Podcast
Questions and Answers
Which of the following is the primary aim of assessing vital signs in nursing practice?
Which of the following is the primary aim of assessing vital signs in nursing practice?
- To identify deviations from normal physiological parameters. (correct)
- To fulfill documentation requirements.
- To enhance communication among members of the healthcare team.
- To implement comfort measures.
Which of the following factors can lead to variations in vital sign measurements?
Which of the following factors can lead to variations in vital sign measurements?
- Time of day and recent physical activity. (correct)
- Room temperature.
- Patient's proximity to healthcare staff.
- Availability of necessary assessment tools.
A nurse is assessing a patient with a known cardiac condition. What specific guideline should the nurse prioritize during the vital sign assessment?
A nurse is assessing a patient with a known cardiac condition. What specific guideline should the nurse prioritize during the vital sign assessment?
- Considering the patient's medical diagnosis, treatment, and medications. (correct)
- Systematically measuring vital signs at regular intervals.
- Communicating effectively with the patient.
- Ensuring the equipment used is reliable.
A patient reports feeling unwell with no obvious signs of distress. According to the guidelines, when should the nurse assess the patient's vital signs?
A patient reports feeling unwell with no obvious signs of distress. According to the guidelines, when should the nurse assess the patient's vital signs?
Which physiological process does body temperature regulation primarily depend on?
Which physiological process does body temperature regulation primarily depend on?
The nurse is assessing a patient whose body temperature is fluctuating widely throughout the day. Which factor is least likely to influence these changes?
The nurse is assessing a patient whose body temperature is fluctuating widely throughout the day. Which factor is least likely to influence these changes?
After exposure to a cold environment, a patient's body temperature drops. Which physiological response primarily helps to elevate the body temperature back to normal?
After exposure to a cold environment, a patient's body temperature drops. Which physiological response primarily helps to elevate the body temperature back to normal?
A patient is diagnosed with hyperthermia. Which temperature reading would be consistent with this condition?
A patient is diagnosed with hyperthermia. Which temperature reading would be consistent with this condition?
A nurse has a patient whose oral temperature averages 37°C. Which consideration is most important when taking oral temperature measurements?
A nurse has a patient whose oral temperature averages 37°C. Which consideration is most important when taking oral temperature measurements?
In which of the following cases should a nurse avoid taking an oral temperature?
In which of the following cases should a nurse avoid taking an oral temperature?
The nurse is preparing to measure an infant’s body temperature. Which method is LEAST recommended for routine use?
The nurse is preparing to measure an infant’s body temperature. Which method is LEAST recommended for routine use?
Which statement accurately describes the correct technique for performing a tympanic temperature measurement?
Which statement accurately describes the correct technique for performing a tympanic temperature measurement?
For which patient is the axillary temperature measurement most appropriate?
For which patient is the axillary temperature measurement most appropriate?
During a pulse assessment, what primary characteristics should the nurse evaluate to accurately describe the patient's pulse?
During a pulse assessment, what primary characteristics should the nurse evaluate to accurately describe the patient's pulse?
Which of the following is a common pulse point used to assess circulation in the foot?
Which of the following is a common pulse point used to assess circulation in the foot?
A nurse assesses a patient’s apical pulse and finds it to be 88 beats per minute, while the radial pulse is 76 beats per minute. What is the patient's pulse deficit?
A nurse assesses a patient’s apical pulse and finds it to be 88 beats per minute, while the radial pulse is 76 beats per minute. What is the patient's pulse deficit?
A nurse assesses an adult patient's pulse and documents it as 'thready'. What does this finding typically indicate??
A nurse assesses an adult patient's pulse and documents it as 'thready'. What does this finding typically indicate??
Why is the patient's arm positioned at heart level when taking their pulse?
Why is the patient's arm positioned at heart level when taking their pulse?
If you are checking the regularity of a patient's pulse for the first time and find it is irregular, how long should you count their pulse?
If you are checking the regularity of a patient's pulse for the first time and find it is irregular, how long should you count their pulse?
Assessing a patient's respiration involves evaluating which set of characteristics?
Assessing a patient's respiration involves evaluating which set of characteristics?
Which of the following best describes 'external respiration'?
Which of the following best describes 'external respiration'?
A patient is breathing rapidly and deeply. Which term should the nurse use to document this breathing pattern?
A patient is breathing rapidly and deeply. Which term should the nurse use to document this breathing pattern?
