Transcript NUR103ModC

VITAL SIGNS
Module C
What are Vital Signs?
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Temperature
Pulse
Respirations
Blood Pressure
Pain (considered the 5th vital sign)
When to measure vital signs?
• On admission to health care facility
• In a hospital on regular hosp schedule or as
MD ordered (q8hours, q4 hours, etc)
• Before and after procedures (surgery,
invasive diagnostic procedures)
• Before, during, and after blood transfusions
• When patient’s general condition changes
(nursing judgment)
GUIDELINES FOR
ASSESSMENT
• Taken by nurse giving care
• Equipment should be in good
condition
• Know baseline VS and normal
range for pt and age group
• Know pt’s medical history
• Minimize environmental factors
GUIDELINES CONTINUED
• Be organized in approach
• Increase frequency of VS as
condition worsens
• Compare VS readings with the
whole picture
• Record accurately
• Describe any abnormal VS
VS MUST BE ACCURATE
• Both measuring and recording
• VS vary according to pt’s
illness/condition
• Compare results with pt’s normal
• Results are used to determine
treatments, medications,
diagnostic work, etc
REPORTING ABNORMAL VS
• WHEN—grossly abnormal, return to
normal, noted change for that pt
• WHY—indicates change in metabolism or
physiological function within the body
• WHO—student reports to instructor, then
TL, RN, Dr (follow chain of command)
• HOW—orally to appropriate person, then
document on chart
Body Temperature
• Difference between heat produced by body
processes and the heat lost to the external
environment
• Range 96.8 – 100.4 F (36 – 38 degree C)
• Average for healthy young adults 98.6F or
37degrees C
• No single temp is normal for all people
HEAT IS PRODUCED BY:
• Metabolism
• Increased muscle
activity
• Vasoconstriction
• External sources
HEAT IS LOST BY:
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Vasodilation
Convection
Radiation
Conduction
Evaporization
TEMP or FEVER?
• TEMPERATURE—the
measurement of heat in
the body
• FEVER—the
measurement of heat in
the body that is above
normal for the individual
TYPES OF THERMOMETERS
READING A THERMOMETER
Normal Range Throughout Life
Cycle
• Adults- 96.8- 100.4
degree F
• Adult Avg 98.6 F Oral
• Adult Avg 99.5 F
Rectal
• Adult Avg 97.7 F Ax
• Newborn range –
95.9- 99.5F
• Infants and children –
same as adults
• Elderly – Avg 96.8F
Frequently used terms:
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Pyrexia or fever
Febrile
Hyperthermia
Hypothermia
Afebrile
FEVER—A DEFENSE
MECHANISM
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Indicator of disease in body
Pathogens release toxins
Toxins affect hypothalamus
Temperature is increased
Rest decreases metabolism and
heat production by the body
PATTERNS OF FEVER
• SUSTAINED- remains above normal with little
change
• RELAPSING – periods of febrile episodes
interspersed with acceptable temp values
• INTERMITTENT—varies from normal to
above normal to below normal (may have a
fairly predictable pattern)
• REMITTENT—fever spikes and falls w/o a
return to normal temp values
Factors Affecting Body Temp
• Age ( newborn- temp
control mechanism
immature, elderlysensitive to temp changes)
• Exercise
• Hormonal level
• Circadian rhythm (temp
normally changes 0.9 to
1.8 degree F /24hr Lowest
1-4AM Max-6PM )
• Stress
• Environment
ORAL TEMPERATURE
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Accessible
Dependable
Accurate
Convenient
RECTAL TEMPERATURE
• Most reliable
• MUST hold
thermometer
in place
AXILLARY
TEMPERATURE
• Safe
• Non-invasive
• Least
accurate
TYMPANIC
TEMPERATURE
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Non-invasive
Safe
Accurate
Disadvantages
– Excessive
cerumen
– Improper
technique
AXILLARY TEMPERATURE
IMPORTANT POINTS
• AXILLA MUST HAVE
ADEQUATE TISSUE &
BE FREE OF
PERSPIRATION
• Not good method for
persons with elevated
temp
• Used when cannot get
oral or tympanic
• Leave in place 10
minutes
ORAL TEMPERATURES
• Wait 15-30 minutes
after eating,
drinking, chewing
gum or smoking
• If mouth breather-do
not take orally
• Leave in place 2 – 4
minutes with glass
thermometer
TYMPANIC TEMPERATURES
• Oral & tympanic readings
will be same/ similar
• Must direct probe toward
TM (eardrum)
• Follow instructions
• Keep plugged in and on
charger when not in use
• Usually preferred method
• Adults –pull pinna of ear
up & back
• Children under 3y/o-pull
pinna of ear down & back
RECTAL TEMPERATURES
• MOST accurate
• MUST hold
thermometer in place
• Very high temp
• Unconscious
• Do not take rectal temp
on clients with heart
conditions
• Leave in place 2-3 min
with glass thermometer
• Lubricate thermometer
• DO Not take hand from
thermometer while
rectal in progress
NURSING DIAGNOSIS
Hyperthermia>
100.4F
Hypothermia
<96.8F
Risk for altered
body temperature
Ineffective
Thermoregulation
Temperature Conversion
• Temperature can be measured in Fahrenheit
(F) or centigrade or Celsius (c)
• To convert F to c, subtract 32 from F
reading and multiply times 5/9. Ex.
