heatlh assessment - vital signs

what does a complete assessment consist of?
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define blood pressureforce exerted by blood on the arterial wallwhat factors affect blood pressure?-force of contraction -arterial wall elasticity -peripheral vascular resistance -blood volume and elasticityexplain systolic and diastolic BP ?-systolic BP = left ventricle contraction; depends on intergrity of heart, arteries, arterioles -diastolic BP = left ventricle relaxation; depends on blood vessel resistanceJNC recommendations slide 12-13 NEEDyou have to have blood vessels that ______ in order to have a mean arterial pressureconstrictwhat is a normal mean arterial pressure?65-110if your MAP is above _____, you need to .... ?>60, needed to perfuse organswhat does it mean if you have low MAP? high?-low = sepsis, trauma, dehydration -high = intracranial blood, hypertensive emergenciespulse pressure = ? normal?sBP - dBP ; normal = 40 mmif you have a wide pulse pressure (>50), what does that mean?-usually SBP increases and DBP is steady -increase stroke volume (SV) -decreased peripheral resistance (PV) -important to note b/c it could mean HTN, atherosclerosis (rigid vessels), or raised ICP (intracranial pressure)if you have a narrow pulse pressure (<30), what does that mean?-usually SBP lowers, DBP increases -decreased stroke volume (SV) -increased peripheral resistance (PV) -important to note b/c it could mean poor heart functionhow do you know when to report a certain finding?-parameters ("call if...") -population (elderly, kid, adult) -trends (trending up or down) -holistic (know your pt) -"gut"*appropriate BP cuff size?* -bladder length encircles at least _______ of the upper arm -bladder width should equal approximately ____ of the upper arm distance from ____ to _____-80% -40%, elbow to shoulderevidence based practice information for blood pressure: [very testable lmao]-room quiet, comfortable temperature -rest for 5 minutes -no smoking/caffeine/exercise for 30 mins -sit erect with back supported -both feet flat on floor (crossing legs/ankles raises BP)*when taking blood pressure, you should avoid:* -affected side of a _______ (b/c it ______ compromised lymphatic circulation and worsens edema) -arteriovenous ________ / ________ shunt (compromises flow through shunt) -avoid arms with _____-mastectomy, decreases -fistula/hemodialysis shunt -IVsif the upper arm is not available to take blood pressure, what the F U C K do you do ?-thigh or wrist -at thigh, make sure you use the correct size at the POPLITEAL ARTERY -at forearm, make sue sure you use correct size below elbow at the RADIAL ARTERY*for accurate BP:* -palpate the _____ artery for viable pulse with your ______ hand -position the arm so that the antecubital space is at ______ (____ intercostal space at sternum) -if pt is seated, rest arm on table a little above pt's ______ -if pt is standing, support arm at ______ level-brachial, nondominant -heart level (4th intercostal space) -waist -midchestyou palpate the brachial artery, and the cuff should be snug _____ above that1 inch (2.5 cm)*estimating BP first to avoid error:* -palpate radial/brachial artery with nondominant hand -inflate cuff with your ____ hand until pulse disappears -note that number -deflate cuff quickly -add ______ to that number -wait _____ before taking BP (some say 15-30 sec)-dominant -30 mm -1 minutewhy do you palpate first?-b/c there are five korotkoff sounds -can have an auscultatory gap (systolic sound, break, sounds again) -could miss first sound if you don't go high enough*after estimate, obtaining BP:* -use bell or diaphragm - hold with nondominant hand over artery -turn thumbscrew clockwise with dominant hand to close valve -pump up cuff to predetermined estimate -slowly deflate cuff - _______ -listen for two consecutive beats (systolic) -deflate slowly until disappears (diastolic) -deflate slowly for another _____ to make sure disappeared -then deflate quickly to zero2-3 mm/sec 10-20 mmwhat errors results in false high readings (BP)?-cuff too small (narrow) -timing (relax before measurement) -legs/ankles crossederrors that result in false low readings (BP)?