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Monday, June 9, 2014. Patient Assessment: Vitals. Review. Let’s review the 4 vital signs! Heart rate Respiratory rate Blood pressure Temperature. Heart Rate. What does heart rate tell you? Tells you part of the patient’s story – how your body is being supplied by oxygenated blood - PowerPoint PPT Presentation
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Patient Assessment: Vitals
Monday, June 9, 2014
Review
Let’s review the 4 vital signs! Heart rate Respiratory rate Blood pressure Temperature
Heart Rate What does heart rate
tell you? Tells you part of the
patient’s story – how your body is being supplied by oxygenated blood
Where can you measure heart rate? 11 sites, 8 discussed last
class How do you describe
(document) heart rate? Site, rate, rhythm, depth
Respiratory Rate Describe the process of breathing
Inhalation and expiration: exchange of gases in the body
What does respiratory rate tell you? Tells you how much oxygen you may need,
and how much carbon dioxide to expel How does respiratory rate relate to
heart rate? Hold your breath Your body needs oxygen, but needs to also
get rid of gas wastes: CO2
Blood Pressure What is blood pressure?
A ratio of the pressure in your arteries when your heart contracts & relaxes
Systolic vs diastolic What is hypotension vs hypertension?
Hypo – below normal, ie. shock Hyper – above normal, ie. cardiovascular disease
What does blood pressure tell you? Tells you whether oxygenated blood is getting
delivered properly
Temperature What does temperature tell you?
The body self-regulates its temperature to ensure cellular reactions work best
What is hypothermia vs hyperthermia? Temperature below or above normal can
seriously affect body function What is the difference between core
and peripheral temperature? Core: taken by ear (T) & rectum (PR) Peripheral: taken by armpit (Ax), mouth
(PO)
Let’s Take Some Vitals!
Manual blood pressure 1) Make sure patient has not been doing
any strenuous activity for about 5 minutes. 2) Take cuff and secure it around patient’s
arm, placing the tubing centre to the patients brachial artery site
3) Locate the radial pulse, and inflate the cuff until you cannot feel the pulse anymore (obliteration), making note of the mmHg
Let’s Take Some Vitals! Manual blood pressure continued
4) Now place your stethoscope on this site and listen for a pulse. Inflate cuff above the obliteration point by 30-40mmHg.
5) Slowly deflate cuff at 2-3mmHg per second, and make note when you begin to hear the pulse again. That’s your systolic!
6) Continue to deflate and make note when you no longer hear the pulse. That’s your diastolic!
Vital Signs Review GameHeart Rate
Respiratory Rate Temperat
ure
Blood pressu
re
Critical thinkin
g100 100 100 100 600200 200 200 200 700300 300 300 300 800400 400 400 400500 500 500 500
HR 100
What is the normal heart range for an adult?
60-100
Back to the Board
HR 200
What is the normal heart rate range for an infant?
110-180 BPM
Back to the Board
HR 300
What is tachycardia?
Increased heart rate over the normal range
Back to the Board
HR 400 There are 11 sites to palpate pulse. 8 were in
the last presentation: name 3 of these sites.
Apical Radial Femoral Popliteal Brachial Carotid Dorsalis pedis Temporal
Back to the Board
HR 500
What are the 4 components of documenting of heart rate?
1) Site 2) Rate 3) Rhythm 4) Depth
Back to the Board
RR 100
How is respiratory rate measured?
Respirations per minute
Back to the Board
RR 200
What is the normal range for a child?
20-25 respirations per minute
Back to the Board
RR 300
Name 2 of the 3 components of documenting respiratory rate.
1) Rate 2) Rhythm 3) Depth
Back to the Board
RR 400
What is the process in which your diaphragm flattens and chest expands allowing exchange of oxygen in your lungs?
Inhalation
Back to the Board
RR 500
Name 2 things that can affect your ability to breath: Bonus points if you can explain how.
Airway is obstructed Lung tissue is poor (ie. inflammation,
thickened) Lung cannot inflate properly (ie.
collapsed, pressure against lung space)
Back to the Board
Temp 100
What is the normal range for temperature?
35.0-37.5*C
Back to the Board
Temp 200
What site is denoted by the letter “O”?
Oral temperature site
Back to the Board
Temp 300
Name the 4 sites to take temperature.
Oral Rectal Axillary Tympanic
Back to the Board
Temp 400
What is the difference between core and peripheral temperatures?
Core refers to temperatures closest to internal organs
Peripheral refers to temperatures away from internal organs
Back to the Board
Temp 500
Which type of temperature sites is the most accurate? Bonus points if you can explain why.
Core temperature sites such as tympanic & rectal
Because they are a better at measuring the temperature of your internal organs and less influenced by fluctuations of your environment
Back to the Board
BP 100
What is the normal blood pressure of an adult?
120/80
Back to the Board
BP 200
What is the unit of measure for blood pressure?
mmHg or “millimetres of mercury”
Back to the Board
BP 300
What is the difference between systolic & diastolic pressures?
Systolic is a measures of the pressure in the arteries when the heart contracts
Diastolic is a measure of the pressure when the arteries relax
Back to the Board
BP 400
What is the normal blood pressure of an infant?
90/55
Back to the Board
BP 500
Give 3 symptoms of hypotension.
Dizziness, light-headedness, syncope (fainting), cold/clammy skin, fatigue, shallow breathing, blurred vision, lack of concentration, nausea
Back to the Board
Critical Thinking 600
BEFORE taking vital signs, what are some observations you can make that may affect how you interpret your findings?
Back to the Board
Critical Thinking 700
A 20 year old man comes into the ER with a stab wound to the stomach. His vitals are T-37.2*C (PO), BP-88/60, HR-121, RR-24. Explain the relationship between his blood pressure and his heart rate.
Back to the Board
Critical Thinking 800
A 77 year old lady becomes increasingly confused so her family takes her to see the doctor. Her vitals are T-37.7*C (PO), BP-109/68, HR-108 and RR-18. The nurse takes a rectal temperature and it’s T-38.2*C (PR). What does this finding mean?
Back to the Board