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Vitals and Obs
| Question | Answer |
|---|---|
| Pulse | A bounding of blood flow in an artery that is palpable (you can feel it) at various points of the body |
| Why do we measure pulse? | ascertain HR, assess volume (strength), assess regularity and character of the pulse |
| What else can we do while measuring pulse? | monitor and evaluate changes in patients health status. Holistic assessment of the patient - are they clammy? Hot? Cold? Are they in pain? Are they agitated? Are they confused? Sensory concerns? |
| Looking for what when take pulse? | Rate Rhythm - regular/irregular Depth or strength - which you can't get it taken electronically |
| Tachycardia bradycardia irregular ectopic thready bouncing | fast HR slow HR weak, disappointing heart working harder than normal |
| Respiratory Rate | The movements of the chest during breathing |
| Looking for when taking RR? | Rate, rhythm, deep/shallow? |
| What could you do when taking pulse/RR? | act like you're taking pulse when you are actually taking respiratory rate (so patient doesn’t overthink it and it becomes unnatural) |
| Hypoxia | low oxygen saturation |
| Tachypnoea | quick breathing |
| Bradypnoea | slow breathing |
| dyspnoea | difficultly breathing |
| apnoea | stop breathing for a short period of time |
| cheyne stoking | barely breathing e.g. breaths with sig length of time between them |
| kussmaul breathing | deep rapid breathing, most commonly very ill patient with diabetic ketoacidosis |
| Pulse oximeter | A pulse oximeter employs 2 light sources and a photo-detector, built into a sensor Red and infrared light, pass through pulsatile vascular bed The PO rapidly gives a reading on the form of a % which is recorded as Sp02 |
| Pulse oximeter reading | above 96% |
| where do you put PO? | finger or toe (depending on local policy and manufacturers recommendations) |
| If need to query a PO... | take a blood test |
| thing to remember when using PO | nail varnish should be removed as it can impede the light from the probe, rotate fingers, record everything, decontamination equipment, don't assume poor reading is always correct (low battery, broken sensor cable etc) |
| why do we measure temp | To determine if core temp within normal range To provide a baseline from which patient's condition can be monitored To determine alterations in disease progression and efficacy of treatment |
| normal temp ranges | 36-37.2 degrees Celsius |
| Hypothermia | 35 degrees Celsius and below |
| Pyrexia | 37.2-39 degrees Celsius considered 'mild pyrexia' |
| Hyper pyrexia | 39 degrees and above |
| where do we measure temp? | Orally (mouth) Axilla (armpit) Rectum (anally) Tympanic (ear canal) - *might have a hearing aid* Blood |
| use to measure temp | - Infra-red tympanic - Sublingual dot matrix - Digital oral - Electronic disposable - Forehead - Don’t use mercury thermometers (?) Rectal probe |
| ACVPU | alert, confusion ('new' confusion), voice, pain, unresponsive |
| new confusional states are considered a sign of... | clinical deterioration |
| blood pressure | the force of blood against the walls of blood vessels, the product of cardiac output and peripheral resistance |
| blood pressure recorded as | two numbers systolic - as heart beats diastolic - as heart relaxes between beats written as systolic over diastolic e.g 135/75 |
| blood pressure measured by | sphygmomanometer |
| all medical equipment you use should be c... | calibrated |
| blood pressure measurements focuses on which artery? | brachial artery |
| normotensive hypertensive hypotensive hypertension | normal BP high BP low BP persistently high BP |
Created by:
user-2004250