-cuff too large (wide) on small arms -inaccurate level of inflationthe blood pressure b/w arms shouldn't be more than a difference in _____; which one do you take if you do both?10; the one with the higher BP-if there are weak or inaudible korotkoff sounds...?-check stethescope placement -repeated inflations? -consider possibility of shockif you see abnormal rhythms with BP (_____), verify findings with ______dysrhythmias, ECGthe "office setting" could alter someone's blood pressure - how so?-white coat hypertension - 20% of pts with elevated BP in clinic; try to relax pt and remeasure later -masked hypertension - 10-15% of pts --> normal BP in office and high rest of day -may need ambulatory/home BP monitoring; new devices inflate every 20-30 mins over 24 hrswhat do you do if you have a hypertensive pt with unequal blood pressure in the arms and legs?-compare BP in arms and legs; normally leg BP > by 5-10 mm -compare volume and timing of radial and femoral pulses -coarctation of the aorta and occlusive aortic diseasewhat is coarctation of the aorta and occlusive aortic disease?-hypertension in upper extremities -low blood pressure in legs -diminished or delayed femoral pulsesspecial techniques for BP if you're fu ck in up-palpable BPs = only gives systolic #, feel for first beat -doppler = ultrasonic device, if you can't even feel it*automated BPS:* -check accuracy by ... ? -select _____ mode --> set ____ and _____ -can retrieve stored data-do HR and BP manually in same arm -set alarms and frequencywhat indicates orthostasis?-postural hypotension indicated by: --> reduction of at least 20 mmHg in systolic BP or at least 10 mmHg in diastolic BP --> increase in pulse rate by 15-20 BPM --> as measured within 3 mins of standing from a lying position -if the pt becomes symptomatic (weak, dizzy, lightheaded, diaphoretic), it is also considered an indicationwhat is the main thing that causes orthostatic BP ?dehydration*orthostatic measurements:* -first _____ position: completely flat if possible (low bed position) ; b/w measurements, and particularly at each change of position ; observe and question the pt for ....?-dizzy -pallor -lightheaded -diaphoresis -syncope*orthostatic measurements:* -pt should rest in supine position for ______ -note any abnormal or difficulty breathing and abort procedure if severe, address pt safety issues and notify the physician -obtain BP and ____, and record-3-10 mins -pulse-after supine blood pressure [orthostatic], you then assist the pt to a ______ position at the side of the bed -within ______ minutes, obtain the BP and pulse again in the same extremity -the arm should be resting either on a table or being held by the assessor at the heart level -remove BP cuff and assist pt to sitting/lying -record standing measurement -if pt becomes symptomatic, return them to bed immediately and take BP reading -support pt and prioritize accordingly-standing -3 minutes*steps to adult orthostatic BP by CDC:* -have pt lie down for _____ -measure BP and _____ -have pt stand -repeat BP and ____ after standing _____-have pt lie down for 5 mins -measure BP and pulse rate -have pt stand -repeat BP and pulse rate measurements after standing 1 minute and 3 minutes*abnormal during orthostatic adult bp:* -drop in BP of ____ -drop in diastolic BP of ____ -lightheaded, dizzy -increase in HR by ____-drop in BP of 20 -drop in diastolic BP of 10 -lightheaded, dizzy -increase in HR by 20-thermoregulatory enter in the ______ regulates temperature -center receives messages from cold and warm ______ in the body -center indicates responses to produce or conserve body heat or increase heat loss-hypothalamus -thermal receptorswhat factors affect body temp?-circadian rhythms (lowest 4-5 am ; highest 4-8 pm) -age (highest in neonates, lowest in elderly) -gender (women higher) -emotions (heightened higher, depressed lower) -environmental temps (hot and cold)*______ temperature:* -reflects 60% of body mass -tightly regulated by body -most accurate @ ______ artery -other: distal _____, _____ membraneCORE -pulmonary artery -distal esophagus, tympanic membrane*______ temperature:* -influenced by extreme environmental and physiologic variables -mouth, bladder, rectum, temporal artery, axilla/inguinalperipheraltemperature - average adult? whats higher and lower?