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Semester 2 Nursing > Nurs 208 - Vital Signs and Pain Assessment > Flashcards

Nurs 208 - Vital Signs and Pain Assessment Flashcards

1
Q

List the 5 Vital Signs

A 
Pulse
Respirations
Temperature
Blood Pressure
SpO2
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2
Q

Pulse

A

By palpating the peripheral pulse you can measure the rate and rhythm of the heartbeat, as well as obtain local data on the condition of the artery

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3
Q

What is the average stroke volume in adults?

A

70 mL

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4
Q

How to assess a pulse

A

Use the pads of your first 3 fingers

Palpate the radial pulse at the flexor of the aspect of the wrist laterally along the radius bone

Press until you feel the strongest pulsation

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5
Q

If the rhythm of the pulse is regular…

A

count the number of beats in 30 seconds and multiply by 2

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6
Q

If the rhythm of the pulse is irregular…

A

as in atrial fibrillation, always count for a full minute

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7
Q

Why can’t we count the pulse for 15 seconds?

A

any one-beat error in counting results in a recorded error of 4 beats per minute

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8
Q

Pulse: It is more important to establish the _______ so that you can accurately determine the _____

A

Rhythm

Rate

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9
Q

4 Things to Assess for Pulse

A

Rate
Rhythm
Force
Equality (when comparing pulses bilaterally)

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10
Q

All symmetrical pulses should be assessed bilaterally except for the ______ pulse

A

Carotid

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11
Q

Normal Resting Heart Rate (Pulse)

A

50 to 96 beats/min
or
60 to 100 beats/kmin

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12
Q

What is the name for a heart rate of less than 50 beats/min?

A

Bradycardia

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13
Q

What is the name for a heart rate of more than 95 or 100 beats/min?

A

Tachycardia

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14
Q

Heart rates in the 50s/min normally occur in? Why?

A

Well trained athletes because their heart muscle develops along with the skeletal muscles

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15
Q

Rapid heart rates normally occur with _____ or with increased ______ to match the body’s demand for increased _______

A

Anxiety
Exercise
Metabolism

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16
Q

Pulse: Rhythm

A

Normally has an even tempo

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17
Q

What is the name for an irregularity in pulse that is common in children and young adults

A

Sinus Arrythmia
- in which the heart rate varies with the respiratory cycle

speeding up at peak of inspiration
slowing to normal with expiration

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18
Q

If any irregularities are detected what do you do?

A

auscultate heart sounds for a more complete assessment

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19
Q

Pulse: Force

A

Shows the strength of the heart’s stroke volume

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20
Q

Pulse Force 3 Point Scale

A 
3+ = Full Bounding
2+ = Normal 
1+ = Weak, thread
0 = Absent

some agencies use a 4 point scale

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21
Q

A “weak, thready” pulse reflects…

A

Decreased stroke volume

as occurs with hemorrhagic shock

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22
Q

A “full, bounding” pulse reflects..

A

Increased stroke volume

as occurs with anxiety, exercise, and some abnormal conditions

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23
Q

Respirations

A

Normally a patient’s breathing is relaxed, regular, automatic, and silent

Count for 30 seconds and multiply by 2
Count for a full minute if you suspect an irregularity

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24
Q

Why can’t we count respirations for 15 seconds?

A

The result can vary by a factor of +/- 4 which is significant with such a small number

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25
Q

What is one full cycle for respirations

A

Inspiration and Expiration = 1 cycle

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26
Q

NORMAL RESPIRATORY RATES

Neonate

A

30-40

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27
Q

NORMAL RESPIRATORY RATES

1 year

A

20-40

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28
Q

NORMAL RESPIRATORY RATES

2 years

A

25-32

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29
Q

NORMAL RESPIRATORY RATES

4 years

A

25-30

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30
Q

NORMAL RESPIRATORY RATES

8-10 years

A

20-26

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31
Q

NORMAL RESPIRATORY RATES

12-14 years

A

18-22

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32
Q

NORMAL RESPIRATORY RATES

16 years

A

12-20

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33
Q

NORMAL RESPIRATORY RATES

Adult

A

10-20

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34
Q

What is blood pressure?