Which respiratory rate is considered within the normal range for an adult?
Which respiratory rate is considered within the normal range for an adult?
A nurse observes a patient experiencing periods of increased rate and depth of respirations, followed by gradual decreases and periods of apnea. Which type of breathing pattern is the patient exhibiting?
A nurse observes a patient experiencing periods of increased rate and depth of respirations, followed by gradual decreases and periods of apnea. Which type of breathing pattern is the patient exhibiting?
Normal respiratory depth increases the diaphragm by how much?
Normal respiratory depth increases the diaphragm by how much?
A patient is experiencing difficult breathing, and their nail beds appear bluish. Which condition is the patient likely experiencing?
A patient is experiencing difficult breathing, and their nail beds appear bluish. Which condition is the patient likely experiencing?
When assessing a patient’s respiration, which action should the nurse prioritize to avoid altering the patient's breathing pattern?
When assessing a patient’s respiration, which action should the nurse prioritize to avoid altering the patient's breathing pattern?
Each inspiration and expiration are counted as what?
Each inspiration and expiration are counted as what?
Pulse oximetry is used in clinical settings to measure:
Pulse oximetry is used in clinical settings to measure:
Which of the following is considered a normal, normal value for oxygen saturation?
Which of the following is considered a normal, normal value for oxygen saturation?
To ensure accuracy when using a finger probe, how is light position to the finger?
To ensure accuracy when using a finger probe, how is light position to the finger?
What is the primary physiological measure indicated by blood pressure?
What is the primary physiological measure indicated by blood pressure?
The measurement of blood pressure involves two readings. Which of the options correctly defines those readings?
The measurement of blood pressure involves two readings. Which of the options correctly defines those readings?
A patient consistently has blood pressure readings above 140/90 mmHg. According to general guidelines documented what is his reading?
A patient consistently has blood pressure readings above 140/90 mmHg. According to general guidelines documented what is his reading?
The radial pulse should be palpated where?
The radial pulse should be palpated where?
What is the typical range for average pulse pressure?
What is the typical range for average pulse pressure?
When measuring blood pressure, what is the correct position for the subject?
When measuring blood pressure, what is the correct position for the subject?
Elevating their arm will allow for the most accurate blood pressure reading.
Elevating their arm will allow for the most accurate blood pressure reading.
When taking a reading from the the first time, a blood pressure cuff should be placed how many cm above the antecubital area, at the brachial artery?
When taking a reading from the the first time, a blood pressure cuff should be placed how many cm above the antecubital area, at the brachial artery?
When listening with the stethoscope what sound correlates to systolic pressure?
When listening with the stethoscope what sound correlates to systolic pressure?
If it is the first time measuring blood pressure on a patient and there is a difference in readings between arms (after waiting 2 minutes) which arm determines the blood pressure?
If it is the first time measuring blood pressure on a patient and there is a difference in readings between arms (after waiting 2 minutes) which arm determines the blood pressure?
What is a recommended action to avoid mistakes in blood pressure assessment?
What is a recommended action to avoid mistakes in blood pressure assessment?
Under which circumstance is it most important to assess a patient's vital signs?
Under which circumstance is it most important to assess a patient's vital signs?
Which factor directly influences heat production in the body?
Which factor directly influences heat production in the body?
A patient's body temperature is measured at 34.9°C. Which condition is the patient experiencing?
A patient's body temperature is measured at 34.9°C. Which condition is the patient experiencing?
When performing oral temperature measurement, where should the thermometer be placed?
When performing oral temperature measurement, where should the thermometer be placed?
Which patient condition makes oral temperature measurement unsuitable?
Which patient condition makes oral temperature measurement unsuitable?
When measuring tympanic temperature, how far should the receiver be placed into the ear?
When measuring tympanic temperature, how far should the receiver be placed into the ear?
For which of these patients is taking a rectal temperature contraindicated?
For which of these patients is taking a rectal temperature contraindicated?
What step is most crucial in ensuring an accurate axillary temperature reading?
What step is most crucial in ensuring an accurate axillary temperature reading?
A newborn has a heart rate of 170. What is this condition called?
A newborn has a heart rate of 170. What is this condition called?
When assessing pulse rhythm, which finding could indicate a potential arrhythmia?
When assessing pulse rhythm, which finding could indicate a potential arrhythmia?
