Transcript Document
VITAL SIGNS GUIDELINES FOR MEASURING VITAL SIGNS Establish a baseline for future assessments. Be able to understand and interpret values. Appropriately delegate measurement. Communicate findings. Ensure equipment is in working order. Accurately document findings. CIRCULATORY NEEDS Circulation is monitored through assessment of Vital Signs along with other collected data. The patient’s physiological status is reflected by their vital signs. VITAL SIGNS:TPR AND BP Signs of Vitality and Life Deviations from normal ranges can indicate in health status. TPR & BP = VS T-temperature P-pulse R-respirations BP- blood pressure VS-vital signs CNS REGULATES VS Hypothalamus: Controls temperature Anterior Hypothalamus Dissipation of heat Posterior Hypothalamusconservation of heat Medulla: Vasomotor center controls BP through vasoconstriction or vasodilation Cardiac center controls pulse Respiratory center controls respirations (rate and depth) RELATIONSHIP BETWEEN VS R = 1/4 P R 20 = P 80 P = diastolic BP P 80 = 120/80 T increases = an increase in P R and BP FACTORS INFLUENCING VS Age Gender Race Diet Weight Heredity Medications Activity MORE FACTORS INFLUENCING VS Pain Hormones Stress Emotions Circadian Rhythms GUIDELINES FOR ASSESSING VS Systematic Normal Range Baseline Recheck Client Norm Treatments Monitor prn HEAT PRODUCTION By product of metabolism B.M.R.- Basal Metabolic Rate Muscle activity Exposure to increased temperature Hormones: Thyroxine, Epinephrine HEAT LOSS (TRANSFER) Conduction - direct transfer of heat by contact HEAT LOSS-CONVECTION Heat dissemination via motion. A fan blows warm air across a warm body. HEAT LOSS-RADIATION Heat given off by rays from the body. Heat loss from an uncovered head. Main form of heat loss. HEAT LOSS-EVAPORATION Conversion of a liquid to a vapor. Perspiration vaporizes from the skin. Diaphoresis ????WHAT ARE SOME OTHER WAYS HEAT IS LOST FROM BODY??? URINE FECES RESPIRATIONS FEVER FEVER PATTERNS Intermittent Remittent Constant Relapsing ?? FEVER TERMINOLOGY ?? WHICH TERM CAN BE USED TO DESCRIBE A FEVER THAT: Is constantly elevated with little fluctuation CONSTANT Fluctuates but does not come down to normal REMITTANT Returns to normal for a day or two, but then goes up again RELAPSING Alternates between normal and fever INTERMITTANT S/S OF FEVER Loss of appetite Headache Dehydration Delirium Seizures Thirst face ????? Rapid pulse Decreased urinary output (OLIGURIA) Flushed TEMPERATURE RANGES Oral- 96.8 – 100.4 F 98.6 = average norm Axillary- approximately 1 degree lower Rectal- approximately 1 degree higher ASSESSING TEMPERATURE Glass Electronic Tympanic Tape/Patch Disposable (ie: Clinidot) ORAL TEMPERATURE Most common site Place against sublingual artery Contraindicated in oral surgery/infection Wait 15 min. if pt. ate/drank smoked Electronic- blue probe or AXILLARY TEMPERATURE Preferred for children under 6 yrs. routinely used on infants. Place in center of axilla against artery off the subclavian. RECTAL TEMPERATURE Last resort for assessing temperature Place against inferior rectal artery Contraindicated rectal surgery/cardiac pt. Lubricate thermometers (CONTINUED) RECTAL TEMPERATURE Electronic thermometers: Red Probe only Insert : ½ - 1 inch adult ¼ - 1/2 inch child Left position is best ??? NURSING DIAGNOSES ??? HYPERTHERMIA HYPOTHERMIA RISK FOR IMBALANCED BODY TEMPERATURE NURSING INTERVENTIONS TEMPERATURE Check VS frequently Assess skin Note change in LOC Seizure precautions ? Monitor I & O REDUCE COVERINGS Encourage fluids Tepid baths Administer antipyretics Promote comfort & REST Hypothermia blanket NURSING INTERVENTIONS TEMPERATURE Check Assess Note VS frequently skin change in LOC Seizure Monitor precautions ? I&O REDUCE COVERINGS HYPOTHERMIA Mild (93.2 – 96.8 F) Moderate Severe (86.0-93.2 F) ( below 86.0 F) EVALUATIONS-TEMPERATURE Is patient afebrile? Are interventions working? i.e. cool compresses, tepid bath, antipyretics? S/S of infection present? Nurse’s Notes 5/31/02 4:15pm Reports headache, feeling “on fire”, face flushed, skin warm, T-104.6 A P-100 R- 20 BP- 150/80. Dr. Arrid notified. Tylenol 650mg po administered as per telephone order. Fluids encouraged, tepid bath given. S.Niggemeier