A

The force of blood pushing against the side of the vessel wall

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35
Q

Systolic Pressure

A

The maximum pressure felt on the artery during left ventricular contraction or systole

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36
Q

Diastolic Pressure

A

The elastic recoil, or resting, pressure that the blood exerts constantly between each contraction

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37
Q

Pulse Pressure

A

The difference between the systolic and diastolic pressures and reflects the stroke volume

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38
Q

Mean Arterial Pressure (MAP)

A

the pressure forcing the blood into the tissues, averaged over the cardiac cycle

A value closer to diastolic pressure plus 1/3 of the pulse pressure

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39
Q

Influences on Blood Pressure (8)

A

Age - rises

Sex - Before puberty, no difference. After puberty, girls have lower BP than males. After menopause, BP higher in women than males

Ethnocultural Considerations - African decent have higher than European descent

Dirunal Rhythm - BP highest in late afternoon or early evening, declines to an early morning low

Weight - BP higher in obese

Exercise - Increases, Within 5 minutes of terminating exercise it normally returns to baseline

Emotions - momentarily rises with fear, anger, and pain as a result of the Sympathetic nervous system

Medications

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40
Q

Width of BP Cuff

A

Should equal 40% of the circumference of the patient’s arm

6 sizes (from newborn to extra large adult)
Match the appropriate size cuff to the patient's arm size and shape not to the patient's age
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41
Q

What happens if you use a cuff size that is too narrow?

Why?

A

it will yield a falsely high BP because it takes extra pressure to compress the artery

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42
Q

The aneroid gage is subject to drift; it must be recalibrated at least _____ each year and it must rest at _____

A

once

zero

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43
Q

BP Recommended Procedure

A

Allow at least a 5-minute rest before measuring BP

Take 3 BP measurements separated by 2 minutes, discard the first, average the second 2

Center the deflated cuff 2.5 cm (1 inch) above the brachial artery

Palpate brachial artery, inflate cuff until pulse is obliterated and then 20-30mmHg beyond to prevent an auscultatory gap

Deflate cuff completely, then wait 15 to 30 seconds before reinflating so that the blood trapped in the veins can dissipate

Reinflate cuff
deflate cuff slowly and evenly, about 2mmHg per heartbeat

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44
Q

When do we verify BP in both arms?

A

On admission or for first complete physical examination

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45
Q

True or False. On occasion, a 5 to 10 mmHg difference may occur in BP in the two arms (if values are different, record the higher value)

A

True

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46
Q

A difference in the two arms of more than 10 to 15 mmHg may indicate…

A

a renal obstruction on the side with the lower reading

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47
Q

BP is falsely ____ when the legs are crossed

A

High

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48
Q

Auscultatory gap

A

a period when Korotkoff’s sounds disappear during auscultation

occurs in about 5% of people, most often in those with hypertension caused by a noncompliant arterial system

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49
Q

Common errors in Blood Pressure Measurement

Falsely High

A

Taking BP when patient is anxious/angry/ has just been active

Faulty arm positon: Below level of heart

Patient supports own arm (falsely high diastolic)

Faulty Leg position (legs crossed)

Examiners eyes are not level with meniscus of mercury column: looking up at meniscus

Inaccurate Cuff size (most common error); cuff too narrow for extremity

Deflating cuff too quickly: falsely high diastolic or falsely low systolic
Deflating cuff too slowly: falsely high diastolic

Halting during descent and reinflating cuff to recheck systolic: falsely high diastolic

Failure to wait 1-2 min before repeating entire reading: falsely high diastolic

50
Q

Common errors in Blood Pressure Measurement

Falsely Low

A

Faulty arm position: Above level of heart

Examiners eyes are not level with meniscus of mercury column: looking down on meniscus

Cuff wrap is too loose or uneven

Failure to palpate radial artery while cuff is inflated: falsely low systolic

Poor inflation of the cuff

Pushing stethoscope too hard on brachial artery: falsely low diastolic

Deflating cuff to quickly: Falsely low systolic or falsely high diastolic

51
Q

Temperature: mean stable core (“deep body”) temp.