What physiological response is indicated by a 'full' or 'bounding' pulse?
What physiological response is indicated by a 'full' or 'bounding' pulse?
What does the term 'pulse deficit' refer to in a cardiovascular assessment?
What does the term 'pulse deficit' refer to in a cardiovascular assessment?
In an emergent situation, which pulse point is most appropriate for assessing circulation in a 0-1 year old?
In an emergent situation, which pulse point is most appropriate for assessing circulation in a 0-1 year old?
Which action will ensure the most accurate radial pulse rate?
Which action will ensure the most accurate radial pulse rate?
What constitutes one full respiration cycle?
What constitutes one full respiration cycle?
What is external respiration?
What is external respiration?
Where is the respiratory center located in the brain?
Where is the respiratory center located in the brain?
A patient admitted to the hospital has periods of difficult breathing, what is the most likely cause?
A patient admitted to the hospital has periods of difficult breathing, what is the most likely cause?
While assessing a patient, the nurse observes their respiration rate to be 9 breaths per minute. How should the nurse document this?
While assessing a patient, the nurse observes their respiration rate to be 9 breaths per minute. How should the nurse document this?
What condition describes the complete absence of oxygen?
What condition describes the complete absence of oxygen?
What should be evaluated during patient respiratory measurement?
What should be evaluated during patient respiratory measurement?
What is the normal respiratory rate range for a NEWBORN?
What is the normal respiratory rate range for a NEWBORN?
What is the normal respiratory rate range for an ADULT?
What is the normal respiratory rate range for an ADULT?
What is considered a hyperventilation breathing pattern?
What is considered a hyperventilation breathing pattern?
A pulse oximeter reading should fall between what range to be considered normal?
A pulse oximeter reading should fall between what range to be considered normal?
What reading placement would indicate abnormal oxygen saturation?
What reading placement would indicate abnormal oxygen saturation?
A pulse oximeter works by measurement throughout:
A pulse oximeter works by measurement throughout:
While measuring blood pressure, what does the systolic pressure measure or indicate?
While measuring blood pressure, what does the systolic pressure measure or indicate?
Which of the following blood pressure readings is considered ideal?
Which of the following blood pressure readings is considered ideal?
What is considered ideal blood pressure?
What is considered ideal blood pressure?
What is considered hypertension?
What is considered hypertension?
What is pulse pressure a measurement of?
What is pulse pressure a measurement of?
The average blood pressure ranges between:
The average blood pressure ranges between:
What position should the subject be in while measuring blood pressure?
What position should the subject be in while measuring blood pressure?
How long should you wait before taking pressure on the other arm?
How long should you wait before taking pressure on the other arm?
When taking a blood pressure reading, what is the ideal position of the patient's arm?
When taking a blood pressure reading, what is the ideal position of the patient's arm?
When a blood pressure cuff is applied, where should it be placed in relation to the antecubital area?
When a blood pressure cuff is applied, where should it be placed in relation to the antecubital area?
The first tapping sound heard while taking blood pressure represents:
The first tapping sound heard while taking blood pressure represents:
Considering the factors that can alter vital signs, how might a nurse interpret a slightly elevated temperature in a patient who has just finished physical therapy?
Considering the factors that can alter vital signs, how might a nurse interpret a slightly elevated temperature in a patient who has just finished physical therapy?
A nurse is assessing a patient with a history of cardiovascular disease. Which of the following vital sign changes would warrant the most immediate concern?
A nurse is assessing a patient with a history of cardiovascular disease. Which of the following vital sign changes would warrant the most immediate concern?
To ensure reliable vital sign measurements, which of the following actions should the nurse prioritize?
To ensure reliable vital sign measurements, which of the following actions should the nurse prioritize?
When evaluating a patient who reports feeling 'unwell', but shows no obvious distress, how should the nurse proceed with vital sign assessment?
When evaluating a patient who reports feeling 'unwell', but shows no obvious distress, how should the nurse proceed with vital sign assessment?
When a patient's body temperature drops due to prolonged exposure to a cold environment, what compensatory mechanism is initiated by the body to restore normal temperature?
When a patient's body temperature drops due to prolonged exposure to a cold environment, what compensatory mechanism is initiated by the body to restore normal temperature?
Which of the following best describes the physiological process behind the regulation of body temperature?
Which of the following best describes the physiological process behind the regulation of body temperature?
