NSB103 Note Compilation on Vital Signs, Health Assessment, and Communication

Flashcards covering key vocabulary and concepts from the lecture notes on vital signs, homeostasis, professional communication, and health assessment.

Vital Signs

Temperature, pulse, respiratory rate, and blood pressure. Additional observations include oxygen saturation, pain, level of consciousness and urine output.

Why are vital signs ‘vital’?

Indicators of cardiovascular, respiratory, nervous, and endocrine systems functioning, changes can indicate life-threatening clinical states requiring urgent intervention.

Body temperature reflects the balance between:

Heat production, heat gain, and heat loss.

Temperature Regulation: When You Get Cold

Thermoreceptors in the skin and hypothalamus detect decreased body temperature, heat-promoting center in the hypothalamus is activated. Blood vessels in the skin constrict, reducing blood flow and minimizing heat loss and shivering is triggered, generating more heat.

Common sites for Assessing Body Temperature

Oral cavity (under the tongue), axilla, rectum, ear (tympanic membrane), and forehead (temporal artery).

Respiration involves:

Movement of air into (inspiration) and out of the lungs (expiration), gas exchange in the lungs, gas transport in the blood, and gas exchange at the tissues.

Homeostatic Control of Breathing

Chemoreceptors in certain arteries and medulla oblongata detect increased CO2 (and H+ ions). Respiratory center in the medulla oblongata is activated. Increased rate and depth of breathing eliminates more CO2. Diaphragm and external intercostal muscles are used, along with accessory muscles when needed.

Assessing Respirations – What are We Looking For?

Rate (breaths per minute), depth (observing chest or abdomen movement), rhythm, and character of respirations (sound and effort).

Assessing the pulse: What are we looking for?

Rate, rhythm, and volume.

Assessing the Pulse – What are We Looking For?

Pulse rate, pulse rhythm (pattern of pulses and intervals), and pulse volume (size and duration of distension).

Systolic pressure

Maximum pressure in the arteries when the heart contracts (systole)

Diastolic pressure

Minimum pressure in the arteries when the heart is relaxed between beats (diastole)

Factors That Determine Blood Pressure

Effectiveness of the heart as a pump, ease with which blood flows through vessels, and volume of circulating blood.

Blood Pressure Regulation: When BP Rises

Baroreceptors in certain arteries above the heart detect increased stretch (due to increased blood pressure). Cardiovascular center in the medulla oblongata receives & processes information from the baroreceptors. Heart rate decreases, blood vessels widen.

Sphygmomanometry

Arterial blood pressure is measured with a sphygmomanometer and a stethoscope.

Professional Communication

Communication that promotes the best possible health care; that is person-centred.

Therapeutic Communication

Occurs when a nurse uses verbal and non-verbal communication techniques in a goal-directed way, ensuring the healthcare needs of patients remain the central focus.

Multidimensional Nursing care

Actions nurses undertake to take ‘care’ of a person; feeling ‘cared for’ - feeling safe and valued; Caring relationships – therapeutic, collaborative.

Family centred care

Recognizes that the health care of a patient happens within the context of their family.

Care of the Older Person: Primary Care

GPs and allied health professionals.

Care of the Older Person: Acute Care

Hospitals.

Care of the Older Person: Community Care

Post-acute care, including hospital in the home.

Care of the Older Person: Residential Aged Care Facilities

Encompassing both low-level and high-level care.

Health Issues Experienced by Older Adults: Impaired cognition

delirium, dementia, depression.

Multidimensional Nursing Care

actions nurses undertake to take ‘care’ of a person; feeling ‘cared for’ feeling safe and valued; Caring relationships therapeutic, collaborative

Multidimensional Nursing Care

Actions nurses undertake to take ‘care’ of a person; feeling ‘cared for’ feeling safe and valued; Caring relationships therapeutic, collaborative

Aged Care Quality Standards highlight:

Consumer dignity and choice; ongoing assessment and planning with consumers; and personal care and clinical care.

Factors facilitative of PCC (Person-Centered Care )

Skilled, knowledgeable and enthusiastic staff with good communication skills. Opportunities for involvement of client, carer, and family. Opportunities for staff to reflect on their own values and beliefs

Domains of health assessment

Medical health, Physical function, Psychological function, and Social function

Sources of assessment information

Patients/clients (self-report). Others who know the patient well (informant report). Observing the patient undertaking various activities of daily living (direct observation).

