Health Assessment 2 Flashcards
(17 cards)
What is the normal range for SpO2 (Oxygen Saturation)?
95%-100%
This range indicates the percentage of oxygen in the peripheral arterial blood.
What does SpO2 assess?
Effectiveness of the person’s respiratory processes
Measured by attaching a probe to a finger to determine the percentage of hemoglobin carrying oxygen.
What should be documented when measuring oxygen saturation?
Whether the person is on supplemental oxygen or ‘RA’ (room air)
This helps provide context for the SpO2 reading.
Name some factors affecting the accuracy of SpO2 readings.
- Interference with light transmission
- Interference with arterial pulsations
- Bright outside light
- Peripheral vascular diseases
- Carbon monoxide poisoning
- Hypothermia
- Finger movement
- Some drugs
- Jaundice
- Low cardiac output
- Intra-vascular dyes
- Hypotension
- Artificial nails and polishes
- Peripheral edema
Each factor can impact the reading by affecting blood flow or light transmission.
What is blood pressure measuring?
The lateral pressure that the pulsing blood exerts on artery walls
Specifically, it measures the pressure exerted on the walls of the aorta just outside the left ventricle.
What are the two readings obtained in a blood pressure measurement?
- Systolic reading
- Diastolic reading
Systolic measures heart contraction; diastolic measures heart relaxation.
What does the ‘pulse pressure’ indicate?
Difference between systolic and diastolic pressures
It is a good indicator of the elasticity of the arteries.
What is considered hypotension?
Below 110 systolic when measured twice at different times
This is only significant if it is not the patient’s normal blood pressure.
What is a dangerous condition related to blood pressure when standing?
Orthostatic hypotension
This can lead to dizziness and falls.
What indicates hypertension?
Above 139 systolic and/or 89 diastolic when measured twice at different times
It may suggest undiagnosed cardiac, vascular, or renal problems.
What is a key consideration in all patient care situations?
Pain management
Nurses play a crucial role in managing pain.
How is pain defined?
An unpleasant sensory and emotional experience associated with actual or potential tissue damage
Pain is subjective and varies from person to person.
What is the Numerical Rating Scale used for?
To measure pain intensity from 0 to 10
0 represents no pain and 10 represents the worst pain imaginable.
What should be documented in patient records?
- Date and time
- Accurate and specific information
- Any deviations from normal values
- Signature, name, and title
Documentation must be clear, accountable, and contemporaneous.
What does the guideline say about errors in documentation?
Do not erase errors; use a single line to cross out, write ‘error’ and initial
This maintains the integrity of the documentation.
What is the importance of blood pressure trends?
They are more useful than isolated readings
Trends provide a better understanding of cardiovascular health.
What is the normal blood pressure range for adults?
110-130/80-90 mmHg
This is considered typical for a healthy adult.
