Mental status and respiratory assessment
What is the term for a normal breathing pattern?
Eupnea
List 3 pulse sites
Temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis
What site do we use to assess BP?
Brachial
What is a pulse oximeter and what can it detect?
A device that measures oxygen saturation, detects hypoxia
Normal HR
60-100 BPM
What are the 4 levels of consciousness?
Alert, Lethargic, Stupor, Comatose
How do we palpate pulses?
Palpate using two fingers (not the thumb) for rate, rhythm, and strength
What sites might we avoid for taking BP?
Sites with injury, IV lines, dialysis shunts, mastectomy on that side
How long do we wait in between positions when taking orthostatic vitals?
3 minutes
Normal RR
12-20 breaths per minute
What are the 4 areas we assess orientation?
Person, place, time, event
How do we assess pulse strength? (what scale)
0=absent
1+=weak/thready
2+=normal
3+=bounding
What Korotkoff sound indicates the systolic BP?
Phase 1, first tapping
How do we take orthostatic vitals?
Measure BP and HR when lying down, sitting, and standing
Normal BP
120/80 mmHg
What are Cheyne-Stokes? When would we see this breathing pattern?
When and why would we use the Doppler technique?
Use when a pulse is difficult to palpate, place the probe over the pulse site and listen for sound waves
What Korotkoff sound indicates the diastolic BP?
Phase 5, sound diappears
What may affect the reading of a pulse oximeter?
Poor circulation, DARK NAIL POLISH, cold extremities
Normal SpO2
95-100%
What technique do we use to wake a patient who appears unresponsive?
Sternal rub (WILL NOT WORK IF THEY ARE COMATOSE!!!!)
When would we auscultate the apical pulse, and how?
When giving cardiac meds, listen for one full minute, and use the bell of the stethoscope
What would we do if the BP cuff doesn't fit around a patient's arm? (too small)
There are larger cuff sizes
What values indicate orthostatic hypotension?
Systolic BP drops by >20, Diastolic BP drops by >10, or HR increases by >20
What would we do if a patient's SpO2 drops below 95%?
2L O2 nasal cannula