A

37.2 (99)

52
Q

Normal Oral Temp vs Rectal Temp

A

Oral = 37 (98.6)

Rectal measures 0.4 C to 0.5 C (0.7 F to 1 F) higher

53
Q

Influences on temp

A

Dirunal Cycle of 1 to 1.5 C - lowest (trough) in morning, peak in late afternoon to early evening

Menstruation Cycle - Progesterone secretion (ovulation), causes a 0.5 to 1.0 C rise in temperature until menses

Exercise - increases

Age - Wider normal variations occur in infants and young children as a result of less effective heat control mechanisms. Temp usually lower in older adults (mean of 36.2 C (97.2 F)

54
Q

Oral Temp

A

Shake mercery-free glass thermometer down to a reading of 35.5
Place thermometer at base of tongue in either of the posterior sublingual pockets
Instruct patient to keep lips closed
Leave thermometer in place 3-4 minutes if patient is afebrile. Up to 8 minutes if febrile

55
Q

How long do you wait to take an oral temperature if the patient has just taken hot or iced liquids?

A

20 minutes

56
Q

How long do you wait to take an oral temperature if the patient has just smoked?

A

2 minutes

57
Q

Hyperthermia

A

above 40 degrees

or fever, is caused by pyrogens secreted by toxic bacteria during infections or as a result of tissue breakdown such as that after myocardial infarction, trauma, surgery, or malignancy. Also neurological disorders

58
Q

Hypothermia

A

below 35 degrees

Usually caused by accidental, prolonged exposure to cold.

Also may be purposefully induced to lower the body’s oxygen requirements during heart or peripheral vascular surgery, neurosurgery, amputation, or gastrointestinal hemorrhage

59
Q

Axillary Temperature

A

Safe and accurate for infants and young children

Not the method of choice in adults, as it is highly insensitive

60
Q

Rectal Temperature

A

Only when other routes are not practical
Wear gloves
Insert lubricated probe cover on an electronic thermometer, insert 2 to 3 cm (1 in) into the adult rectum

61
Q

Disadvantages of Rectal Temperature

A

patient discomfort

time consuming

62
Q

Temporal Artery Temperature (TAT)

A

Takes multiple readings, provides an average
Takes approximately 6 seconds
More accurate than TMT

63
Q

Tympanic Membrane Temperature (TMT)

A

The tympanic membrane shares the same vascular supply that perfuses the hypothalamus thus making it an accurate measurement of core temperature

64
Q

Measurement of Oxygen Saturation (SpO2)

A

pulse oximeter
a sensor attached to patient’s finger or earlobe has a diode that emits light and a detector that measures the relative amount of light absorbed by hemoglobin

65
Q

Normal SpO2

A

97% to 99%

value of >95% is acceptable for an individual with normal hemoglobin

66
Q

SpO2 in infants

A

Tape probe to large toe

67
Q

If you are using a finger, make sure the hand is ____

A

warm

68
Q

At lower oxygen saturation, the _______ probe is more accurate

A

earlobe

69
Q

When do we use thigh pressure?

A

When BP measured in the arm is excessively high, particularly in adolescents and young adults, compare it with the thigh pressure to check for coarctation of the aorta

70
Q

Normally, blood pressure of the thigh is ______ than the pressure in the arm

A

higher

71
Q

Coarctation of the aorta

A

a congenital form of narrowing

arm pressures high
thigh pressure is lower because the blood supply to the thigh is below the constriction

72
Q

What artery is used for thigh pressure?

A

popiliteal artery

73
Q

Systolic vs Diastolic values in thigh vs arm

A

Normally the systolic value is 10 to 40 mmHg higher than in the arm, diastolic pressures are the same

74
Q

List the 5 Types of Pain

A 
Nociceptive
Neuropathic
Referred
Acute
Chronic
75
Q

Nocioceptive Pain

A

Pain caused by tissue injury

Well localized

often described as aching or throbbing

Can be further classified as Somatic or Visceral

76
Q

Nocioceptive Pain: Somatic

A

can be superficial, derived from the skin surface, or deep, derived from joints, tendons, muscle, or bone

77
Q

Nocioceptive Pain: Visceral

A

originates from the larger interior organs (ie. kidney, intestine, gall bladder, pancreas)
can be constant/intermittent
may be poorly localized

