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Flashcards

Vital Signs

Kyha Avery Patient Assessment Resp Therapy English 52 cards

BP stage classification

Cards in this deck (52)

  1. 14 classic vital signsTemperature
    Pulse
    RR & Pattern
    BP
  2. 2What is the 5th vital sign?SpO2
  3. 3Additional vital signsHeight & Weight
    Level of Consciousness
    Level & Type of Pain
    General Appearance
    ECG
  4. 4What is a differential Dx?Is the distinguishing of a particular disease or condition that presents with similar clinical features
  5. 57 components of general assessment1.) General Clinical Presentation
    2.) Height & Weight
    3.) Temperature
    4.) Pulse
    5.) Respiratory Rate & Pattern, WOB
    6.) Blood Pressure
    7.) SpO2
  6. 6What do we look at in the general clinical presenation?First impression of pt status
    1.) How severe does their health status appear?
    2.) Are they in distress?
    3.) Level of consciousness
    4.) Postion
  7. 7What are the positions a pt can be in?1.) Semi fowlers (45 degrees)
    2.) Low fowlers (30 degrees)
    3.) Trendelenburg
  8. 81.) Why is pt weight important? 2.) Why is pt height important?1.) Drug dosing, G-tube feeding, fluid balance for IV's
    2.) Calculate IBW, PPV settings uses IBW
  9. 9What is included in Status sensorium?1.)Evaluation of Person, Place & Time (orientated x 3)
    2.) Patient cooperation/coordination
  10. 10What's included in Level of consciousness?1.) Measure of adequate cerebral oxygenation (Deterioration to coma)
    2.) Measure of adequate ventilation
    (CO2 levels affect LOC)
    (Normal to obtunded)
  11. 11What are 6 signs of hypoxemia?1.) Cool extremities
    2.) Diaphoresis
    3.) Decreases mental function/impaired judgment
    4.) Increased Rate & Depth of breathing
    5.) Tachycardia
    6.) Increased BP initially
  12. 12Body temperature is lowest in the ------ & highest in the ------Lowest in the morning
    Highest in the late afternoon
  13. 13When can temperature increases (normal situations)1.) Pregnancy
    2.) Exercise
  14. 14The generation of heat is the byproduct ofnormal metabolism
  15. 15How does the hypothalamus cool us down?stimulates peripheral vasodilation and sweating for heat loss
  16. 16How does the respiratory system lose heat?Through humidification
  17. 17Normal time & temp for: 1.) Oral 2.) Axillary 3.) Rectal 4.) Ear1.) Oral (36.5-37.5) (3-5 mins)
    2.) Axillary (35.9-36.9) (20 seconds)
    3.) Rectal (37.1-38.1) (2-3 mins)
    4.) Ear (same temp as rectal) (2-3 sec)
  18. 181.) Most common place to take temp? 2.) Safest place to take temp in enfants? 3.) Rectal temp shows our?1.) Ear
    2.) Axillary
    3.) Core body temp
  19. 19Hyperthermiaincrease in body temperature due to normal activities
  20. 20Feverincrease in body temperature 2˚ disease.
  21. 21What temperature is likely indicative of infection>39
  22. 22An increase in temp by 1 degree does what?Increases O2 demand by 10%
  23. 23In what instance would an infection not result in increased temp?Immunocompromised
  24. 24Hypothermia is define as a temp less then35
  25. 25What can cause Hypothermia?1.) Prolonged exposure to cold temperatures
    2.) Head injury
    3.) Damage to the Hypothalamus
  26. 26What mechanisms does hypothermia use?Slows metabolism
    1.) Results in decreased O2 consumption & CO2 production
    2.) Decreases ventilatory drive (slow & shallow breathing)
    3.) Peripheral Vasoconstriction
    4.) Shivering
  27. 27When would we want slowed metabolism?Post-cardiac arrest patients to prevent against further organ damage
  28. 28Evaluation of Pulse should include:Rate
    Rhythm
    Regularity
    Strength/Grade
  29. 29Normal Pulse rate? Tachycardia Rate? Bradycardia Rate?Normal: 60-100
    Tachycardia: >100
    Bradycardia <60
  30. 30Causes of tachycardiaFever, exercise, low SpO2, anxiety, low BP
  31. 31Causes of bradycardiaAthletes
    Beta blockers
  32. 32Pulse Sites1.) Radial
    2.) Brachial