-average adult = 37 C (98.6 F) --> 35.8 C am, 37.3 pm -axillary/inguinal and temporal are lower than oral by 0.3-0.6 C -rectal and tympanic are higher than oral by 0.3-0.6 Chyperprexia? hypothermia?-hyperprexia = >44.1 C (106 F) -hypothermia = <35 C (95 F), rectallymost accurate noninvasive:-rectal -oral -tympanic -axillary, temporal, chemical dot (not in ICUs) -rectal - avoided in neutropenic-fever = abnormal elevation in body temperature -chills = feeling cold, shivering - usually with _____ temperatures -sweating = feeling hot and sweating - usually with ____ temperatures -what can night sweats indicate?-chills = rising temps -sweating = falling temps -night sweats = TB, cancers*oral temperature:* -place in posterior ______ pocket, perfused by _________ -close/open lips? -influenced by fluids and ______ [fast breathing, especially through mouth] -if they have been doin what (?) , you wait how long?-posterior sublinguinal pocket, perfused by external carotid artery -closed lips -hot/cold, gum, smoking = wait 15 minswhen is oral temperature contraindicated?-unconscious -disoriented -unable to close mouth -seizure prone -young kids -infants*rectal temp:* -privacy, lubricate -how far towards umbilicus? -do you have to hold it until it completes? -clean thermometer and pt -influenced by ____ in the rectum-3-4 cm towards umbilicus -hold -influenced by stools in rectumwhen is rectal temp contraindicated?-risk of bleeding -infection -injury -slow HR, etc.*axillary/inguinal temp:* -gently pat dry with tissue (moisture conducts heat) -axillary = probe in _________ ; pt lower elbow and hold _______probe in center of axilla ; pt lower elbow and hold firm contact*tympanic temp:* -free of cerumen/drainage (ear wax ______ temp) -pull up and back, seal canal, angle toward nose, hold for ___ secs -if lying with ear on pillow, allow ______ to normalize temperature before assessing -user error and pt anatomy reduce accuracy-ear wax lowers temp -allow 20 mins to normalize temp*______ temp:* -not significantly influenced by thermoregulatory changes - perfusion stable and closely reflects core -exergen TAT thermometer (1) place on _____ of forehead (2) depress button (3) hold and slide across mid forehead to ______ (4) touch behind ______ (5) release button and readTEMPORAL ARTERY TEMP -center of forehead -mid forehead to hairline -touch behind earlobeis the oral tempadot recommended?noerrors in accuracy while taking temperature?-choice of measurement site -instrument related errors -operator errorsrecommendations about temp: -_____ method throughout episode of care -note _____ -evaluate other _______-same method -note trends -other vital signsheart rate and rhythm are regulated by the _____ through cardiac ______ nodeautonomic nervous system through cardiac sinoatrial node-parasympathetic stimulation ______ heart rate -sympathetic stimulation ______ heart ratedecreases increaseswhat do think when checking heart rate and rhythm?-do "extra" beats appear isolated or in a regular rhythm? -rhythm vary with respiration? -is it irregularly irregular? -strong, weak?-pulse rate on a peripheral pulse = ? -what is commonly used? -which fingers? -how much pressure?-number of pulsations over a peripheral artery in 1 minute -commonly use radial pulse -use index/middle fingers (ring finger) -moderate pressure, excessive pressure can obliterate pulsewhen assessing the peripheral pulse, you count for 30 seconds and multiply by 2, but what if it's irregular or unusually fast or slow?-count 60 seconds -one beat = lub dubnormal heart rate?60-100 bpmtachycardia?-HR greater than 100 -causes: pain, anxiety, fever, stress, DEHYDRATION (hypovolemia), meds, heart disease -actions to take = treat cause, monitorcauses: -pain -anxiety -fever -stress -dehydration (hypovolemia) -meds -heart diseasetachycardiabrachycardia?