A nurse is caring for a patient whose oral temperature typically averages 37°C. What consideration is most important when using an oral thermometer?
A nurse is caring for a patient whose oral temperature typically averages 37°C. What consideration is most important when using an oral thermometer?
Which assessment finding would contraindicate the use of the oral method for measuring a patient’s temperature?
Which assessment finding would contraindicate the use of the oral method for measuring a patient’s temperature?
For a patient who is uncooperative and resists oral or tympanic temperature measurements, which alternative route is most appropriate?
For a patient who is uncooperative and resists oral or tympanic temperature measurements, which alternative route is most appropriate?
A nurse assesses a patient's pulse and documents it as 'thready'. What is the most accurate interpretation of this finding?
A nurse assesses a patient's pulse and documents it as 'thready'. What is the most accurate interpretation of this finding?
What underlying physiological factor leads to a 'bounding' pulse characteristic?
What underlying physiological factor leads to a 'bounding' pulse characteristic?
The difference between apical and radial pulse rates is referred to as the pulse deficit. How does this manifest?
The difference between apical and radial pulse rates is referred to as the pulse deficit. How does this manifest?
During an emergency, for rapid assessment of young children (ages 0-1), which pulse location provides the most reliable and accessible indication of heart rate?
During an emergency, for rapid assessment of young children (ages 0-1), which pulse location provides the most reliable and accessible indication of heart rate?
How should the nurse modify their respiration assessment technique to ensure they do not alter the patient's breathing pattern?
How should the nurse modify their respiration assessment technique to ensure they do not alter the patient's breathing pattern?
A patient has a respiratory rate of 9 breaths per minute. What term should a healthcare provider use to document this?
A patient has a respiratory rate of 9 breaths per minute. What term should a healthcare provider use to document this?
For an adult patient, hyperventilation is characterised by:
For an adult patient, hyperventilation is characterised by:
What rationale supports waiting to record respiratory measurements until after the pulse has been taken?
What rationale supports waiting to record respiratory measurements until after the pulse has been taken?
To best ensure the accuracy of pulse oximetry readings via a finger probe, what action is most important?
To best ensure the accuracy of pulse oximetry readings via a finger probe, what action is most important?
What is the optimal placement location for a pulse oximeter's light source to ensure accurate SpO2 readings?
What is the optimal placement location for a pulse oximeter's light source to ensure accurate SpO2 readings?
After an initial blood pressure measurement, a nurse finds the reading is significantly elevated. What is the most appropriate next step?
After an initial blood pressure measurement, a nurse finds the reading is significantly elevated. What is the most appropriate next step?
Flashcards
What are Vital Signs?
What are Vital Signs?
Basic indicators of an individual's overall health status.
Nurse's role in vital signs
Nurse's role in vital signs
The nurse must know how to obtain findings and inform team members.
What is body temperature?
What is body temperature?
Body temperature is the balance between heat produced and consumed.
How is heat lost?
How is heat lost?
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Factors Affecting Body Temperature
Factors Affecting Body Temperature
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What is the hypothalamus?
What is the hypothalamus?
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What is Hypothermia?
What is Hypothermia?
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What is Hyperthermia?
What is Hyperthermia?
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36.5 °C - 37.5 °C
36.5 °C - 37.5 °C
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Mercury Thermometers?
Mercury Thermometers?
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Oral measurement
Oral measurement
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Oral temperatures should be avoided for
Oral temperatures should be avoided for
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Rectal Termperature
Rectal Termperature
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Where is the Axillary Region?
Where is the Axillary Region?
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What is Pulse?
What is Pulse?
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Normal adult pulse
Normal adult pulse
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What is Bradycardia?
What is Bradycardia?
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What is Tachycardia?
What is Tachycardia?
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What do you do with patients experiencing arrhythmia?
What do you do with patients experiencing arrhythmia?
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What is a Pulse Deficit?
What is a Pulse Deficit?
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Pulse volume reflects
Pulse volume reflects
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Temporal artery
Temporal artery
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Apical
Apical
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Eupnea
Eupnea
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Bradypnea
Bradypnea
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Tachypnea
Tachypnea
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What is Dyspnea?
What is Dyspnea?
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What is Anoxia?
What is Anoxia?
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Low O2 Sats
Low O2 Sats
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What is Systolic Pressure?
What is Systolic Pressure?
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Diastolic Pressure:
Diastolic Pressure:
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What is Pulse Pressure?