RN---------------------------4:45pm T-102.2 A P- 88 R-18 BP 130/78 taking fluids, feels “better than before”. S.Niggemeier RN----------------------------- PULSE-PHYSIOLOGY SA node- creates electrical impulses causing contraction of atria. A wave of blood is pumped into the arteries. Throbbing sensation is felt - Pulse Pulse rate should = the heart rate Pulse rate is the number of pulsations felt in a minute. Pulse usually = diastolic pressure PULSE RATES Newborn 120-150 Infant 80-140 Child 75-110 Adult 60-100 Pulse rates ????? as age increases CARDIAC OUTPUT CO=SV X HR Cardiac output (CO) is the amount of blood pumped/min by the heart and = approximately 5000ml or 5L/min Stroke Volume (SV) is the amount of blood ejected from the L ventricle with each contraction. Heart rate (HR) is the number of times the heart contracts. Inversely relatedwhen SV goes up the HR goes down. ?? CARDIAC OUTPUT ?? CV (5000) = SV(70) X HR In the above equation, what would the client’s heart rate be? APPROXIMATELY 71 BPM If a client had a weak heart (ie:CHF) that was only able to eject a SV of 50, what would happen to the client’s HR? IT WOULD RAISE TO 100 BPM If a client had a well-conditioned heart muscle (ie: athlete) that was able to eject a SV of 100, what would their HR be? IT WOULD DECREASE TO 50 BPM PULSE SITES Temporal Carotid Apical Brachial Radial Femoral Popliteal Dorsalis Pedis Posterior Tibia PULSE ASSESSMENT Rate -number of beats /min Rhythm- pattern of the rate. Regular or Irregular. Count irregular rhythm for 1 min. Quality- strength of the pulse 0-4+ PULSE - QUALITY SCALE 4+ bounding very strong, does not disappear with moderate pressure 3+ normal, easily felt, 2+ weak, light pressure causes it to disappear 1+ thready, not easily felt, disappears with slight pressure 0- no pulse ??? NURSING DIAGNOSES Decreased cardiac output Ineffective tissue perfusion Activity intolerance NURSING INTERVENTIONS-PULSE Monitor Note for symmetry pulse deficit Promote circulation – i.e. massage EVALUATIONS Is pulse with normal range? All pulses present Equally Are Bilateral? interventions to promote circulation working? i.e. massage TERMINOLOGY Bradycardia- HR below 60/min Tachycardia- HR above 100/min Sinus Arrhythmia- HR increases on inspiration and decreases on exhalation common in children and young adults TERMINOLOGY Dysrhythmia- abnormal rhythm Palpitation-aware of your HR without feeling for it…usually rapid Pulse deficit- difference between apical and radial pulses Apical-100 Radial-80 then the Pulse deficit is 20 PULSE DOCUMENTATION 23/11/2010 1:20am : palpitations. P-96 reg 3+. No pulse deficit.------------------S.Niggemeier RN RESPIRATIONS PHYSIOLOGY Process whereby CO2 and O2 are exchanged in the tissues. Oxygenation of the body CO2 is the stimulus for breathing Inspiration - breathing in Diaphragm contracts – pulls down Expiration- breathing out Diaphragm relaxes – moves up Normal Tidal Volume = 500 ml RESPIRATION RATES Newborn 40-60/min Child 20-30 School age 18-26 Adult 16-20 Respirations decrease as age increases ASSESSING RESPIRATORY STATUS Oxygenation status Neurological state Musculoskeletal status OXYGENATION STATUS Note S/S of hypoxia (oxygen deprivation Cyanosis - bluish tinge caused by decrease in O2 in RBC. Cyanosis is assessed by checking the mucous membranes of the conjunctiva (lower eyelids), under the tongue and inside the mouth..should be pink not pale or bluish ??OTHER SIGNS OF DYSPNEA?? ANXIOUS LOOK FLARED NOSTRILS USE OF ACCESSORY MUSCLES INTERCOSTAL RETRACTIONS NEUROLOGICAL STATE Hypoxia results in neurological changes alert becomes anxious then irritable progresses to drowsiness eventually a coma MUSCULOSKELETAL STATUS Abnormalities that prevent the thorax from expanding result in hindered respirations Scoliosis Lordosis Pectus excavatum Kyphosis Pectus carinatum RESPIRATORY ASSESSMENT Rate- number of breaths/min Rhythm - even, Quality- deep, labored shallow PULSE OXIMETRY Indirect measurement of arterial oxygen saturation of hemoglobin 95% - 100% normal range Below 90% = hypoxia Factors that interfere with accurate measurement: dark nail polish, anemia,vasoconstriction (PVD, hypothermia), carbon monoxide poisoning, movement, excessive background light, tight