Transcript Chapter 17
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 17
Vital Signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Six Vital Signs
Blood pressure (BP)
Temperature (T)
Pulse (P)
Respiration (R)
Oxygen saturation (SpO2)
Pain
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Six Vital Signs
TPR
BP
Pulse oximetry (pulse ox) or oxygen saturation
Pain
Be sure to collect a full set of vital signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Significance of the Five Objective
Vital Signs
Reveal how certain systems are functioning
Provide data regarding patient’s overall
condition
Provide a baseline against which subtle
changes can be measured
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Significance of Vital Signs
Monitor patient’s physiological condition
Identify new problems
Determine if an intervention should be
performed
Determine if prior interventions were effective
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Priceless
Vital signs are only of value when they are
accurate!
Only a piece of the puzzle
Must assess the whole person
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Assess Vital Signs
Admission to hospital
Each visit to a clinic or emergency room
Each home health or hospice visit
Every 8 hours or according to hospital policy
According to physician’s orders
When a patient complains of feeling unusual
or different
When you suspect a change in condition
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Assess Vital Signs (cont.)
When administering medications
Before, during, and after blood product
transfusion
Before, during, and after surgical and
diagnostic procedures
Every 4 hours when one or more vital signs
are abnormal
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Assess Vital Signs (cont.)
A second time when an assessment finding is
different from the last assessment
Every 5 to 15 minutes if patient condition
unstable
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Guidelines for Assessing Vital Signs
Use an organized and systematic approach
Use the appropriate equipment for each
patient
Be familiar with normal ranges for different
ages
Compare vital signs with previous vital sign
range for that specific patient
Know the patient’s medical history, meds,
therapies
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Guidelines for Assessing Vital Signs
(cont.)
Understand and interpret the vital sign
findings
Record and communicate significant vital sign
changes to the physician and next shift nurse
Minimize environmental effects on vital signs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
When to Reassess Vital Signs
After administering IV medications
Change in level of consciousness
Unstable postoperative condition
Uncontrolled bleeding
Pale, cold, and clammy skin
Whenever you detect or suspect a change in patient
condition
Whenever a serious condition is suspected
Whenever your instinct says to reassess
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Body
Temperature
Afebrile: without fever
Febrile: fever
Hyperthermia: fever
Hypothermia: temperature below normal
Pyrexia: fever, commonly above 105°F (40.5°C)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Temperature
Body temperature
Difference between the amount of heat the body
produces and the amount of heat that is gained or
lost to the external environment
Core temperature
Temperature of the deeper structures and tissues
Normally slightly warmer than superficial body
tissue
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Temperature
Core temperature
Most important measurement to maintain
Determines the conditions brain, heart, and
internal organs to survive
Sterile thermometer probe inserted into the
pulmonary artery, heart, or urinary bladder
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermogenesis
Production of heat
Heat is produced
Digestion
Absorption
Breakdown and synthesis of proteins
Intake of food--↑metabolism--↑heat
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermogenesis
Shivering
↑ heat production four to five times normal
Exercise
↑ up to 50 times normal
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermoregulation
Hypothalamus
Elevated temp
Blood vessels dilate—blood brought to skin
surface—radiation
Sweat produced—evaporation
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Thermoregulation
Below normal temp
↑ heat production—cause muscles to shiver
Constrict blood vessels—redirect blood flow to
vital organs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Body Temperature
Environment
Time of day
Gender
Physical activity and exercise
Medications
Stress
Food or drink
Illness
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes Used for Taking
Temperature
Oral—elongated tip
Tympanic
Axillary—elongated tip
Skin—strip applied to skin
Temporal artery
Rectal—round, red tip
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
Body temperature most accurate at a site with
a good blood supply
Oral
Can not eat, drink, or smoke 15 to 30 minutes
prior to measurement
Plastic sheath
Place under tongue
Non-mercury
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oral Route
Do Not Use for
Infants
Small children
Confused
Unconscious