What is Pulse Pressure?
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Normal BP range
Normal BP range
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What is Hypertension?
What is Hypertension?
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What is Hypotension?
What is Hypotension?
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Study Notes
Vital Signs Overview
- Vital signs are the fundamental indicators reflecting an individual's health status
- Assessing vital signs enables the identification of health problems
Factors Influencing Vital Signs
- Vital signs can be affected by time of day, age, ovulation state, and seasons
- Physical activity, dressing type, and environmental factors also affect vital signs
- Stress and presence of disease also cause changes to patient's vital signs
Guidelines for Assessing Vital Signs
- Nurses need to know how to obtain and evaluate vital signs, and how to inform team members
- Reliable equipment is required
- Selection of equipment should be based on the patient's condition and characteristics
- Normal vital sign values must be known, as well as all medical diagnoses, treatments, and medications
- Environmental factors also need consideration
Measuring Vital Signs
- Vital signs should be measured systematically at regular intervals
- Nurses need to communicate effectively with patients and cooperate with physicians
- Vital signs must be analyzed with great care
Frequency of Vital Sign Measurement
- Vital signs are measured upon patient admission
- Frequency of measurement increases before and after surgery
- Before and after diagnostic procedures, vital signs are measured
- Monitor vital signs after administering drugs affecting the heart and respiratory system
- If there is sudden deterioration of the patient's condition, and before and after medical interventions that may affect life signs
- Vital Signs should be taken when "the patient feels a difference"
Body Temperature Regulation
- Thermoregulation maintains consistent internal temperature
- Body temperature is the balance between heat produced and heat loss
- Heat production must equal heat consumption
- Body temperature should be consistent and balanced around 36-37°C
- Heat is produced through food and is lost through the lungs (breathing), skin (sweating), and bodily wastes
- Thermoregulation center is in the hypothalamus
- The hypothalamus acts as a thermostat
- Vazodilation, sweating, muscle tremors, and piloerection work to generate and release heat
Factors Influencing Body Temperature
- Age, exercise, hormone level, and basal metabolic rate all affect body temperature
- Stress, environment, emotional states, and nutrition influence temperature
- Diseases and the induction of the sympathetic nervous system impact body temperature
Temperature Changes
- Hypothermia occurs when body temperature drops to 35°C or below
- Hyperthermia occurs when body temperature rises above 38°C
Routes of Body Temp Measurement
- Oral temperature averages 37°C (36.5°C-37.5°C)
- Ear temperature averages 37°C (36.5°C-37.5°C)
- Axillary/forehead temperature averages 36.5°C (36°C-37°C)
- Rectal temperature averages 37.5°C (37°C-38°C)
Oral Measurements
- Oral measurement places the measuring device to the right or left of the tongue and averages 36.5°C - 367.5 °C
Tympanic Measurements
- Tympanic measurement is made in 1-2 seconds
- The receiver is placed 1/3 of the way into the outer ear canal
- A disposable plastic cover should be placed over the receiver
Cautions for taking Oral Temperatures
- Do not take oral temperature in patients with dyspnea
- Do not take oral temperature in children or the elderly
- Avoid in psychiatric and non-conscious patients, and after surgery
- Avoid with mouth operations, infections, and patients on continuous oxygen
Key Points for Oral Temperature Measurement
- The patient should have their own thermometer.
