Transcript Fundamentals II

Stressors that Affect
Circulation:Vital Signs
NUR101 LECTURE # 9
FALL 2008
K. BURGER, MSEd, MSN, RN, CNE
PPP by Sharon Niggemeier RN BSN MSN
Guidelines for Measuring
Vital Signs
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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
 Blood
circulation affects all
aspects of well being.
 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
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Signs of Vitality and
Life
Deviations from normal
ranges can indicate
chg in health status.
TPR & BP = VS
T-temperature
P-pulse
R-respirations
BP- blood pressure
VS-vital signs
CNS Regulates VS
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Hypothalamus:
Controls temperature
Anterior Hypothalamus
-Dissipation of heat
Posterior
Hypothalamusconservation of heat
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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
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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
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More Factors Influencing
VS
Pain
 Hormones
 Stress
 Emotions
 Circadian
Rhythms
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Guidelines for Assessing
VS
Systematic
 Normal Range
 Baseline
 Recheck
 Client Norm
 Dx
 Treatments
 Monitor prn
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Temperature Regulation
 Thermal
Balance
 Heat Production
 Heat Loss
 Core vs
Surface
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
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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.
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Heat Loss-Evaporation
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Conversion of a
liquid to a vapor.
Perspiration
vaporizes from
the skin.
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Diaphoresis
????What are some other ways
heat is lost from body???
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URINE
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FECES
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RESPIRATIONS
Fever
 Pyrexia
100.4 – 104.0 F
 Hyperpyrexia
Above 104.0 F
Fever Patterns
 Intermittent
 Remittent
 Constant
 Relapsing
?? Fever Terminology ??
Which term can be used to
describe a fever that:
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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
Resolutions of Pyrexia
 Crisis-
sudden return to normal
body temp.
 Lysis-
gradual return to normal
body temp.
S/S of Fever
Loss of appetite
 Headache
 Dehydration
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Flushed face
Delirium
Seizures
Thirst
?????
Rapid pulse
 Decreased urinary output
(OLIGURIA)
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Temperature ranges
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Oral- 96.8 – 100.4 F
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98.6 = average norm
Axillary- approximately
1 degree lower
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Rectal- approximately 1
degree higher
Fever
 Onset-
(Chill)
 Course ( Flush)
 Abatement (fever subsides)
Assessing Temperature
Glass
 Electronic
 Tympanic
 Tape/Patch
 Disposable (ie: Clinidot)
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Oral Temperature
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Most common site
Place against sublingual artery
Contraindicated in oral surgery/infection
Wait 15 min. if pt. ate/drank
or smoked
Electronic- blue probe
Axillary Temperature
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Preferred for children under 6 yrs. routinely
used on infants.
Place in center of axilla against artery off
the subclavian.
Blue probe -electronic thermometer
Document 102.4 A
Rectal Temperature
Last resort for assessing temperature
 Place against inferior rectal artery
 Contraindicated rectal surgery/cardiac
pt.
 Lubricate thermometers
 REMEMBER PPE
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(Continued) Rectal
Temperature
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Electronic thermometers:
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Red Probe only
Insert : ½ - 1 inch adult
¼ - 1/2 inch child
Left position is best
 Document 102.8 R
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Electronic Thermometers
Check for baseline number- specific
number after being turned on.
 Error indicators- low battery
 # completeness- digital display clearly
shows entire numbers
 If probe cover breaks- discard, check
pt.mouth/axilla/rectum for broken
pieces.
 Do not use bent probes.
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??? Nursing Diagnoses ???
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HYPERTHERMIA
HYPOTHERMIA
RISK FOR IMBALANCED BODY
TEMPERATURE
Nursing Interventions
Temperature
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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
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Heat Stroke
 Hot,
dry skin
 Dizziness
 Abdominal pain
 Delirium
 Eventual LOC
Hypothermia
(93.2 – 96.8 F)
 Moderate (86.0-93.2 F)
 Severe ( below 86.0 F)
 Mild
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
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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
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Cardiac Output CO=SV x HR
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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.
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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
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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
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Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Dorsalis Pedis
Posterior Tibia
Pulse assessment
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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
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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
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Decreased cardiac output
Ineffective tissue perfusion
Activity intolerance
Nursing Interventions-Pulse
Monitor for symmetry
 Note pulse deficit
 Promote circulation – i.e. massage,
TEDS,
 Teaching – i.e don’t cross legs
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Evaluations
Is pulse with normal range?
 All pulses present
 Equally Bilateral?
 Are interventions to promote
circulation working? i.e. massage,
TEDS etc.
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Terminology
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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
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
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5/23/02 1:20am c/o 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
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Newborn 40-60/min
Child 20-30
School age 18-26
Adult 16-20
Respirations
decrease as age
increases
Assessing Respiratory
Status
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Oxygenation status
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Neurological state
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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
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??Other signs of dyspnea??
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ANXIOUS LOOK
FLARED NOSTRILS
USE OF ACCESSORY MUSCLES
INTERCOSTAL RETRACTIONS
Neurological state
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Hypoxia results in neurological changes
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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
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Respiratory Assessment
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Rate- number of
breaths/min
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Rhythm - even,
labored
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Quality- deep,
shallow
Pulse Oximetry
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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??
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Impaired gas exchange
Ineffective airway clearance
Ineffective breathing pattern
Risk for aspiration
Respiratory Considerations
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Age
Gender
Pain
Anxiety
Smoking
Body Position
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Meds
Neurological injury
Illnesses
Impaired 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?
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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
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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
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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
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Normal Blood
Pressure < 120/80
Prehypertension
Systolic 120-139
Diastolic 80-89
Stage 1
Systolic 140-159
Diastolic 90-99
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Stage 2
Systolic >160
Diastolic >100
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Hypotension
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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
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Indirect BP Measurement
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Auscultating with
stethoscope and
sphygmomanometer
Palpating- feeling for
an estimated systolic
Doppler amplifies
Korotkoff sounds
Electronic metersmonitor BP with no
need for stethoscope
Sphygmomanometers
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Aneroid-measures
mmHg on
calibrated dial
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Mercury - measures
mmHg via mercury filled
cylinder (no longer used
due to mercury hazardous
material)
Cuff Sizes
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Vary in size
Must use
appropriate size for
pt.
Pedi cuff, small,
medium, large etc..
Thigh cuffs
Stethoscope Use
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Use either bell or
diaphragm to
auscultate sounds
Make sure ear tips
block out noise
Clean after each
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
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Brachial
Use either arm
 Preferred site
 Easy access
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Popliteal
Use either thigh
 Less preferred
 Difficult to access
 Systolic pressure
will be 10-40
mmHg higher than
brachial
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BP by palpation
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Cuff is inflated 30mmHg above the point
where pulse is no longer palpated.
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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
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Nursing Interventions- Blood
Pressure
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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
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Teaching - i.e. diet, exercise, stress, etc.
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Evaluation –Blood pressure
B/P within normal range?
 C/O headaches or other s/s
 Teachings regarding diet, weight,
exercise, stress etc being followed?
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What affects blood pressure?
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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