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
Axillary
Placed under arm in axillary site
Hold in place 5 to 8 minutes unless electronic
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Axillary Route
Must be continually held in place
Temperature may be slightly lower
Can be used on unconscious patient
Non-invasive
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
Tympanic
Infrared device
Adult—pull pinna up and back
Child <3—pull pinna down and back
Gently insert—pointing tip toward the mandible
on the opposite side of the face
Must be facing tympanic membrane
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Tympanic Route
Walls of ear canal are cooler than tympanic
membrane
Cannot be used for patients with ear
infections or after ear surgery
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
Skin
Disposable strip
Apply to clean, dry skin
Perspiration can affect reading
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
Rectal
Plastic sheath
Lubricate the tip of the thermometer
Insert 1-1½” (adult) ½ -1” (child) ½” (infant)
Leave in place 2 minutes, unless electronic
Not recommended as a route of choice due to risk
of intestinal perforation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Rectal Route
Position patient properly
Risk of body fluid exposure
Contraindications to use
Severe hemorrhoids
Rectal surgery
Immunocompromised
High risk for bleeding
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Rectal Route
Must hold in place continuously
Embarrassing—provide privacy
Clean area after removal
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Routes
Temporal artery
Special thermometer
Scans temporal artery
Press scan button—place probe on a dry forehead
and slowly move across the width of the forehead
and temple then lift off skin and touch neck just
behind the earlobe
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal Body Temperature by
Route
Oral 98.6 F (37 C)
Tympanic 98.6 F (37 C)
Rectal 99.6 F (37.5 C)
Axillary 97.6 F (36.4 C)
Range: 97° to 99.6°F or 36.1° to 37.5°C
ALWAYS document route temperature was
obtained
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fahrenheit-Celsius Conversion
Formula
C = (F – 32⁰) X 5/9
(102⁰ F – 32⁰) 70 X 5 350/9 = 38.9⁰C
F = (C X 9/5) + 32
(38.9⁰ C X 9 350.1/5 70 + 32 = 102⁰F
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Conversion Formula
°F -32/1.8 = °C
100.4°F – 32 = 68.4/1.8 = 38°C
°C x 1.8 + 32 = °F
34°C x 1.8 = 61.2 + 32 = 93.2
103.6°F
37°C
95°F
35.6°C
104°F
38.8°C
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Elevated Temperature
Natural response
Immune system functioning properly
Most physicians will not attempt to reduce
fever until it elevates above 102⁰F (38.9⁰C)
Elevations above 105⁰F (40.5⁰C) can result in
damage to body cells
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Signs and Symptoms
Flushed, warm skin
Dry mucous membranes
Glassy or droopy eyes
Increased irritability or restlessness
Photophobia
Thirst
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Signs and Symptoms
Headache or myalgia
Lethargy or drowsiness
Diaphoresis
Anorexia
Confusion, especially in children and elderly
Seizures in infants and children
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care
Assess vitals at least q2h—more often
depending upon the degree of abnormality
Provide allowed fluids—prevent
dehydration—observe for s/s of dehydration
Offer small frequent meals rather than large
meal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care
Provide mouth and skin care
Encourage limited activity and rest
Minimal coverings unless shivering
Apply cool compresses or ice packs (covered)
forehead, neck, axillae, groin
Keep gowns and linen clean and dry
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Care
Administer antipyretic medication as ordered
Salicylates
Acetaminophen
Ibuprofen
May need to provide supplemental oxygen to
meet the body’s increased metabolic needs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypothermia
Body temperature below 96⁰ F (34.4⁰ C)
Slows body metabolism
May be deliberate
Mild hypothermia
Warm blankets, clothes, ingestion of warm drinks
Cover head
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Hypothermia
More severe hypothermia
Additional measures
Heating blankets
Hot water bottles
Warmed IV fluids
Warm baths
Return to normal temperature slowly
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to
Abnormal Pulses
Bradycardia: heart rate below 60 bpm
Tachycardia: heart rate above 100 bpm
Pulse deficit: the difference between the
apical and radial pulse when the radial pulse is
slower than the apical pulse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
How many chambers in the heart?
Oxygenated blood leaves which ventricle?
Stroke volume? Cardiac output?
Pulse—arterial fluid wave palpated as a gentle
pulsing, tapping or throbbing sensation at
various points over the body
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Circulation
http://www.youtube.com/watch?v=PgI80UeAMo
http://www.youtube.com/watch?v=tBQa8IBzP
6I
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
Corresponds to the contractions or beats of
the heart
Count a pulse by the number of beats or
pulsations per minute
Central or primary pulse site?