ABS Survey of Definition of Disability

Loss of sight not corrected by glasses or contact lenses; Loss of hearing when communication is restricted; Speech difficulties.

Social Mechanisms of Disability

Spoken language, body language, social interaction, values and beliefs, power relationships, and culture.

Physiological Mechanisms of Disability

Congenital disorders, Trauma, Chronic diseases, and Ageing.

Psychological Mechanisms of Disability

Nervous or emotional conditions causing restrictions in everyday activities; a mental illness for which help or supervision is required; and a brain injury, including stroke.

Critical characteristics of PCC ( Person-Centered Care )

Understanding the patient as a unique person presenting with individual characteristics, needs, values, beliefs, and preferences.

Stages of the Interview Process: The Joining Stage

Introduction to the interview; nurse and patient establish trust; and nurse and patient get to know each other.

Stages of the Interview Process: The Working Stage

Bulk of patient data is collected; ensure the person knows why you are collecting the data.

Stages of the Interview Process: The Termination Stage

Information is summarised and validated; look at options or next steps.

Planning for the Patient Health Interview

Gather all available patient information; Seek appropriate setting for the interview; Set aside sufficient time for the interview; and Ensure emotional readiness to undertake interview.

The Complete Health History Assessment Tool

Source and reliability of information; patient profile; Reason for seeking health care; present health and history of present illness; past health history (PHH); family health history (FHH); and Social history.

Past Health History (PHH)

Communicable Diseases/Injuries/accidents/Chronic illnesses/Serious episodic illness.

Family Health History

Records the health status of the patient and their immediate blood relatives. Ideally grandparents, aunts, and uncles should also be incorporated.

Gathering Social Information

Explain reason for gathering social information; establish rapport first; and maintain eye contact.

Cultural Implications of Holistic Health Assessment

Bilingualism, Multiculturalism, Cultural identity.

Concluding the Health History (Terminating Phase)

Explain the next step in the assessment and when to expect it; thank the patient; and ask the patient about additional information to discuss.

General Survey

Head-to-toe (cephalocaudal) approach. sign and symptom-related questions and disease-related questions. Document positive and pertinent negative findings.

Documentation

Legal record of patient encounter; may be used by many professionals, and is a mechanism of communication; document in a professional and legally acceptable manner.

Thinking Like a Nurse Involves:

Logic, intuition, rationality, creativity, assessment, evaluation, reflection.

Critical Thinking Definition

The intellectually disciplined process of actively and skilfully conceptualising, applying, analysing, synthesising, and/ or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action.

Clinical Reasoning Cycle

A visual framework for clinical decision-making and An 8-stage process in 4 phases: Assess, Plan, Implement and Evaluate.

Summary of Clinical Reasoning

Clinical reasoning is a cyclical process involving assessment, planning, implementation, and evaluation.

Mechanisms of Disability

Physiological, psychological, and social mechanisms

Physiological Mechanisms of Disability

Congenital disorders (occur prenatally or during birth) or Trauma (the leading cause of disability).

Ageing Mechanisms of Disability

Normal ageing e.g. sensory impairments or reduced cardiac output and increased systolic BP, loss of balance, decreased muscle mass and strength- restricting physical activity.

The Older Adult in Australia

Number of older adults in Australia is rapidly increasing and predicted to increase in coming years.

Ageing Related Changes

Structural and physiological changes are normal parts of the ageing process, but should not be generalised as routine.

Some changes can indicate underlying:

Systemic or localized disease.

Health issues experienced by older adults

Includes impaired cognition, falls or urinary incontinence

Neurological System Changes

Myelin sheath of nerves degenerates, decreasing neurotransmitter production in neurons.

Cognitive Changes with Ageing

Decline in mental flexibility, abstract thinking, and recall.

Cardiovascular System Changes

Size of cardiac muscle decreases, decreased cardiac output or calcifications and fibrosis of cardiac valves.

Respiratory System Changes

Musculoskeletal changes of the chest limit chest wall expansion, and the diaphragm flattens.

Genitourinary and Renal Systems Changes

Kidney shrinkage or glomerular filtration rate decreases.