78
Q

Neuropathic Pain

A

caused directly by a lesion or a disease affecting the somatosensory nervous system

can result from damage to the nerve pathway at any point along the nerve, from the terminals of the peripheral nociceptors to the cortical neurons in the bran

described as burning, shooting, or lancinating

often intensifying at night

79
Q

Examples of Neuropathic pain

A

spinal cord injury, herpes zoster/HIV/diabetes
may be medication-induced
chemotherapy, antiretroviral therapy, sciatic pain

80
Q

Referred Pain

A

originates at one location but is felt at another site - both sites are innervated by the same spinal nerve and it is difficult for the brain to differentiate the point of origin

81
Q

Example of referred pain

A

appendicitis

82
Q

Acute Pain

A

Short Term and Slef-limiting

Follows a predictable trajectory and dissipates after an injury heals

It warms the actual or potential tissue damage

ex. pain caused by surgery, trauma, and kidney stones

83
Q

Chronic Pain/Persistent Pain

A

Pain that has been persistent for 6 months or longer than the time of expected tissue healing

Can be Categorized as Malignant or Nonmalignant

84
Q

Chronic Pain: Malignant

A

cancer-related pain

pain induced by tissue necrosis or stretching of an organ by the growing tumour

severity fluctuates

85
Q

Chronic Pain: Nonmalignant

A

often associated with Musco-skeletal conditions such as arthritis, low back pain, and fibromyalgia

86
Q

Acute pain can lead to chronic pain through 2 processes:

A

Peripheral Sensitization - reduction of pain threshold and an increased response of the peripheral end of the nociceptors

Central Sensitization - increase in the excitability of neurons within the CNS

87
Q

True or False. Pain is a normal process of ageing

A

FALSE. Pain is NOT a normal process of ageing

88
Q

Initial Pain Assessment (OPQRSTUV)

A 
O - Onset
P - Provocative/Palliative
Q - Quality of Pain
R - Region of the body/radiation
S - Severity of Pain
T - Treatment/Timing
U - Understanding of pain
V - Values
89
Q

Questions to ask:

Onset

A

When did the pain start?

90
Q

Questions to ask:

Provocative/Palliative

A

Does your pain increase with movement or activity?
Are the symptoms relieved with rest?
Were any previous treatments effective?

91
Q

Questions to ask:

Quality of Pain

A

What does your pain feel like?

What words describe your pain?

92
Q

Questions to ask:

Region of the body/radiation

A

Where is your pain?

Does the pain radiate, or move to other areas?

93
Q

Questions to ask:

Severity of pain

A

How would you rate your pain on an intensity scale?

94
Q

Questions to ask:

Treatment/Timing

A

What treatments have worked for you in the past?

Is it a constant, dull, or intermittent pain?

95
Q

Questions to ask:

Understanding of pain

A

What do you believe is causing the pain?

96
Q

Questions to ask:

Values

A

What is your acceptable level for this pain?
Is there anything else you would like to say about your pain?
Are there any other symptoms related to the pain?

97
Q

True or False. Pain is a subjective experience

A

True

98
Q

What is the most reliable indicator that an individual is experiencing pain?

A

The self-report of pain

Pain is whatever the experiencing person says it is, existing whenever he/she says it does

99
Q

True or False. Those who are unable to report pain are at high risk for the undertreatment of pain

A

True

100
Q

How to assess pain in an unconscious individual

A

The Critical Care Pain Observation tool

-behaviours assessed include facial expression, body movement, muscle tension, vocalizations, and degree of compliance with ventilation

They still can feel pain!

101
Q

Pain Developmental Considerations

Neonates

A

because neonates and young infants are preverbal and incapable of self-report, pain assessment is dependent on behavioural and physiological cues

102
Q

Pain Developmental Considerations

Infants and Young Children

A

By 20 weeks gestation, infants have the same capacity for pain as do adults

Infants are more sensitive to pain because the inhibitory neurotransmitters are in insufficient supply until birth at full term

Toddlers and children older than 2 years of age can report pain and point to its location but are unable to rate pain intensity

It is helpful to ask the parent/caregiver what words their child uses to report pain (boo-boo, owie)

Be aware that some children will try to act “grown up and brave” and often deny having pain in the presence of a stranger, or if they are fearful of receiving a shot

103
Q

Pain Developmental Considerations

Older Adults

A

NO evidence suggests that older adults perceive pain to a lesser degree or that sensitivity is diminished with age