Contraction is the strongest at the
__________ of the heart
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
Apical pulse is most accurate
Can hear both heart sounds
Information about valves and contraction of
the atria and ventricles
Unable to detect the above with peripheral
pulses
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
Listen for a full minute
Normally hear two sounds
S1 and S2
Lubb/dupp
Together the two sounds represent one
complete heartbeat
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Normal
Apical Pulse
S1: as the ventricular contraction begins, the
tricuspid and bicuspid valves (AV valves) slam
shut; the first heart sound; the longer, lowerpitched sound; the lubb of “lubb dupp”
S2: as the ventricles begin relaxation, the
pulmonary and aortic valves (semilunar
valves) close; a shorter, sharper sound; the
dupp of “lubb dupp”
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Apical Pulse
Assessing pulse rate in children <3
When radial pulse is weak or irregular
Prior to administering heart rate altering
medication
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
www.youtube.com/watch?v=xS3jX1FYG-M
www.youtube.com/watch?v=7j_LniUd2Po
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
Apical pulse = peripheral pulse
If not
Heart not pumping effectively
Blood flow not strong enough to consistently
deliver a fluid wave to the more distant pulse sites
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse
Irregular heart beat
Apical pulse rate faster than the radial pulse rate
Pulse deficit
Radial pulse is slower than the apical pulse rate
Ex. Apcial 88 Radial 82 Pulse deficit 6
Number of heart contractions to weak to produce
a fluid wave strong enough to be felt at radial site
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
Rate
60 to 100
<60 referred to as ___________________
>100 referred to as ____________________
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Pulse Rate
Age
Newborn—120-160 bpm
1-2 years—90 to 120 bpm
3-18 years—80 to 100 bpm
Adults—60 to 100 bpm
Emotions
Stimulate SNS, ↑pulse rate
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Pulse Rate
Medications—can either speed up or slow
down pulse rate
Caffeine and nicotine—speed up the rate
Exercise—speeds up the rate—well
conditioned athletes may have a pulse rate
< 60
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Pulse Rate
Meditation, rest, and sleep—lower pulse rate
Circadian rhythm—slowest predawn to dawn
and faster as the day progresses
Decreased blood volume
Hemorrhage or dehydration
Pulse rate increases
Attempt to transport oxygen to tissues faster
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
Factors affecting pulse rate
Increased fluid—fluid overload pulses full and
bounding, sometimes faster
↑ temp—heart rate ↑ (10 bpm for each degree)
As body cools—each degree slows pulse 10 bpm
Hypoxia--↑ pulse rate
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
Cardiovascular disease—varies on disease or
disorder—can increase, decrease, or cause
irregularity
↑ intracranial pressure—typically lowers the
pulse rate and may cause irregularity
Table 17-4, pg. 358
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
Rhythm
If all beats are evenly spaced—rhythm is regular
If differences in the interval lengths—rhythm is
irregular
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peripheral Pulse Sites
Temporal: used when radial not accessible
Carotid: used in cardiac arrest
Brachial: measured BP
Radial: used for pulse rate assessment
Femoral: determines leg circulation
Popliteal: determines leg circulation
Posterior tibialis: determines foot circulation
Dorsalis pedis: determines foot circulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peripheral Pulse Assessment
Strength:
Absent or 0
Weak or 1+ (may also be thready) can be
obliterated with slight pressure—lose it
Strong or 2+ easily detected—can be obliterated
with moderate pressure--normal
Bounding or 3+ very strong and full—does not
obliterate even with moderate pressure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peripheral Pulse Assessment
Equality:
Equal strength bilaterally
Weaker than opposite side
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Pulse Assessment
Non-palpable peripheral pulse
Palpate the next proximal pulse in that
extremity
If non-palpable, move to the next proximal
pulse
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Non-palpable Peripheral Pulse
Also assess
Color
Temperature
Sensation
Capillary refill
Following assessment—obtain doppler
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Term for Normal Respirations
Eupnea: evenly spaced respirations of normal
depth, between the rate of 12 and 20 breaths
per minute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Terms
Apnea: respirations cease or are absent
Bradypnea: respiratory rate below
12/minute
Tachypnea: respiratory rate above
20/minute
Dyspnea: labored or difficult breathing
Stertorous: noisy, snoring, labored
respirations that are audible without a
stethoscope
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Terms (cont.)
