vital signs, transfers, body mechanics, and positioning (exam 2 patient care)

vital signs

-body temp

-heart rate

-pulse

-blood pressure

-respiratory rate

-determination of sense of pain

Baseline of vital signs

-take vital signs prior to treatment and after exercise/activity

-important for elderly, very young, debilated patients, trauma patients, diseases, and major surgeries

influencing factors of vital signs

-level/amount of physical activity

-environmental temp

-age

-emotional status

-physiological status

adverse response to activity

-mental confusion

-fatigue

-lethargy

-slow reactions

-decreased verbal response

-complaints of nausea, syncope, vertigo

-diaphoresis

-increase in blood pressure

body temperature

-indication of intensity or degree of heat within the body

-normal range is 96.8-99.3

factors affecting body temp

-time of day

-age

-environmental temp

-infection

-physical activity

-emotional status

-site of measurement

-menstrual cycle

assessment of body temp

-typical duty of nursing

-no treatment when temp is elevated

-sites=oral cavity, rectum, axilla, ear canal, and inguinal fold

-equipment= oral thermometer, chemical thermometer, temporal artery scanner, ear thermometer, infrared thermometer

pulse

-indirect measure or contraction of left ventricle of heart

-movement of blood in the artery

-normal values=

• children over 10 and adults= 60-100

• newborn= 100-150

• infants=90-120

• children=70-130

factors affecting pulse

-age

-sex

-environmental temp

-infection

-physical activity

-emotional status

-medications

-cardiopulmonary disease

-insufficient sleep

assessment of pulse

-sites= temporal, carotid, brachial, femoral, radial, pedal, popliteal, posterior tibial arteries

description of pulse

-strong and regular= even beats and good force

-weak and irregular= uneven beats and weak force

-irregular= strong and weak beats

-thready= weak and irregular

-tachycardia= more than 100bpm

-bradycardia= less than 60bpm

pulse oximetry

-measures blood oxygen levels, monitors pulse rate, and calculates heart rate

-place it over the index or ring finger

-normal blood saturation= 95-100%

-3 types of devices= stationary digital, handheld oximeter, finger pulse oximeter

blood pressure

-amount of force of blood against artery walls

-tools=sphygmomanometer (BP) and stethoscope

-systolic pressure= contraction of left ventricle (korotkoff’s level 1 sound)

-diastolic pressure= rest period of heart (korotkoff’s level 5 sound)

-normal value= less than 120/80

-assess BP at brachial artery

Factors affecting blood pressure

-obesity

-physical inactivity

-excessive use of nicotine, alcohol, or salt

-arteriosclerosis

-diabetes mellulitis

-advanced age

-kidney disease

-diet

-dehydration

-cardiac output

mean arterial pressure

-average pressure during a single cardiac cycle

Korotkoff sounds

1- clear, sharp tapping sound; indicates systolic pressure

11- soft swishing (murmer)

111- louder rhythmic thumping

1V- sudden muffling; indicates diastolic is beginning

V- complete silence; marking diastolic pressure

Respiration

-inspiration and expiration of air between environment and lungs

-1 respiration= 1 inhale and 1 exhale

-normal values= 12-18 per min for adults; 30-50 for infants

assessment of respiration

-observation of rate, rhythm, depth, and 1 exhale

-rate= breaths per min

-thoracic or abdominal breather

-depth= volume of air exchanged

-rhythm= regularity

-character= deviations from normal

apnea

absence of breathing

dyspnea

labored breathing

SOB

shortness of breath

Rale

abnormal discontinuous nonmusical sound heard on chest, crackle (pneumonia)