(104 F – 32) x 5/9 = 40 degree c
• To convert c to F, multiply the c reading by
9/5 and add 32 to the product. Example
(40 x 9/5) + 32 =104 F
Pulse
• Pulse- is the palpable bounding of the blood
noted at various points on the body. It is an
indicator of circulatory status.
TERMS RELATED TO PULSE
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Pulse—Rate, Rhythm, Quality
Pulse Deficit
Auscultate
Palpate
Tachycardia, Bradycardia
Pulse Sites
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Temporal
Carotid
Apical
Brachial
Dorsalsis Pedis
(Pedal)
• Radial and Apical are
most common pulse
sites used!
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Radial
Ulnar
Femoral
Popliteal
Posterior Tibial
PULSE RANGES
AGE
RANGE
ELDERLY (65+)
60-100
AVERAGE ADULT
60-100 (50 or below if
extremely athletic)
NEWBORN
0-24 HOURS
INFANT
1 MONTH – 1 YEAR
CHILDREN
120-160
100-120
(varies with age)
TECHNIQUE
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Feel over BONY area
DO NOT use thumb
Use 2-3 fingers
DO NOT squeeze
Count 30 seconds if regular
x2
• Note Rate, Rhythm, Quality
• If irregular, count for 1 full
minute or take apical pulse
for 1 minute.
APICAL-RADIAL PULSE
• Requires 2 nurses
• 1 nurse counts apical
heart rate
• 1 nurse counts radial
pulse
• BOTH count during
the same 60 seconds
• 1 nurse acts as
timekeeper for both
nurses
PULSE DEFICIT
• Count apical-radial pulse
• The difference is the PULSE DEFICIT
• Apical pulse will always be the same or
higher than the radial pulse if both are
counted correctly
• If the radial pulse is higher, one or both
nurses counted incorrectly
Factors Affecting Pulse Rates
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Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural Changes
Pulmonary Conditions
Variations of Pulse Rates
• Tachycardia – Abnormally elevated pulse
rate. (above 100 beats/ min)
• Bradycardia – Abnormally slow pulse rate
(less than 60 beats / min)
Pulse Rhythm
• Regular – A regular interval of time occurs
between each heartbeat or pulse felt.
• Irregular – Interval interrupted by early,
late, or missed beat.
Strength and Quality of Pulse
• Pulse strength may be described as weak, strong,
bounding, or thready.
• PULSE GRADING (0-4 rating scale)
• 0 – absent, not palpable
• 1+ - diminished, barely palpable
• 2+- easily palpable, normal pulse
• 3+ - full, increased strength
• 4+ - bounding, cannot be obliterated
Respirations
• Mechanism the body uses to exchange
gases between the atmosphere, blood, and
the cells. Involves three processes:
• Ventilation
• Diffusion
• Perfusion
PROCESS OF RESPIRATION
• EXTERNAL RESPIRATION
– Inhaled air enters lungs, at alveoli O2 crosses over
to bloodstream
– CO2 and other wastes cross over from
bloodstream to alveoli and are exhaled
• INTERNAL RESPIRATION
– O2 carried in bloodstream crosses over to body
cells
– CO2 and other wastes from body cells cross over
to the bloodstream
RESPIRATION
• Chest Cavity—airtight vacuum with
negative pressure
• INSPIRATION—diaphragm contracts
and pulls down, ribs move up, lungs fill
with air
• EXPIRATION—diaphragm relaxes and
moves up, ribs move down, lungs
expel air
NORMAL RESPIRATION RANGE
AGE
RANGE
ELDERLY (65+)
12-20
AVERAGE ADULT
12-20
NEWBORN
30-60
0-24 HOURS
INFANT
30-50
1 MONTH – 6 Months
CHILDREN
(varies with
age)
COUNTING RESPIRATIONS
• Count pulse first, then
count respirations while
holding wrist
• Note rate, rhythm,
quality, and character
• Observe a full
inspiration and
expiration
• Respiratory rates below
12 or greater than 20
require further
assessment.
