a toe or ear lob)
Wait for the readings to settle on the machine (they can fluctuate for a short time after application of the probe)
Check the pulse to ensure it matches the reading on the machine
As long as they match, record SPO2 reading
What factors can affect the accuracy of pulse oximetry?
Nail varnish Cold extremities Poor peripheral circulation Motion (shaking etc) Strong ambient lighting Carbon monoxide poisoning Dark skin
What are some limitations of pulse oximetry? (8)
Colour interferences:
Nail polish said to affect validity of SPO2 measurements.
Carbon monoxide poisoning:
Due to affinity of CO to haemoglobin, CO would cause oxygen to disassociate from haemoglobin and would instead combine to form carboxyhaemoglobin. Pulse oximeters are unable to detect this change from oxyhaemoglobin to carboxyhaemoglobin resulting to inaccurate results being displayed
Poor peripheral circulation:
Being cold or having hypotension can cause poor pumping of liquids into organs and tissues (perfusion), affecting pulse waves that that are detected by the pulse oximeter. As well as, blood levels below 80mmHg systolic can lead to inaccurate and unreliable results of pulse waves
Motion artefact:
Tremors, seizures and shivering can effect signal detection of pulse waves
High intensity lighting:
The light would interfere with the probe leading to false readings. This can be overcome by reducing bright light sources.
Age, sex and dark skin:
These factors are stated not to interfere with SPO2 readings, but recent studies have shown that dark skin can reduce oxygen sats that are recorded. But further research is required to support this claim
High bilirubin levels in hepatitis and cirrhosis of the liver and some blood dyes used in angiography:
The problem with these is that it can cause the colour of the blood
Naturally fast pulse rate:
Conditions that affect pulse may reduce accuracy. For instance, atrial fibrillation
When taking pulse, what should be considered?
The pulse rate
Rhythm (steady or erratic?)
Volume (weak or strong?)
What is the normal pulse rate of an adult?
60-100 beats per minute (bpm)