stridor

inspiratory musical wheeze heard over trachea, secondary to tracheal obstruction

wheezes and rhonchi

secondary to restricted airway and heard during exhale, musical

pulmonary auscultation

listening for breath sounds in lungs

normal breath sounds

tracheal, bronchial, bronchiovesicular, vesicular

tracheal

heard at neck, high pitch, loud, harsh

bronchial

heard at sternum, loud, tubular, less harsh

bronchiovesicular

heard at scapula, soft, high pitch

vesicular

heard over lungs, soft, low pitch

abnormal breath sounds

nonmusical= rale and crackles

musical= wheezing, ronchi, and stridor

rale and crackles

heard over chest, pneumonia

stridor

inhale, heard over trachea, secondary to tracheal obstruction

wheezes and rhonchi

exhale, secondary to restricted airway

muscle pain

dull and aching

nerve root pain

sharp and shooting

nerve pain

sharp and lightning like

sympathetic nerve pain

burning

bone pain

deep and nagging

fracture pain

sharp and severe

vasculature pain

throbbing

purpose of changing positions

-to prevent contractures

-relieve pressure

devices/techniques to reduce friction

-mechanical lift

-sliding board

-lift sheet

-trapeze bar

-cornstarch

skin inspection

-inspect skin before and after treatment

-red, paleness, blanching, numbness and tingling indicate excessive pressure

high risk areas in sitting

-ischial tuberosities

-scapula and vertebral spinous process

-olecrannon process

-medial epicondyle of humerus

-back of knees

-heels of foot

preventive positioning for transfemoral amputation

-avoid prolonged hip flexion

-avoid elevation of residual limb

-limit sitting to 40 mins of each hour

-avoid hip abduction

-maintain residual limb in extension

preventive positioning for transtibial amputation

-avoid prolonged hip and knee flexion

-avoid elevation of residual limb

-limit sitting to 40 mins of each hour

-maintain residual limb in extension

-encourage prone

preventive positioning for hemiplegia

-avoid prolonged shoulder abduction and internal rotation

-avoid elbow flexion

-avoid forearm pronation/supination

-avoid wrist, finger, and thumb flexion and adduction

-avoid prolonged hip and knee flexion, hip adduction and external rotation

-avoid ankle plantar flexion and inversion

preventive positioning for rheumatoid arthritis

-avoid prolonged immobilization of involved joints

-protect bony prominences

-perform gentle exercises several times a day

preventative positioning for burns

-avoid prolonged positions of affected joints

-avoid positions of comfort

-perform gentle and frequent exercises

preventive positioning for spinal cord injury

-no bending, lifting , or twisting

-turn every 2 hours

-use 30 degree sidelying

-encourage prone

total knee replacement

-maintain extension and neutral position of knee

total hip replacement

-no adduction past neutral

-no hip rotation (toes straight up)

-no hip flexion past 90 degrees

sims position

-patient lies between supine and prone with knee flexed with a pillow under it

fowler position

patient supine with head of bed at 45 degrees

semi fowler position

patient supine with head of bed at 30 degrees

Independent transfer

patient can perform transfer without any assistance

modified independent

patient may require verbal cues or assistive device

dependent transfer

requires total physical assistance

assisted

requires assistance bewteen 25-75%

standby assistance

patient requires tactile cues from another person close to but not touching

contact guarding

caregiver has hand on patient or gait belt during transfer

min assist

patient performs more than or equal to 75%

mod assist

patient performs 50-74%

max assist

patient performs 25-49%

valsalva phenomenon

holding breath while performing physical activity

position for lifting

-neutral position of lordosis of lumbar spine

-partial to full hip and knee flexion

-contraction of core muscles

deep squat lift

-hips below knees

-feet straddling object

-arms parallel

-grasp opposite sides

-maintain vertical trunk and lumbar spine in lordosis

power lift

-half squat so hips above knees

-feet parallel and behind object

-arms parallel

-maintain neutral spine position

straight leg lift

-knees slightly bent or straight

-LE parallel or straddling object

-trunk vertical or horizontal

-neutral spine position

one leg stance (golfer stance)

-used to lift light objects

-weight shift to forward leg

-partially hip flex and knee flex on forward leg

-extend NWB leg

half kneeling lift

-kneel on 1 knee behind object

-position other leg with foot flat and knee and hip flexed 90 degrees

-place object on thigh of flexed leg

-move object close to body and begin standing

traditional lift

-face object with feet in anteroposterior position and in a deep squat

-contract flexors of elbow and shoulders

-contract extensors of legs

-hold object close to body and lift with LE

stoop lift

-partially flex hip and knee

-use legs to raise object

-feet are positioned shoulder width and in anteroposterior position