Hypoxemia: decreased oxygen level in
blood
Hypoxia: decreased oxygen level in
tissues
Orthopnea: difficulty breathing unless
in upright position
Stridor: an audible high-pitched crowing
sound that results from partial
obstruction of the airways
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respiration
Exchange of oxygen and carbon dioxide
Breathing in—inhalation or inspiration
Breathing out—exhalation or expiration
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
Be inconspicuous
Placement of hands
Assess radial pulse and keep same position
while counting respirations
If respirations abnormal—assess for a full
minute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors to Assess Regarding
Respiratory Rate
Rate per minute
Depth
Rhythm
Pattern
Respiratory effort
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
Rate
One inspiration + one expiration= a respiration
Observe the rise and fall of the chest
Count the number of respirations
Normal rate—12 to 20
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
Depth
Observe the amount of chest expansion with each
breath
The volume of air that is inhaled
Subjective
Shallow, normal, or deep
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
Rhythm and pattern
Regular or evenly spaced intervals between
respirations
If not evenly spaced—irregular
Discuss irregular respirations noted in Table 17-7,
pg. 362
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Pattern
Cheyne-Stokes respirations
Respirations begin shallow, gradually increase in
depth and frequency then begin to decrease in
depth and frequency until slow and shallow—
followed by a period of apnea (can last 10 to 50
seconds)
Then starts over again……
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Cheyne-Stokes Respirations
Ominous sign
Coma
Heart failure
Head injury
Drug overdose
Impending death
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Pattern
Biot’s Respirations
Respirations are faster, deeper and irregular with
periods of apnea
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Biot’s Respirations
Meningitis
Central nervous system disorders
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Respiratory Pattern
Kussmaul’s Respirations
Respirations increased in rate and depth with
long, strong, blowing or grunting exhalations
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Kussmaul’s Respirations
Diabetic ketoacidosis
Renal failure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
Respiratory effort
Amount of work required to breathe
Effortless and performed without thinking
If working hard to breathe—startled, wide-eyed,
anxious
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Respirations
Exertional dyspnea
Speaking, eating, repositioning, or ambulating
Use of accessory muscles—neck and
abdominal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Breath Sounds
Wheezes—musical, whistling—audible or
auscultation
Crackles or rales (fine or coarse)—air moving
over secretions--fluid
Rhonchi—continuous low pitched, rattling,
bubbling, snoring…
Stridor (sometimes heard without use of a
stethoscope)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Breath Sounds
www.youtube.com/watch?v=QPBZOohj2a0
http://www.easyauscultation.com/crackleslung-sounds
http://emedicine.medscape.com/article/1894
146-overview
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Blood Pressure
Diastolic pressure: measurement of the pressure
exerted by the blood on the artery walls while the
heart ventricles are not contracting (at rest); the
lower of the two pressures; the bottom number
of the BP
Systolic pressure: measurement of the pressure
exerted by the blood on the artery walls while the
heart ventricles are contracting; the highest of the
two pressures; the top number of the BP
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Abnormal
Blood Pressure
Hypertension: the systolic BP consistently over
140 mm Hg or the diastolic BP consistently
over 90 mm Hg
Hypotension: the BP suddenly falls 20 mm Hg
to 30 mm Hg below the patient’s normal BP or
falls below the low normal of 90/60 mm Hg
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Terminology Related to Abnormal
Blood Pressure (cont.)