probe ?? NURSING DIAGNOSES?? Impaired gas exchange Ineffective airway clearance Ineffective breathing pattern Risk for aspiration RESPIRATORY CONSIDERATIONS Age Meds Gender Neurological Pain Illnesses Anxiety Impaired Smoking Body Position injury O2 carrying capacity of the blood eg. anemia NURSING INTERVENTIONSRESPIRATIONS Elevate HOB (head of the bed) Promote calm atmosphere Administer oxygen as needed Relaxation techniques EVALUATION- RESPIRATORY Rate within normal range? SOB? Dyspnea? Breathing less labored? Less cyanotic? TERMINOLOGY Apnea Adventitious sounds Rales/crackles Gurgles /rhonchi Stertor Wheeze Cheyne-Stokes TERMINOLOGY Bradypnea Dyspnea Hyperinflation Hypoxia Orthopnea Tachypnea Documentation 5/30/02 Reports dyspnea. R = 24, labored , shallow. HOB elevated. Dry crackles auscultated bilaterally. Dr. C. Stokes notified. O2 2L via NC applied. S. Niggemeier RN------------------------ BLOOD PRESSURE -PHYSIOLOGY Blood pressure is the force against the arterial walls. Maximum BP is achieved when the Left ventricle contracts - Systolic pressure Lowest BP is when the heart rests - Diastolic pressure Pulse pressure is the difference between the Systolic and Diastolic pressures BP 140/90 PP (pulse pressure) = 50 Maintaining and Regulating Blood Pressure Peripheral Resistance Pumping Action of heart (Cardiac Output) Blood volume Viscosity of blood Elasticity of vessel walls Hormonal factors: renin, aldosterone HYPERTENSION Elevated BP above normal for sustained time Unknown cause primary or essential hypertension Known causesecondary hypertension 3 or more elevated readings to confirm DX HYPERTENSION Normal Blood Pressure < 120/80 Stage 1 Systolic 140-159 Diastolic 90-99 Prehypertension Systolic 120-139 Diastolic 80-89 Stage 2 Systolic >160 Diastolic >100 HYPOTENSION Low BP - systolic of 90 or below Can be drug induced or illness related (MI, burns, blood loss) Orthostatic (Postural) Hypotension –drop in BP when rising to an erect position, common after periods of bed rest TERMINOLOGY Auscultatory Gap Diastolic Korotkoff sounds Pulse Pressure Systolic DIRECT BP MEASUREMENT Measure BP by means of inserting a catheter (arterial line) into an artery and measure by machine Used in critical care INDIRECT BP MEASUREMENT Auscultating with stethoscope and sphygmomanometer Palpating- feeling for an estimated systolic Doppler amplifies Korotkoff sounds Electronic meters- monitor BP with no need for stethoscope SPHYGMOMANOMETERS Aneroid-measures mmHg on calibrated dial Mercury - measures mmHg via mercury filled cylinder (no longer used due to mercury hazardous material) CUFF SIZES STETHOSCOPE USE Vary in size Use either bell or Must use diaphragm to appropriate size for auscultate sounds pt. Make sure ear tips Pedi cuff, small, block out noise medium, large etc.. Clean after each Thigh cuffs use with alcohol pads AUGMENT KOROTKOFF SOUNDS Raise arm over head for 15 sec prior to retaking BP Have pt. open/close hands - empties veins Pump bulb up quickly Wait 30-60 sec between readings Don’t reinflate cuff once air is being released it muffles sounds BRACHIAL Use either arm Preferred site Easy access POPLITEAL Use either thigh Less preferred Difficult to access Systolic pressure will be 10-40 mmHg higher than brachial BP BY PALPATION Cuff is inflated 30mmHg above the point where pulse is no longer palpated. Release cuff and as air is releasing feel for return of pulse …that is the systolic No stethoscope is used. No diastolic pressure can be assessed NURSING INTERVENTIONS- BLOOD PRESSURE Be seated, feet flat, arm at heart level Monitor BP trends Pt not to smoke or drink caffeine 30 min prior to measurement Rest for 5 min before measurement Administer antihypertensives as ordered Teaching - i.e. diet, exercise, stress, etc. EVALUATION –BLOOD PRESSURE B/P within normal range? C/O headaches or other s/s Teachings regarding diet, weight, exercise, stress etc being followed? WHAT AFFECTS BLOOD PRESSURE? Age Circadian rhythms Stress Ethnicity Gender Meds Exercise TERMINOLOGY A/R- apical radial FUO - fever unknown origin PP -pulse pressure SOB - short of breath VS- vital signs ?? DOCUMENTATION OF VS ?? On what type of chart form are vital signs usually documented? GRAPHIC FLOW SHEET