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Nursing Skills > Vital Observations > Flashcards

Vital Observations Flashcards

1
Q

What are vital observations?

A

Vital signs are measurements of the body’s most basic functions. The four main vital signs routinely monitored by medical professionals and health care providers.

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2
Q

Why are vital observations so vital?

A
  • Recognising the deteriorating patient (RCP, 2017, BTS, 2017)
  • Complete the procedure as per best evidence based practice (NMC 2018, HCPC 2012)
  • Referral if needed
  • Ensure any equipment used is properly serviced and maintained
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3
Q

What is the purpose of respiration?

A

Respiration supplies the body with oxygen and removes carbon dioxide

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4
Q

Why measure respiration?

A
  • To determine per minute the rate, depth and pattern of respiration as a base measurement for future comparison
  • To monitor fluctuations in respiration
  • To evaluate the patients response to medications or treatments
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5
Q

What are the observations for respiration?

A

Rate: The rate and depth will together determine the type/quality of respiration
Depth: Indicates the volume of air moving in and out of the lungs with each respiration
Pattern: Changes in pattern are often due to problems with the respiratory centre in the brain

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6
Q

What is the terminology for irregular respiratory rates?

A
  • Bradypnoea
  • Tachypnoea
  • Dyspnoea
  • Hyperpnoea
  • Apnoea
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7
Q

What is Bradypnoea?

A

Abnormally slow

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8
Q

What is Tachypnoea?

A

Elevated and rapid

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9
Q

What is Dyspnoea?

A

Shortness of breath with an elevated, normal or decreased respiratory rate

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10
Q

What is Hyperpnoea?

A

Abnormally deep and laboured- it may occur with or without rapid breathing

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11
Q

what is Apnoea?

A

Absence of breathing

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12
Q

What is the average respiratory rate of a Newborn?

A

30-60 breaths per minute

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13
Q

What is the average respiratory rate of a 1-3 year old?

A

24-40 breaths per minute

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14
Q

What is the average respiratory rate of a 4-5 year old?

A

22-34 breaths per minute

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15
Q

What is the average respiratory rate of a 6-12 year old?

A

18-30 breaths per minute

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16
Q

What is the average respiratory rate of an adolescent?

A

12-16 breaths per minute

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17
Q

What is the average respiratory rate of an adult?

A

12-20 breaths per minute

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18
Q

What is hypoventilation (bradypnoea)?

A

Below levels considered to be normal (RR<12)

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19
Q

What is hyperventilation (Tachypnoea)?

A

Above levels considered to be normal (RR>90)

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20
Q

What is a pulse?

A

The pulse is a pressure wave of blood caused by the alternating expansion and recoil of the elastic arteries during each cardiac cycle.

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21
Q

What is the purpose of measuring a pulse?

A
  • To obtain a base measurement for future comparison
  • To monitor fluctuations in pulse
  • To determine per minute information regarding heart rate, pattern (rhythm), and amplitude (strength)
22
Q

How do you observe a pulse?

A
  • Felt anywhere an artery can be palpated against something firm
  • Rhythm: Normally regular, contained by contraction of the heart muscle in response to specific nerve stimulus
  • Amplitude: The reflection of the pulse strength and arterial elasticity
23
Q

What is the average pulse rate of a 1 week-3 month old?

A

100-160 beats per minute

24
Q

What is the average pulse rate of a 3 month-2 year old?

A

80-150 beats per minute

25
Q

What is the average pulse rate of a 2-10 year old?

A

70-110 beats per minute

26
Q

What is the average pulse rate of a 10 year old-adulthood?

A

50-90 beats per minute

27
Q

What is Tachycardia? (pulse)

A

Above levels considered to be normal (>100 BPM)

28
Q

What is Bradycardia? (pulse)

A

Below levels considered to be normals(<60 BPM)

29
Q

What is a normal Capillary Refill Rate?

A
  • Normal CFT is considered to be shown to return within 2-3 seconds
  • A delay in this return may be a sign of reduced skin perfusion, hypovolemic shock, circulatory diseases
30
Q

What is blood pressure?

A

The force exerted by blood on the walls of the vessel in which it is contained.

31
Q

What is the purpose of measuring blood pressure?

A
  • To determine the patient’s blood pressure as a base for comparing future measurements
  • To monitor fluctuations in blood pressure
32
Q

What is the measurement of blood pressure?

A

-mmHg (millimetres of mercury) is the unit of measurement

33
Q

What is systolic pressure (blood pressure)?

A

Pressure exerted on the blood vessel walls following ventricular systole, when the arteries contain maximum pressure.

34
Q

What is diastolic pressure (blood pressure)?

A

Pressure exerted on blood vessel walls during ventricular diastole, when the arteries contain least pressure.

35
Q

What is hypertension (blood pressure)?

A

A BP above levels considered to be normal (BPS>140)

36
Q

What is hypotension (blood pressure)?

A

A BP below levels considered to be normal (BPS<90)

37
Q

What is body temperature?

A

Is the balance between heat gain and heat loss

38
Q

What controls body temperature?

A

Hypothalamus- heat loss- heat conservation/ production

39
Q

What is the body temperature range?

A

36-37.5 degrees- optimum core temp is 37 degrees

40
Q

What are the temperature values?

A
  • Hypothermia 35 degrees
  • Normal range in accordance with definitions: 35.1-37.9 degrees
  • Optimal range for homeostasis: 36.5-37.5 degrees
41
Q

What are the 6 ways to measure core temperature?

A
  • Tympanic
  • Nasalpharyngeal
  • Oesophageal
  • Rectal
  • Axillary
  • Sublingual
42
Q

What is hyperthermia (pyrexia)?

A

Above levels considered to be normal (Above 38 degrees)

43
Q

What is hypothermia?

A

Below 35 degrees

44
Q

How do you measure oxygen saturation levels (SP02%)?

A
  • Using a probe attached to the finger, ear or toe (depending on age or the patient)
  • Photodetector and light-emitting diodes (LED) on probe
45
Q

What is considered a normal oxygen saturation level?

A

Normal pulse oximeter reading 94-98%. Below 94% requires investigation

46
Q

What is NEWS?

A

National Early Warning Scores- National early warning system to identify “at risk” patients at an early age

47
Q

What is MEWS?

A

Modified Early Warning Scores

48
Q

What is PEWS?

A

Paediatric Early Warning Scores

49
Q

What is a PAR score?

A

Patient at risk scoring

50
Q

What should you do for all procedures?

A
  • Gain consent
  • Decontaminate hands
  • Clean equipment
  • Dispose equipment safely
  • Record, report and act on results

Nursing Skills (9 decks)

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