Orthostatic hypotension or postural
hypotension: when position changes result
in a systolic pressure drop of 15 to 25 mm
Hg or the diastolic pressure falls 10 mm Hg
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Blood Pressure
Measurement of the pressure or tension of
the blood pushing against the walls of the
arteries
The amount of pressure is determined by a
combination of the following four circulatory
qualities
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Four Circulatory Qualities
Strength of the heart contraction or pumping
action of the heart
Blood viscosity or thickness
Blood volume
Peripheral vascular resistance or elastic recoil
ability of the blood vessel walls
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Factors Affecting Blood Pressure
Age, race, obesity
Exercise, rest, level of hydration
Circadian rhythm
Anxiety
Medications
Nicotine and caffeine
Hemorrhage, increased intracranial pressure
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
Systolic
Measurement of the force exerted by the blood
against the walls of the arteries during the
contraction of the heart ventricles
Diastolic
Measurement of the pressure exerted by the
blood on the artery walls while the heart is resting
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
Measured in millimeters of mercury (mm/Hg)
Written as a fraction
132/74
Systolic—132
Diastolic—74
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
Pulse pressure
Measurement of the difference between the
systolic and diastolic pressures
Subtract the smaller number from the larger
Usually 30 to 50
Pulse pressure <30 or >50 is abnormal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
Adult normal range
90/60 to 120/80
Systolic >120—pre-hypertension
Refer to Table 17-1, pg. 347
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Management
Hypertension
Systolic readings consistently >140 or diastolic
consistently >90
Medical diagnosis of hypertension
BP elevation must be documented on at least two
or more separate occasions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Equipment
Stethoscope
BP cuff—sphygmomanometer
Aneroid
Electronic pressure manometer
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Equipment
Cuff size makes a difference
Cuffs available in child, small and large adult
Correct size is necessary for an accurate
reading
Too large ________________
Too small ________________
Width should cover approx. 2/3 upper arm
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Assessment Sites
Normally upper arm with stethoscope over
the brachial artery at the antecubital site
Lower arm with stethoscope over the radial
artery
If necessary—midthigh with stethoscope over
the popliteal artery—Figure 17-4, pg. 348
Systolic may be 10 to 40 mm/Hg higher
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Korotkoff Sounds
First sound: clear, rhythmic tapping sound,
gradually increasing in intensity
Second sound: soft, swishing or murmuring
sound, representing turbulent blood flow
Third sound: sharper, crisper rhythmic sound
Fourth sound: softening or muffling of
rhythmic sound
Fifth sound: silence
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
First sound—Systolic
Point at which you last hear any sound—
documented as diastolic
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
Blood Pressure Sounds
http://www.practicalclinicalskills.com/bloodpressure-course-contents.aspx?courseid=102
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
How high to pump?
2 to 3 mm/Hg per second
Be careful—auscultatory gap
Inflate enough
Listen 10 to 15 mm/Hg after hearing last
sound
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
BP Measurement
Do not use if
Mastectomy or removal of lymph nodes
Shunt for dialysis
Casts, braces, dressings
Recent vascular surgery or trauma to area
CVA
PICC line or IV
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthostatic Hypotension
Hypotension occurring with position change
When stand from a lying or sitting position
Dizziness, lightheadedness, or faint
Mild or prolonged
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthostatic Hypotension
Normally
Stand—blood pools in legs—body senses ↓--HR
↑--blood vessels constrict to ↑BP
Possible causes—dehydration, heart disease,
diabetes, nervous system disorders, medications,
blood loss
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Orthostatic Hypotension
Lying—Sitting—Standing
Within 1 to 3 minutes
BP and pulse rate
If systolic drops 20 mm/Hg or diastolic drops
10 mm/Hg
If HR rises > 20 bpm
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Effects of Hypertension
on the Body
Gradual loss of elasticity in arterial walls
results in less stretch and recoil
Heart has to work harder to pump blood
through the cardiovascular system
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Risk Factors for Hypertension
Family history
Smoking
Chronically high stress level
Moderate to heavy alcohol consumption
Obesity
Elevated cholesterol levels in blood
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Treatment
Lifestyle changes
↓ dietary salt and fat intake
Weight loss
Smoking cessation, reduce or stop excessive
alcohol intake
Stress reduction
↑ physical activity and exercise
Medications
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Damage Caused by
Untreated Hypertension
Brain, in the form of a stroke
Heart, in the form of congestive heart failure
or myocardial infarction (heart attack)
Kidneys, resulting in kidney failure
Retinas of the eyes, resulting in loss of vision
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Saturation
Pulse oximeter
Assessment sites
Fingertip, earlobe, bridge of the nose or when
circulation adequate, the toe
Infants?
Pulse saturation—SpO2
Intermittent or continuous
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Oxygen Saturation
Assessment site
Adequate blood flow
Clean and dry—moisture interferes with accuracy
No artificial nails
No dark fingernail polish
Patient movement interferes with accuracy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Pain
to Be Assessed
Site or location
Characteristics
Constant or intermittent?
Sharp, dull, stabbing, cramping, or burning
Severity of pain using a pain scale that is
appropriate for age and comprehension
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Neuro Check
Assessing neurological system
Monitoring neurological system
Pupils—PERRL
Level of Consciousness—LOC
Verbalization
Facial symmetry
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Neuro Check
Upper extremity strength
Assess right and left side—equal in strength?
Lower extremity strength
Assess right and left side—equal in strength?
Copyright © 2011 F.A. Davis