Transcript Vital Signs
Vital Signs Taylor, ch 24 Jensen, ch 6 Mosby items and derived items © 2005 by Mosby, Inc. General Guidelines • • • • Nurse’s responsibility/delegation Equipment Knowledge of client’s range Knowledge of client’s history and current status • Environmental factors • Systematic approach Mosby items and derived items © 2005 by Mosby, Inc. Guidelines (cont'd) • • • • • • Approach with the client Frequency of assessment Assessment for medications Analysis and verification of results Communication of results Teaching Mosby items and derived items © 2005 by Mosby, Inc. Temperature Regulation • Regulated by hypothalamus which has one part for heat loss, one for conservation • Hypothalamus receives info from thermoreceptors in skin and body core • Sends info to cerebral cortex (voluntary), sweat glands, blood vessels, and skeletal muscles (shivering) Mosby items and derived items © 2005 by Mosby, Inc. Temperature Maintenance • Maintenance—heat loss = heat production • Heat loss can occur through vasodilation, sweating, increased RR, increased fluid intake, moving to cooler environment, or putting water on skin. Mosby items and derived items © 2005 by Mosby, Inc. Maintenance cont’d • Heat production can occur in three ways: – Shivering – Exercising – Increased metabolic rate Mosby items and derived items © 2005 by Mosby, Inc. Factors Affecting Temperature • • • • • • • • • • Age Exercise Hormone level Circadian rhythm Stress Environment Disease conditions Nutritional status Drugs, anesthesia, alcohol, cigarettes Hot and cold liquids Mosby items and derived items © 2005 by Mosby, Inc. Temperature Terms • • • • • Pyrexia, febrile (fever) Afebrile Hyperthermia (heatstroke, exhaustion) Hypothermia (frostbite) Antipyretic Mosby items and derived items © 2005 by Mosby, Inc. Temperature Courses • • • • • • Intermittent Remittent Constant Relapsing Crisis Lysis Mosby items and derived items © 2005 by Mosby, Inc. Assessment of Temperature • Symptoms—HA, anorexia, hot dry skin, flushed face, thirst, malaise, delirium • Sites—oral, rectal, axillary • Thermometers—glass, electronic, tympanic, tape. Oral and rectal thermometers and probes should be clearly delineated. Mosby items and derived items © 2005 by Mosby, Inc. Guidelines for Oral Temps • • • • 97.6—99.6 Sublingual pocket 2-5 minutes or 20 secs Contraindications: – – – – – Children < 6 Confused, combative Seizure-prone Mouth breathers Smoking, chewing, eating < 15 min Mosby items and derived items © 2005 by Mosby, Inc. Guidelines for Rectal Temps • • • • 98.6—100.6 Insert ½ to 1 ½ inches, L side and lubricated 2-3 minutes or 20 secs Contraindications: – – – – – Rectal surgery Cardiac patients Diarrhea Combative Children < 6 Mosby items and derived items © 2005 by Mosby, Inc. Guidelines for Axillary Temps • • • • 96.6—98.6 Midaxilla and held tightly 10 minutes or 20 secs Contraindications: – Area just washed – Shoulders or arms impaired – Deeply recessed axilla Mosby items and derived items © 2005 by Mosby, Inc. Treating Febrile Conditions • • • • • Antipyretics Hypothermia blankets IV fluids Irrigations of stomach and bowel Tepid and alcohol baths and ice packs may increase shivering • Know conversions of Fahrenheit to centigrade and vice versa Mosby items and derived items © 2005 by Mosby, Inc. Asepsis and Safety • Use personal glass thermometers or disposable covers for glass and electronic • Before using glass, clean bulb to stem; after using, clean stem to bulb using twisting motion each way • Wash glass with soap, rinse, place in antiseptic • Right bulb for right site Mosby items and derived items © 2005 by Mosby, Inc. Pulse Physiology • Contraction of left ventricle forcing blood into aorta • Surge on elastic arteries causes wavelike distention and recoil—this is the pulse • Terms: – Bradycardia – Tachycardia – Dysrhythmia Mosby items and derived items © 2005 by Mosby, Inc. Pulse Sites • Temporal • Carotid—CPR site • Apical—PMI; use if radial is out of range, irregular, not palpable, and in children<2 • Radial—most common • Brachial—CPR in infants • Femoral • Popliteal—difficult to palpate • Pedal—diff to palpate in pts with circ probs, casts Mosby items and derived items © 2005 by Mosby, Inc. Pulse Characteristics • Rate—only necessary in radial and apical • Rhythm—same as rate • Strength—important at all sites • Equality—important at all sites Mosby items and derived items © 2005 by Mosby, Inc. Guidelines for Assessing Pulse • Assess 4 characteristics and for pulse deficit. 