Gastrointestinal System Changes

Decreased salivary secretions, decreased number of taste buds or decreased peristalsis.

Female Reproductive System Changes

Adipose tissue of the breast atrophies, Diminished breast tissue, or Pendulous and sagging breasts.

Male Reproductive System Changes

Testicular degeneration,Decreased sperm count, Prostrate enlargement.

Musculoskeletal System Changes

Decreased bone density, Decreased muscle mass and strength or Bone demineralisation.

Integumentary System Changes

Integumentary System Changes Skin colour spotty pigmentation in areas exposed to the sun pallor, dry, scaly skin, cooler extremities, decreased perspiration

Other Physiological Changes

Impaired facial symmetry due to loss of teeth, decreased visual acuity or sense of smell declines.

Objective assessment data

Physical data observable through senses.

Subjective assessment data

Information from the patient/carer. How they are feeling, symptoms, or concerns.

Abnormal assessment data

Deviates from normal and outside normal vital sign ranges.

Acute patient deterioration

Physiological changes, cognition, and mental state changes.

The General Survey

Ascertaining your impression of the person and includes general health state and obvious physical characteristics.

The General Survey: Physical Status Data

Includes general health state and obvious physical characteristics and forms the first part of objective data collection.

The Primary Survey

Systematic assessment of a patient. Assessing for injuries or medical conditions.

Core Physical Assessment

The correct primary survey and core assessment is arranged in a specific order of performance.

Normal Blood Pressure

Adult: 120-129/80-84mmHg or Older Adult Not more 140-145/90mmHg

Normal Heart Rate (bpm)

Adult: 60-100 bpm (average 72); or Older Adult 60-100 bpm (average 70):

Abnormal (Tachycardic)

Adult: >100 bpm (average 72); or Older Adult: >100 bpm (average 70):

Abormal (Bradycardic)

Adult: 60-100 bpm (average 72); or Older Adult 60-100 bpm (average 70):

Normal Respiration Rate

Adult: 12-20 respirations per min; or Older Adult: 15-20 respirations per min

Queensland Adult Deterioration Detection System (Q-ADDS)

Respiratory Rate, O2 Saturation, Oxygen Delivery Method, Blood Pressure, Heart Rate, Temperature or Consciousness

Queensland Adult Deterioration Detection System (Q-ADDS)

A scoring system used to detect patient deterioration.

Abnormalities of the Neurological System Classified as

Vascular disorders, Infections, Structural disorders, Functional disorders, Degeneration, Cancers or Injuries to spinal cord and brain

Additional Pathology testing

Arterial blood gases Blood pH (7.35-7.45) and Haemoglobin and haematocrit

QUT acknowledges the Turrbal and Yugara people as the:

First Nations owners of the lands where QUT stands.

Clinical assessment

The primary survey forms the basis of clinical assessment in every patient encounter.

Primary surveys

Used to rapidly identify potential or actual life threats that require immediate intervention.

Danger

Prioritize safety and be aware of potential hazards before approaching the patient.

Airway

Assessing and managing the patient's airway.

AVPU Scale

A - Awake (Patient is awake; V - Verbal (Patient responds to a verbal stimulus; P - Pain (Patient responds to a pain stimulus and U - Unresponsive

Exposure

Expose the patient to assess for any obvious injuries or conditions, while also preventing heat loss.

Why Children Are Different, What are some key features of Paediatric Assessment?

Response to illness differs from adults and absolute size and relative body proportions change with age.

Rapid assessment of the Pediatric patient is defined by?

Pediatric Triangle Airway; Breathing; and Circulation.

Paediatric Vital Signs : Pulse

Apex beat, use stethoscope, Palpation difficulty depends on age (brachial or femoral in young children).

Paediatric Vital Signs: Blood Pressure

Age-dependent or it may indicate that hypotension being a late sign.

Refill assessment

Child refill < 2 seconds and Reflected to cardiac perfusion, delivery of oxygen and nutrients like glucose.

Child :Circulating Blood Volume

80 ml/kg

Difference with Circulating Blood Volume from Adult/Child

Infants :Compensatory Methods are less effective ,90 ml/kg or Adult: -Compensatory Mechanisms with Decreased Circulating Blood Volume or Rapid Heart Rate= 70 ml/kg