- Advise patients not to eat or drink anything prior to measurement
- Thermometer should be placed under the tongue
- Keep mouth closed during oral measurement, but without squeezing the teeth
Rectal Measurements
- Used when heat can't be taken orally or through the axillary route
- The room door and curtains should be closed
- The patient is placed into Sims' position and the upper leg is flexed
- Apply water-soluble lubricant to the probe, and separate the patient's hips with your hand
- Measure rectal temperature as asking the patient to breathe slowly and deeply
- Advance the degree 2.5-3.5 cm in adults, 2-2.5 in children, and 1.2cm in newborns
Contraindications for Taking Temperatures Rectally
- Rectal Bleeding
- Rectum Surgeries
- Birth
- The period of maternity
- Continuously as a routine way in children
- Diarrhea cases
Axillary / Forehead Measurements
- This axillary region is the most commonly used region
- Very unlikely for infections to transmit this way
- Patient should have their own personal thermometer
- The armpit should not be sweaty
Methods of Taking Forehead Temperature
- Use a special digital thermometer
- The device is placed on the forehead
Pulse
- Pulse represents the number of heartbeats, measured per minute
Aspects of Pulse Assessment
- You must consider Pulse Rate, Pulse Rhythm, and Pulse Volume
Pulse Rate Values
- Newborn: 120-160/min
- Children: 80-120/min
- Adult: 60-100/min
When to Count Pulse
- Counts in order to decide the rate, rhythm and contraction of the heart
- Counts in order to identify peripheral vascular diseases
Pulse Rate Abnormalities
- Bradycardia: Pulse rate below 60 beats per minute
- Tachycardia: Pulse rate above 100 beats per minute
Factors Affecting Pulse Rate
- Age, gender, metabolism and bleeding affect pulse rate
- Exercise, hyper/hypothermia, and acute pain/anxiety also impact pulse rate
- Chronic pain, drugs, and posture changes also factor
Pulse Rhythm
- If the heartbeat is regular, it is a regular rhythm. If it is irregular then it is an irregular rhythm
- In arrhythmia, the difference between the apical and radial pulse should be checked
- In arrhythmia, a pulse deficit (Pulse deficit) develops
- Pulse deficit represents the difference between the apical and peripheral pulse rates
The Significance of Pulse Deficit
- Pulse deficit signifies an arrhythmia
- Occurs even as the heart contracting, the pulse isn't fully reaching the periphery
- The radial pulse is lower than the apical pulse, and these two pulse rates are called "Pulse deficit"
3-Pulse Volume / Feeling the Pulse
- Pulse volume signifies the fulness of the pulse as well as left ventricular contraction
- If the pulse is normally palpated, the pulse is easily found and with every beat, it is felt in a similar fullness
- A pulse in this state represents a full/bounding pulse
- A "weak pulse" is very difficult to palpate, even with applied pressure. A weak pulse disappears easily
- A weak pulse is also called «filiform pulse» or «thready pulse»
Causes of Abnormally Weak Pulses
- Difficult to palpate, develops in bleeding, shock, or heart failure.
- Weak pulse = filiform pulse=thready pulse, with a Pulse rate is over 130 per minute
Emergency Pulse Points
- 0–1 age: apical, brachial, or femoral artery
- Age 1+: carotid artery
Peripheral Pulse Assessment- Process
- Wash hands, introduce, and inform
- Evaluate affecting factors
- Evaluate patient condition and pulse rate
- Patient should be resting and positioned appropriately
- Feel, and Record
Peripheral Pulse - Steps for Assessment
- Place the sign, middle, and ring finger are placed on the artery without excessive pressure
- If the pulse is measured for the first time and is irregular, is counted for 1 minute.
- If the heart rate is regular, it is counted for 30 seconds and multiplied by two to find the heart rate.
- Findings should be recorded.
Respiratory System Overview
- Respiration is a process where the organism uses breathing by to take in oxygen and release carbon dioxide
Breathing
- Oxygen goes and use CO2 release
Stages of Respiration
- These stages include external, internal, external, diffusion, and perfusion
External Respiration
- Relates to processes occurring between the atmosphere and the lungs
- Oâ‚‚ is released into the blood and COâ‚‚ is released through the respiratory/circulatory systems
Internal Respiration
- Exchange of oxygen and carbon dioxide between cells and blood circulation
Ventilation
- Ventilation is broken down into inspiration and experiation
Diffusion
- Is when O2 passes from the alveoli to the lung circulation
- CO2 passes from lung circulation to the alveoli
Perfusion
- The process by which O2, which enters the lung circulation, is carried in the blood and passes to the tissues
- CO2 accumulated in the tissues enters the lungs through circulation
Respiratory Regulation
- The respiratory center is located in the medulla oblongata and pons in the brainstem
Components of Respiratory Measurement
- Respiratory rate, depth, and type
Respiratory Measurement Numbers
- Newborns normally respire 30-60/min
- Adults normally respire 12-20/min
Types of Respiration
- Normal respirations, with equal rate and depth= 12-20 breaths/min
- Slow respirations, 10 breaths/min
- Fast respirations, 24 breaths/min, usually shallow
- Respirations that are regular but abnormally deep and increased in rate
- Irregular respirations of variable depth usually shallow alternating with periods of apnea (absence of breathing)
- Gradual increase in depth of respirations, followed by gradual decreasea and then a period of apnea
- Absence of breathing
Common Breathing Types
- Hyperpnea causes a increase of rate and depth of breaths
- Hypoventilation-Causes causes a decrease of rate and depth of breaths and is commonly irregular
Breathing Problems
- Anoxia: Absence of oxygen
- Hypoxia: Cells and tissues can not get enough oxygen
- Dyspnea, or Difficult breathing
Cyanosis
- A discoloration to the skin caused by low oxygen saturation
- "defined as the bluish or purplish discolouration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation."