Counting Respirations cont.
• If respirations regular, count respirations for 30
seconds and multiply times 2.
• If irregular, less than 12 or greater than 20, count
for 1 full minute.
• Quality of respirations- assess movement of chest
or abdominal wall- deep, normal, shallow
• Deep- full expansion of lungs
• Normal- normal
• Shallow- limited expansion of lungs
Factors Influencing
Characteristics of Respirations
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Exercise
Acute Pain
Anxiety
Smoking
Body position
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Medications
Neurological injury
Age
Environmental Temp
Hemoglobin Function
Blood Pressure
• Force exerted on the walls of the artery. Created
by the pulsing blood under pressure of the heart.
• Systolic- Peak and maximum pressure of ejection
of blood from the heart into the aorta. This is the
top number.
• Diastolic- The minimal pressure remaining the
heart when the heart relaxes. This is the bottom
number.
• Recorded as a ratio Ex. 120/80
• Pulse pressure- Difference between the systolic
and diastolic. ( 120/80 – Pulse pressure 40)
EQUIPMENT FOR BP
“DOPPLER” OR ELECTRONIC
BP READINGS
ALTERNATIVE SITES
MEASURING BP
MEASURING BLOOD
PRESSURE
• Cuff must be appropriate
size
• Cuff should be snug, not
loose
• Do not put stethoscope
under cuff ( place cuff 1-2
inches above elbow)
• Make mental note of
systolic and diastolic
numbers
MEASURING BP CONT’D
• If unsure of reading,
wait 30 seconds and
recheck-if unsure,
have someone else
check with you
• Loosen cuff even if to
be checked q 15
minutes
• Make sure all air is out
cuff before applying
MEASURING BP
• False high if cuff too
small, false low if cuff is
too loose
• Auscultatory gaptemporary disappearance
of sound between first
sound and next sound.
• Don’t take BP on arm with
IV, sling, surgery,
mastectomy, renal dialysis
shunt, etc.
MEASURING BP CONT’D
• Pt should be sitting or
lying with arm at the
level of the heart
• Distinguish Korotkoff
sounds (sounds heard
when taking BP) from
artifact
ASSESSMENT OF BP IN
BOTH ARMS
• Heart disease
• 1st time BP
• 5-10 mm Hg
difference-use reading
that is highest
• Difference of 10mm
Hg should be reported
HOW and WHY BP TAKEN BY
PALPATION
• HOW-apply cuff over
brachial artery
• Pump up to 20-30 points
above last systolic reading
• Feel with 2 fingers for
systolic pressure; will not
feel diastolic pressure
• WHY- unable to hear
weak BPs
FACTORS AFFECTING BP
• Exercise-increases
• Arteriosclerosis (loss
of vessel elasticity) &
Atherosclerosis (build
up of plaque)increases
• Transfusionsincreases
• Emotions -increases
FACTORS CONT’D
• Drugs
• Medications
• Diurnal variations
FACTORS CONT’D
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PAIN-increases
Hemorrhage –decrease
Sex/Gender
RACE-Blacks more prone
increase
• Age
• Heredity-increased chance
if immediate family
history
Alterations in Blood Pressure
• Hypertension – most common alteration in
BP. Most often asymptomatic.
Characterized by persistently elevated BP.
Noted when diastolic is greater than 90
mm/Hg and systolic is greater than
140mm/Hg. Optimal BP for 18 y/o and
older is less than 120/80mm/Hg.
Alterations In BP cont
• Hypotension- When systolic blood pressure
falls to 90 or below.
• Orthostatic (Postural) Hypotension- Occurs
when a normotensive person develops
symptoms and low blood pressure when
rising to an upright position.
Common Mistakes in Blood
Pressure Assessments
• Cuff too wide or too
narrow
• Cuff wrapped too
loose or unevenly
• Inflating cuff too
slowly
• Deflating cuff too
slowly or too quickly
• Arm above or below heart
level or not supported
• Repeating assessment too
quickly
• Inaccurate inflation level
• Poorly fitting stethoscope
• Impairment of examiners
hearing
Documentation of Vital Signs
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Graphic sheets
Flow sheets
Nurses notes
Computerized
Pain – Fifth Vital Sign
• Process of measuring pain:
• Verbal and nonverbal
• Characteristic of pain- onset, duration, location,
quality, intensity, variations
• Factors affecting pain – culture, developmental
stage, gender, anxiety, previous experience
• Pain scale- numerical (0-10), verbal (descriptive),
visual analog( faces pain rating scale)