HNN112 Study Guide - Final Guide: Peripheral Artery Disease, Typhoid Fever, Sphygmomanometer
HNN112
DETERIORATING PATIENT
1
Vital sigs proide iforatio aout the oditio of a perso’s ital orgas. Vital sigs that are ithi
oral liits reflet a perso’s physiologial elleig, hereas aoral ital sigs ay e a early
warning of clinical deterioration.
Vital signs:
- Respirations
- Body temperature
- Pulse rate
- Blood pressure
- Blood oxygenation
- Pain levels
The monitoring of vital signs enables a nurse to detect deviations from normal that may indicate an
alteratio i the perso’s health status ad potetial liical deterioration.
Aoralities i respiratory rate, pulse ad lood pressure are early ues to oe’s deterioratio.
These vital signs are to be documented on an observation chart to highlight inconsistencies and recognise
hages i a pt’s vital sigs.
RESPIRATION
Respiration is the act of breathing.
Inhalation refers to the intake of air into the lungs.
Exhalation refers to breathing out or the movement of gases from the lungs to the atmosphere.
There are two types of breathing:
- Costal (thoracic): this involves the external intercostal muscles and other accessory muscles. This
can be observed by watching the movement of the chest, upward and outward.
- Diaphragmatic (abdominal): this involves the contraction and relaxation of the diaphragm and it is
observed by the movement of the abdomen, which occurs as a result of the diaphrag’s
contraction and downward movement.
VITAL SIGN
NORMAL RANGE
Respiration
12-20bpm
Oxygen Saturation
95%-100%
Heart Rate
60-100bpm
Temperature
36-38 Celsius
Systolic blood pressure
100-130 mm/Hg
Diastolic blood pressure
60-90mm/Hg
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ASSESSING RESPIRATIONS
Resting respirations should be assessed when the person is relaxed because exercise and anxiety affects
respirations.
The nurse should be aware of:
- Pt’s oral reathig patter
- Influence of their health problems on breathing
- Medications or therapies that can affect it
- Their relationship of respirations to cardiovascular functions
Breathing normally is called eupnoea, breathing abnormally slow is called bradypnoea, abnormally fast is
called tachypnoea, and absence of breathing is called apnoea.
FACTORS AFFECTING RESPIRATION
Factors that increase RR:
- Exercise
- Stress
- Increased
environmental
temperature
- Lowered oxygen
concentration
Factors that decrease RR:
- Decreased environmental temperature
- Increased intracranial pressure
- Certain medication
(narcotics)
Tidal volume is the volume of
air we take in, an adult takes in
500mL during normal
respiration. Breaths can be
described as deep or shallow
or normal.
Body position can affect the amount of air being taken in; people in supine position suppress respiration
because there is an increase in the volume of blood inside the thoracic cavity and compression of the
chest.
Certain medications can also affect respiratory depth. Such as narcotics, which depress the respiratory
centre in the brain.
RESPIRATORY INHALATION
RESPIRATORY EXHALATION
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HNN112
DETERIORATING PATIENT
3
Hyperventilation is very deep, rapid respirations.
Hypoventilation is very shallow respirations.
Laboured breathing is breathing that is with substantial effort.
A pulse oximeter can measure the amount of haemoglobin in arterial blood that is saturated with oxygen;
it provides a digital readout of a perso’s pulse rate ad oxygen saturation.
OXYGEN SATURATION
During ventilation, oxygen and carbon dioxide diffuse across the alveolar capillary membrane. These gases
diffuse from the area of high concentration to the area of low concentration.
Diffusion of these gases occurs in the alveoli (collection of air sacs surrounded by capillaries carrying
arterial blood from the right ventricle).
Oxygen is carried in the blood as either dissolved oxygen or as oxygen bound to haemoglobin in red blood
cells.
The concentration of oxygen dissolved in plasma is the partial pressure of arterial oxygen (PaO2), in
contrast, the saturation of arterial oxygen (SaO2) is a ratio of oxygen bound to haemoglobin.
Therefore, oxygenation can be measured as a correlate of the PaO2 and SaO2.
Changes in body temperature, metabolism and blood pH affect the distribution of oxygen to the tissues
A PULSE OXIMETER is a non-iasie deie that estiates a perso’s SaO2 eas of a sesor attahed
to their finger.
FACTORS AFFECTING OXYGEN SATURATION READINGS
- Haemoglobin: if the haemoglobin is fully saturated with oxygen, SpO2 (SaO2) will appear normal
even if the total haemoglobin level is low. Therefore, a person could be severely anaemic and have
inadequate oxygen supply to the tissues but the oximeter has a normal value.
- Circulation: the oximeter will not return an accurate reading if the area under the sensor has
impaired circulation, such as occurs in peripheral vascular disease or if a person is very cold.
- Activity: shivering or excessive movement of the sensor site may interfere with accurate readings.
- Dark-coloured nail polish or discolouration of the nail bed: false readings typically arise when a
person has either of these. (Discolouration can include nicotine stains or a subdermal haematoma).
- Carbon monoxide poisoning: pulse oximeters cannot discriminate between haemoglobin saturated
with carbon monoxide vs. oxygen.
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Document Summary
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