- Cyanosis can be clearly observed from the lips, ear lobes nails and oral mucosa.
Assessing Respirations
- Observe the rate, rhythm, and depth of respiration.
- The rate, rhythm, and depth of respirations should be regular
- After the pulse is counted, the respiratory rate is counted by observing the patient's chest
- Number of breaths counted based on the chest's rise and is fall for one minute before the next breath is counted
- Each complete cycle is considered ONE respiration
Respiration Measurement Considerations
- Never tell the patient while measuring that the resperation is being counted
- Resperations must be measure after after measuring pulse
Respiration Measurement- Process
- Prepare the and collect materials
- Wash hands and introduce yourself
- Give the patient with instructions and inform them of the process
- Evaluate the patient's exercise, fatigue, eating status, health, etc
- Position the patient in a area where you can see see their the rib cage is
- Check the watch, note then start time and value
- Evaluate and find both expiration and inspiration value and count one breath.
- If breathing is regular, count for 30, seconds and multiply that by 2
- If breathing is not regular, then count for 1 whole minute
- Note depth and value
- Position the patient for whatever feels convenient.
- Put the materials away.
- Wash your hands again following the assessment.
- Record findings and and precautions for anything with an abnormal result.
Oxygen Saturation
- A oximetry to a procedure measure to the measurement in the oxygen in the blood.
- Consideread an invasive general- oxygen
- Measures of maximum hemoglobin
Blood Pressure
- Blood pressure is a measure of the force that heart uses to pump blood around your body.
Classifying Hypertension
- Systolic pressure – pressure when heart pushes blood out, or systole of the ventricles
- Diastolic pressure – the pressure when heart rests between beats, or diastole of ventricles
Systolic and diastolic Normal Numbers
- Ideal blood pressure: 90/60mmHg and 120/80mmHg
- Ideal pressure: 120/80
- When above: (140/90mmHg or higher)
- Low: 90/60mmHg or lower
Pulse Pressure Calculation
- The numeric difference between systolic and diastolic blood pressure is called pulse pressure
- Example: If resting blood pressure is 120/80 millimeters of mercury, then pulse pressure is 40
- Pulse pressure should normally be approximately 30-50mmHg
Influences On Blood Pressure
- Influenced by age, stress, race, and gender
- Effects brought on by medicines, food, and everyday life
- Can also influenced by physical factors and levels of stress
Hypertension
- The World Health Organization states the limit value for hypertension in adults is at 140/90mmHg.
Arterial Blood
- Value "Blood pressure = 90mmHgValue"
- This what is is known and and it, hypotension.
Hypotension Characteristics
- It exists only as the and normal artery levels value.
Measuring Arterial Blood Pressure- Materials
- You must collect a blood pressure: and Manometer) Stethoscope Suitable Disinfectant that is a good substitute for a hospital grade version of the product.
- Pen and have Registration Wash. your hands
Assessment - Procedure
- Position: have semi or Fowler Position To make assessment easier we can, In seated position, the patient's ,elbow arm flexed. If the patient is Anxious or Has done has an activity, you must allow must allow the pulse or stressers Take minute to the the correct pressure.
How to Take Arterial BP- Process
- Position has and. and
- Cuff should have arterial cm and the pulse is taken in front Also to Make we find zero for our position of this pointer on you on the position where your finger has hit zero
How To get Blood Pressure
Now you are getting and going and get that
- Hold your breath
-
- Now To find your find , listen pulse with fixed sound
- Time now a cuff so the we and for both
- After both values of pressure, are taken wash your hands and. repeat for. values
Common Factors That Affect Blood Pressure
• Make sure the pointer starts at zero • Take pulse or brachial artery • Fast cuff: (between mmHg) • Now cuff we for you or values to the sound for measure
Measuring for First Time
• Now arm then now arm- to from in has and. to you and
• After- - the now higher side to higher to measure • Record and wash to end proccesure.
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