Although a common experience, pain is NOT a normal process of ageing

Older adults may express fears about becoming dependent or perceive that they are taking an excessive number of medications

May need more time to respond to assessment questions

The incidence of chronic pain conditions is higher in the adult population: such conditions include diseases such as arthritis, osteoarthritis, osteoporosis, peripheral vascular disease, peripheral neuropathies, and angina

104
Q

Pain Gender Differences

A

Women are more likely to experience migraines with aura, fibromyalgia, irritable bowel syndrome, rheumatoid arthritis

Men are more likely to experience cluster headaches, gout, coronary artery disease, and duodenal ulcers

Pharmacological treatments for pain and the related adverse effects may not be the same for both genders

105
Q

Pain Ethnocultural Considerations

A

Pain can have different meanings for different cultures

Indigenous children tend not to express pain outwardly: often manage it and silently suffer. This response to pain is thought to be a result of cultural traditions and the effects of the residential school system

Indigenous have higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis

106
Q

Pain Assessment Tools

Unidimensional Aspects vs Multidimensional Components

A

Unidimensional Aspects: eg. Intensity

Multidimensional Components: eg. effect on ADL’s and quality of life

107
Q

Selection of pain assessment tool is based on:

A

Its purpose

Time involved in administration

patients ability to comprehend and complete the tool

108
Q

Pain Assessment Tools

Visual Analogue Scale/Numeric Scale (from 0 to 10) - Where do we want them to be?

A

Want them to be a 4 or lower

109
Q

Pain Assessment Tools
The Faces Pain Skill - Revised (FPS-R)
Why was it revised?

A

To remove the tears because we do not want children to associate pain with fear/tears

6 drawings of faces that show pain intensity

110
Q

Pain Assessment Tools

Descriptor Scale

A

Lists words that describe different levels of pain intensity, such as no pain, mild pain, moderate pain, and severe pain

Older adults may find the number scale too abstract and may respond better to this scale

111
Q

Pain Scales for those with intellectual/cognitive disability

A

PAINAD Scale
(Pain Assessment in Advanced Dementia)

Abbey scale

112
Q

Order of Vital Signs

Infant

A

Reverse the order of vital sign measurement

Respiration first, then pulse and temperature

113
Q

Developmental Considerations

Temperature: Tympanic/Temporal

A

TMT and TAT are useful with toddlers who sqiurm at the restraint needed for rectal route and it is useful for preschoolers who are not yet able to cooperate for an oral temperature measurement but fear the rectal route

114
Q

Developmental Considerations

Temperature: Axillary

A

Safer and more accessible than the rectal. Accuracy and reliability have been questioned.

115
Q

Developmental Considerations

Temperature: Oral

A

Use the oral route when the child is old enough to keep the mouth closed

  • usually at age 5 or 6 years but some 4 year olds can cooperate
  • Use electronic thermometer when one is available
116
Q

Recommended Temp. Technique based on age

Birth to 2 years

A
  1. Rectal (definitive)

2. Axillary (screening low risk children)

117
Q

Recommended Temp. Technique based on age

From 2 to 5 years of age

A
  1. Rectal (definitive)
  2. Axillary, tympanic (or temporal artery if in hospital)
    (screening)
118
Q

Recommended Temp. Technique based on age

Older than 5 years

A
  1. Oral (definitive)
  2. Axillary, tympanic (or temporal if in hospital)
    (screening)
119
Q

Developmental Considerations

Pulse - Infants

A

In children older than 2 years, use the radial site

Count the pulse for a full minute to take into account normal irregularities, such as sinus arrhythmia

Heart rate normally fluctuates more in infants and children than in adults in response to exercise, emotion, and illness

120
Q

Developmental Considerations

Respirations - Infants

A

Watch infants abdomen for movement (respirations are more diaphragmatic than thoracic

Count for a full minute because the pattern varies from rapid breaths to short periods of apnea

Faster

121
Q

Developmental Considerations

Blood pressure - infants

A

In children aged 3 years and older and in younger children at risk, take a routine BP measurement at least annually

Cuff width must be over 2/3 of upper arm, cuff bladder must encircle it completely

Semester 2 Nursing (28 decks)

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