-HR < 60 -causes: conduction abnormalities, vagal response, young/athlete, sleeping, meds -actions to take = assess if pt is symptomatic, monitorcauses: -conduction abnormalities -vagal response -young/athlete -sleeping -medsbrachycardia*respirations:* -changes in response to ______ demands -controlled by respiratory centers in the _____ and _____ -activated by impulses from _______ -increase in carbon dioxide is the most powerful respiratory _______-changes in response to tissue demands -controlled by respiratory centers in the medulla and pons -activated by impulses from chemoreceptors -increase in carbon dioxide is the most powerful respiratory stimulant*factors affecting ______:* -exercise -respiratory/CV disease -alterations in fluid, electrolyte, and acid balances -meds -trauma -infection -pain -emotionsrespirations*observing _________ rate AND rhythm:* -depth - shallow/deep -effort of breathing (labored, unlabored)respiratorynormal adult resp rate? inhales or exhales? count?-12-20 breaths per minutes -one = inhalation plus exhalation -30 seconds x 2 OR 1 full minutetachypnea?-high respiratory rate (RR) > 30 -causes = anxiety, hypoxia, lung/heart disease -actions = assess further, treat causebradypnea?-low RR < 12 -causes = narcotics, sleeping, head injury, coma -actions = assess further, wake ptif the pt's respiratory rate suddenly INCREASES, assess him for other signs of respiratory ______distressassessing for respiratory distress ?-anxiety -work of breathing: nasal flaring, accessory muscle use -abnormal breath sounds, grunting -cyanosischaracteristic bluish discoloration in the nail beds, on the lips, under the tongue, in the buccal mucosa, or in the conjunctivacyanosis (sign of resp distress)pulse oximetry AKAoxygen saturation SpO2what does pulse oximetry mean?-saturation of arterial Hgb with oxygen -"infrared" light through pulsating arterial bed detects color absorbed by arterial blood -"healthy" oxygen saturation is 95-100%oxygen saturation probes fit on fingers, but if it's an infant or young kid ?ear, toethings to do when doing oxygen saturation with finger?-remove false fingernails/polish -position hand at heart level to eliminate venous pulsationsthings to do when doing oxygen saturation with ear?-use alcohol swab and massage lobe x 15 secs until mild erythema -leave in place for 3 or more mins to stabilize for readingwhat if the pulse oxygen heart rate does not equal the actual heart rate?inaccurate saturation readingcommon interferences of oxygen saturation ?-dyes -excessive light (surgical lamps) -excessive pt movement -hypothermia -hypotension -vasoconstriction -automatic BP cuff will interfere inflationswhat is one of the most common symptoms that is often under assessed and under treated?painacute vs chronic pain?-acute = occurs suddenly with recent injury or illness -chronic = pain that persists for more than 3-6 months; recurring at intervals of months or yearshow to assess for pain COMMUNICATIVELY ?-Onset: date, time, gradual/sudden -Pp: provocative/palliative -Q: quality -R: region/radiation -S: severity/intensity -Tt: timing - duration, frequency -U: understandingpain - non communicative?APP vs CPOT -assume pain present vs critical care pain observation toolassume pain present:-observation of behaviors -history of painful condition, illness, trauma, or surgery expected to cause pain -presence of instruments such as chest tubes/ventilators -extended stay in critical care -invasive/noninvasive proceduresCPOT*critical care pain observation tool* -facial expression -body movements -compliance with ventilator (intubated) or vocalization (extubated) -muscle tension__________: -efficient -consolidate a lot of info -can show trends over time (vitals, weights) -can show complex pic of care delivered (primary form of documentation in ICUs)flowsheetsattributes of desirable documentation?-legible -permanent -accurate -signed/dated -accepted abbreviations ONLY -appropriate -complete -conciseshould you do these things? l o l : -leave blank space for a colleague to chart later -chart in advance of an event -use vague terms -chart for someone else -alter a record even if requested by a superior or a a physician -record assumptions or words reflecting bias = "complainer" or " disagreeable" -red/blue/pink ink or pencil -scribble out an entire wrong entryno lmfao -black ink -one line through when ya f u c k up