Midterm Flashcards
Why do we make vital sign assessments?
it provides: -information of pt.'s health status -baseline status -monitoring a patient's condition -identifying problem evaluating the pt.'s response to intervention
How do we make vital sign assessments?
pulse
-palpate for apical, carotid, radial or brachial pulsations
respiration
-inhalation and exhalation counts ass one breath
-breathing can be seen through the chest (women) and abdomen (men)
blood pressure
- the measurement of pressure pulsations exerted against the blood vessel walls during systole and diastole
oxygen saturation
temperature
pain
- P (protective or palliative)
- Q (quality or quantity)
- R (region or radiation)
- S (severity scale)
- T (timing)
- U (understand patients perception of the problem
Physiology of normal regulation of body temperature
body temperature (thermoregulation) is regulated by:
- neural and vascular control
- heat production (regulated by posterior hypothalamus); heat is produced as a by-product of metabolism via BMR [basal metabolic rate], voluntary movements, shivering, non-shivering thermogenesis [neonates with brown fat]
- heat lost (regulate by anterior hypothalamus); heat is lost through: radiation (transfer of heat from one surface to another without direct contact, conduction (transfer of heat but using direct contact), convection heat moved away by air movement), evaporation (lost heat/fluid [600-900 mL] through sweat [diaphoresis] which occurs through the skin or breathing.
Physiology of normal regulation of pulse
it is affected by stroke volume (it is the amount of blood your heart pushes into the artery every time it contracts), cardiac output and compliance (how elastic an artery is which allows blood to flow more easily.
Physiology of normal regulation of respiration
involves three processes:
- ventilation: the mechanical movement of gases in and out of the lungs
- diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood cells
- perfusion: the distribution of red blood cells to and from the pulmonary capillaries
Physiology of normal regulation of blood pressure
regulated through:
- cardiac output: the amount of blood coming from heart
- peripheral vascular resistance: resistance of blood flow
- blood volume: circulating volume
- blood viscosity: thicker blood causes more pressure to be made which increases blood pressure
- artery elasticity or “compliance”
Physiology of normal regulation of oxygen saturation
accuracy is dependent upon light transmission and adequate arterial pulsations
Normal vital signs
temperature - 36-38 degree Celsius (96.8-100.4 degree Fahrenheit) pulse - 60-100 bpm respiration - 12-20 bpm blood pressure - <80 oxygen saturation - 95-100% pain - absence of pain
Abnormal vital signs
temperature
- hypothermia (mild 93.2-96.8; moderate 86-93.2; severe 105 degree Fahrenheit
- frostibite
pulse
- tachycardia > 100 bpm
- bradycardia < 60 bpm
- dysrhythmia, bounding, weak, thread, unequal, absent
respiration
- bradypnea < 9 bpm
tachypnea > 24 bpm
- hyperpnea, apnea, hyperventilation, hypoventilation [shallow], cheyne-stokes, kussmaul’s (hyperventilation), biot’s respiration
oxygen saturation
- < 95%
blood pressure
- hypotension (a systolic blood pressure of < 90 mmHg)
- orthostatic hypotension (a symptomatic drop in BP with change in position
- hypertension (associated with thickening and loss of elasticity in arterial walls; decreased blood flow to vital organs
Abnormal vital sign interventions
- review, analyze, decide if further investigation is necessary/notify the physician
- proper functioning equipment
- equipment appropriate for pt.
- know the pt.’s baseline; educate pt. to know their baseline
- medical Hx and medications
- have a routine for taking vital signs
- frequency of measurement dependent on diagnosis
- indication for medication administration
- analyze and interpret significant changes
- communicate significant changes
Factors that affect temperature measurement
- age
- exercise
- hormone level
- circadian rhythm
- stress
- environment
Factors that affect pulse measurement
- exercise
- temperature
- emotions
- drugs
- hemorrhage
- postural changes
- pulmonary conditions
Factors that affect respiration measurements
- exercise
- acute pain
- anxiety
- smoking
- bod position
- medications
- neurologic injury
- hemoglobin
Factors that affect blood pressure measurements
- age
- stress
- ethnicity
- gender
- daily variation
- medications
- activity and weight
- smoking
- caffeine
- diet
Various aspect of hygiene care
- skin hygiene
- oral hygiene
- bathing skin care
- perineal care
- hair care
- eye care
- feet and nails
Interventions to prevent the spread of infection
Hand hygiene before and after all pt. contact
- When to use hand hygiene: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a pt., after touching pt. surroundings
- Alcohol-based hand sanitizer: 20-30 seconds
- Soap and water: 40-60 seconds
Visibly soiled
Coming into contact with a pt. that has spore-forming microorganisms
Proper use of supplies
Proper disposal of certain supplies
Good technique of donning and removing PPE
Critical thinking
Artificial nails (don’t have, get them)
Proper procedure for applying alcohol-based hand sanitizer
For 20-30 seconds:
- Apply a palm-full in a cupped hand, covering all surfaces.
- Rub hands palm to palm.
- Right palm over left dorsum with interlaced fingers and vice versa.
- Palm to palm with fingers interlaced.
- Backs of finger to opposite palms with fingers interlocked.
- Rotational rubbing of left thumb clasped in right palm and vice versa.
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in let palm and vice versa.
- Once dry, your hands are safe.
Proper procedure for using soap and water
for 40-60 seconds:
- wet hands with water
- Apply enough soap to cover all hand surfaces
- Rub hands palm to palm
- Right palm over left dorsum with interlaced fingers and vice versa.
- Palm to palm with fingers interlaced.
- Backs of finger to opposite palms with fingers interlocked.
- Rotational rubbing of left thumb clasped in right palm and vice versa.
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in let palm and vice versa
- Rinse hands with water
- Dry hands thoroughly with a single use towel
- Use towel to turn off faucet
- your hands are now safe
Types of isolation
Tier I
- Standard precautions: Don gloves when in contact with bodily fluids or mucous membranes
Tier II
- Contact precautions Ie. Rhino virus, c. diff., MRSA, VRE, MDRO (multi-drug resistant organisms); Don gown and gloves
- Droplet precautions Ie. Pneumonia, bacterial meningitis, shingles, influenza; Don gloves, gown, face mask
- Air-borne precautions Ie. Chicken-pox, tuberculosis; All PPE + N95 mask (Mask is specifically fitted to fit an individual’s face)