30” x 2 if regular; 1’ if not (x apical) • 70-72 in males; 78-82 in females • Use three fingers with light pressure for peripheral sites • Apical at 5th intercostal space, midclavicular line (4th in children <=7). • Pulses located distal to trauma, procedures, and surgery are important to assess for perfusion Mosby items and derived items © 2005 by Mosby, Inc. Factors Affecting Pulse • • • • • • • • • • Emotions, pain Exercise Fever Eating Drugs/smoking Hypoxemia Illness, injury Obesity Pregnancy Position Mosby items and derived items © 2005 by Mosby, Inc. Physiology of Respiration • Controlled by chemoreceptors in the carotid and aorta that respond to increased levels of CO2 in the blood. • These chemoreceptors stimulate the respiratory center in the brain (medulla oblongata) to increase RR. • Respirations are voluntary when we take deep breaths or when we realize someone is counting them. Mosby items and derived items © 2005 by Mosby, Inc. Respiration Terms • • • • • • • External/internal respiration (cellular) Ventilation—hypo/hyper Inspiration/expiration Bradypnea/tachypnea/eupnea Apnea/dyspnea/orthopnea Cheyne-Stokes/Biots/Kussmaul Adventitious—rales, rhonchi, wheeze, rubs Mosby items and derived items © 2005 by Mosby, Inc. Factors Influencing Respirations Same as pulse +: – Brain injury – High altitudes – Low hemoglobin Mosby items and derived items © 2005 by Mosby, Inc. Guidelines for Assessing Respirations • Rate, rhythm, depth • Do not let patient know you are taking respirations—take with pulse • Look for cyanosis, restlessness, confusion, reduced LOC, pain, dyspnea, orthopnea, coughing, sputum production, noisy breathing Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure Physiology • Pressure the blood exerts against the arterial wall (usually brachial) • Pressure is measured in mms of Hg by sphygmomanometer • Blood supply to artery is occluded, then allowed to return slowly • Two ways pressure is measured: – When heart beats (systolic pressure) – Between heart beats (diastolic pressure) Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure Maintenance • Depends on: – – – – – Cardiac output Peripheral resistance Blood volume Viscosity Elasticity Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure Terms • • • • • • • Systolic pressure Diastolic pressure Pulse pressure Hypertension Hypotension Orthostatic hypotension Postural blood pressures (orthostatic) Mosby items and derived items © 2005 by Mosby, Inc. Influencing Factors Age Stress Ethnicity Gender Diurnal variation Medications Cold environment Hot showers Site and position Eating, socializing Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure Measurement Equipment—Manual and automatic Auscultated Palpated Sites Children Self-measurement Mosby items and derived items © 2005 by Mosby, Inc. Guidelines for Assessment Appropriate size cuff Sitting or lying; arm at heart level; manometer at eye level Place cuff securely 1 inch above antecubital space Palpate artery and pump to absence of pulse Release air; wait 30 seconds Mosby items and derived items © 2005 by Mosby, Inc. Guidelines cont’d • Place stethoscope over artery; inflate within 7 seconds to 30 mm over absence of pulse • Deflate slowly (2-3 mm/sec) • Note Korotkoff sounds (536) • Wait 30 seconds if need to recheck • Do not take BP at site of mastectomy or atriovenous fistula used for hemodialysis Mosby items and derived items © 2005 by Mosby, Inc. Additional Nursing Interventions • Compare to previous readings, if available • Client teaching • Reporting and recording Mosby items and derived items © 2005 by Mosby, Inc. Common Mistakes • See p. 537, Table 24-10 • In addition: – Taking BP over clothing can make it difficult to hear correct BP – Sleeve rolled up too tight can cause abnormally high reading – Improper placement of earpieces – Stethoscope diaphragm turned to wrong side – Environmental noise – Tubing rubbing together Mosby items and derived items © 2005 by Mosby, Inc.