    3.)Femoral
    4.) Carotid
    5.) Pedal
  33. 33In what 2 pulse sites is the pulse preserved at low BPCentral pulses (carotid & femoral)
  34. 34How to check radial pulse (best practice)1.)Evaluation should occur for at least 60 seconds
    2.) Rhythm and strength are assessed first
    3.) Pulse rate can be assessed for 15 seconds (multiply by 4)
    If the pulse is deemed regular!!
    4.) Irregular pulses should be assessed for the full 60 seconds
  35. 35Explain the 3 pulse Rhythm types1.) Regular: Pulse with equal intervals between beats
    2.) Regularly Irregular: Irregularity that occurs in a continuous & predictable pattern
    3.) Irregularly Irregular: Irregularity that has no discernable pattern
  36. 361.) What is pulsus Paradoxus? 2.) What is Pulsus Alternans1.) Pulse strength decreasing during inspiration
    2.) Alternans, combination of strong and weak pulses
  37. 37What is the amplitude scale for pulse?4=Bounding
    3=increased
    2=Normal
    1=Weak/thready
    0-Absent or non-palpable
  38. 38Normal Adult RR Extremely abnormal would be?12-20
    Abnormal >40
  39. 39What else to look for while assessing RR?1.) Pattern
    2.) Depth
    3.) Chest expansion
    4.) Work of breathing: Flared nostrils, accessory muscle use, intercostal and sternal retractions
  40. 40Indications of increased WOB1.) Increased RR
    2.) Nasal Flaring
    3.) Tracheal Tug
    4.) Accessory muscle use (Sternocleidomastoids or abdominal muscles)
    5.) Forced exp phase/ belly breathing
  41. 41Definition of arterial BP. Include the normalforced exerted by the blood against the walls of the arteries. Normal is < 120/80 mmHg
  42. 42Systolic BP definition with normalpeak force exerted during contraction of the left ventricle. Normal is <120 mmHg
  43. 43Diastolic BP Definition with normalforce occurring when heart is relaxed, normal is 80 mmHg
  44. 44Definition of Pulse Pressure (PP) with the normalDifference between systolic and diastolic, normal is 35-40 mmHg
  45. 45BP stage classificationBP stage classification
  46. 46BP cuff in adults should cover how much vs children?BP cuff adults - 80%
    BP cuff in adults - 100%
  47. 47How to take manual BP?1.) Palpate Brachial Artery
    2.) Place cuff - 2cm above ACF. Line artery up w/ arrow. 2 fingers should fit under cuff
    3.) Inflate Cuff - While palpating radial artery, inflate cuff until pulse no longer palpable. Add 30 mmHg more to the cuff
    4.) Place stethoscope over brachial artery and auscultate
    5.) Slowly deflate cuff listening for changes in blood flow sounds – Korotkoff Sounds. Note the pressure sounds appear (systolic ) and pressure sounds disappear (diastolic)
  48. 48What phase is Systolic? What phase is diastolic?Phase I
    Phase V
  49. 49On normal inspiration, how much does systolic BP decrease?Decreases by 2-4 mmHg
  50. 50How is pulsus Paradoxus Created?negative intrathoracic pressure created by the respiratory muscles during inhalation. The negative intrathoracic pressure encourages venous blood to return to the right ventricle and discourages arterial blood flow out of the left ventricle. The increased venous return to the right ventricle during inspiration increases the right ventricular filling pressures, which causes the interventricular septum to distend toward the left ventricle. This results in reduced left ventricular filling, reduced stroke volume, and decreased systolic blood pressure simultaneous with inhalation.
  51. 51In what two conditions is it normal to see pulsus paradoxes occur?Asthma
    Cardiac Tamponade
  52. 521.) Normal SpO2 2.) In hospital 3.) COPD or other chronic lung condition SpO2 4.) Palliative SpO21.) >95%
    2.) >92%
    3.) 88-92%
    4.) Target comfort

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Resp Therapy Patient Assessment Flashcards on Vital Signs, created by Kyha Avery on 02/12/2023.
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Kyha Avery
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