Week 4: Basic Observations Flashcards

1
Q

Why do we take basic obs?

A

A baseline so abnormal changes can be identified and to make a plan for immediate treatment

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2
Q

What is heart rate/pulse?

A

The rise and fall of pressure associated with the contraction and relaxation of the heart, can be felt palpating an artery

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3
Q

How do you measure a pulse?

A

-measure for 1 minute ( or 30s X2)
- check for regularity, volume and character

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4
Q

How long should you take a paediatrics pulse for?

A

1 whole minute

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5
Q

What are some common sites for palpating arterial pulses?

A
  • carotid
  • brachial
  • femoral
  • radial
  • popliteal
  • posterior tibia
  • dorsalis pedis
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6
Q

What does tachycardia mean?

A

Rapid resting heart rate <100bpm

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7
Q

What does bradycardia mean?

A

Slow heart rate >60bpm

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8
Q

What are some factors that affect heart rate?

A
  • exercise
  • stress
  • illness
  • overdose/drugs/intoxicated
  • anxiety
  • excitement
  • cardiac related issues
  • pain
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9
Q

What is first vital observation to alter in a patient whose condition is deteriorating?

A

Respiratory Rate

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10
Q

What can resp rate be influenced by?

A
  • pain
  • stress
  • emotion
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11
Q

Define tachypnoea

A

A raised respiratory rate

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12
Q

Define hyperventilation

A

When breathing removes more CO2 than is produced

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13
Q

Define dyspnea

A

Difficulty breathing/SOB

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14
Q

Define orthopnea

A

Difficulty in breathing when laying flat

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15
Q

Define apnea

A

No resp rate

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16
Q

What are the two ways oxygen is transported to the tissues?

A

-98.5% bound to haemoglobin
-1.5% dissolved in the plasmas

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17
Q

What is pulse oximetry?

A

A measure of the amount of heamoglobin saturated with oxygen by projecting 2 pulsating beams of light through the peripheral blood vessel, a portion is absorbed by the HB and converted to saturation

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18
Q

What is a normal value of SPO2?

19
Q

When should you be mindful when taking SPO2?

A

Nail polish or cold peripherals

20
Q

When resting where generates the most heat?

A

Heart, liver, brain and endocrine glands

21
Q

What is a normal range for temperature?

A

36.5-37.2 C

22
Q

What is blood pressure?

A

A measure of the pressure exerted by the blood against the walls of the blood vessels. The most simple indicator of haemodynamic well-being

23
Q

Why is blood pressure important?

A
  • oxygen transport
  • tissue perfusion
24
Q

What are the two numbers associated with blood pressure?

A
  • systolic (the highest pressure when the heart beats)
  • diastolic (the lowest pressure in between beats)
25
What is the average blood pressure for a health adult?
120/80mmHg
26
What are some physiological factors that affect blood pressure?
- vol of blood - viscosity of blood - elasticity of arteries - pumping action of the heart - amount of resistance in the circulation
27
What factors cause hypertension?
- physical activity - strong emotion - obesity - heart disease - arteriosclerosis - vasoconstriction - circulatory overload - polycythemia
28
What health conditions cause hypotension?
- hypovolemia - lack of sympathetic tone-vasodilation - cardiac arryhthmias - anemia
29
Define hypertension in numbers
- systolic >140mmHg - diastolic >90mmHg
30
Define hypotension in numbers
- systolic <90mmHg - diastolic <60mmHg
31
What do we use to measure blood pressure?
A sphygmomanometer and a stephoscope
32
What are the three types of sphygmomanometers?
- mercury - aneroid - automatic
33
What is heard in phase 1 of Korotkoffs sounds?
First appearance of faint clear tapping sounds which gradually increase in intensity
34
What is heard in phase 2 of korotkoffs sounds?
The softening of sounds which may be swishing
35
What is heard in phase 3 of korotkoffs sounds?
The return of sharper sounds which become crisper but never fully regain then intensity of phase 1 sounds
36
What is heard in phase 4 of korotkoffs sounds?
The distinct abrupt muffling of sounds, which become soft and blowing
37
What is heard in phase 5 of korotkoffs sounds?
The point at which all sounds disappear completely
38
In what order should we record obs?
1. resp rate 2. SPO2 3. temp 4. BP 5. pulse rate 6. level of consciousness 7. blood glucose levels 8. cap refill <2 seconds
39
What does a low NEWS score (1-4) prompt?
An assessment from a registered nurse
40
What does a medium NEWS score (5-6) prompt?
Urgent review by a clinical skilled with competencies in the assessment of acute illness
41
What does a high NEWS score (7 or more) prompt?
The emergency assessment by a clinical team/critical care outreach team
42
What are some red flags obs on adults?
- NEWS 2 greater or equal to % and or look well with a Hx of infection - systolic is <90 - HR > 130 bpm - RR > 35 bpm - oxygen is >925 and they require supplementary oxygen ACVPU is either VPU
43