Transcript Chapter 29 Vital Signs

Chapter 29
Vital Signs
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Vital Signs
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Temperature, pulse, respiratory rate, blood
pressure
Pain
Oxygen saturation also frequently measured
Vital signs are used to:
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Monitor patient’s condition
Identify problems
Evaluate response to intervention
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Guidelines for Measuring Vital Signs
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Ensure that equipment is functional and is
appropriate for the size and age of the
patient.
Appropriately delegate measurement.
Be able to understand and interpret values.
Know the patient’s usual range of vital signs.
Determine the patient’s medical history,
therapies, and prescribed medications.
Control or minimize environmental factors
that affect vital signs.
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Guidelines for Measuring Vital Signs
(cont’d)
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Use an organized, systematic approach when taking
vital signs.
Know the acceptable ranges for your patients before
administering medications, and use vital sign
measurements to determine indications for
medication administration.
Communicate findings.
Accurately document findings.
Analyze the results of vital sign measurement.
Instruct the patient or family caregiver in vital sign
assessment and the significance of findings.
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Case Study
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Ms. Coburn is a 26-year-old schoolteacher.
Her maternal grandparents immigrated to
America from Brazil. She smokes one pack of
cigarettes a day and has smoked since she
was 16. She is 20 lbs overweight.
She made an appointment because she
started to have headaches and frequently felt
tired.
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Body Temperature Physiology
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Body temperature:
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Acceptable temperature range:
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Heat produced
Heat lost
98.6° F to 100.4° F or 36° C to 38° C
Temperature sites:
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Oral, rectal, axillary, tympanic membrane,
temporal artery, esophageal, pulmonary artery
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Body Temperature Regulation
Neural and vascular
control
Heat production
Heat loss (radiation,
conduction,
convection,
evaporation)
Skin temperature
regulation
Behavioral control
Thermoregulation
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Case Study (cont’d)
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Miguel is a 42-year-old Hispanic nurse who
works at the clinic Ms. Coburn is visiting. He
enjoys providing health-related teaching to
the patients and has provided Mrs. Coburn
care for 2 years.
During the visit, Miguel assesses Ms.
Coburn’s symptoms. He asks her about her
headache and fatigue, then takes her vital
signs.
Her temperature is 98° Fahrenheit.
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Factors Affecting Body Temperature
Age
Exercise
Hormonal level
Circadian rhythm
Environment
Temperature
alterations
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Temperature Cycle
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Temperature Alterations
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Pyrexia (fever): important defense mechanism
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Hyperthermia
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Pyrogens
Febrile/afebrile
Fever of unknown origin (FUO)
Malignant hyperthermia
Heatstroke (104° F or higher)
Heat exhaustion
Hypothermia
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Frostbite
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Hypothalamic Temperature Control
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Patterns of Fever
Sustained
Constant above 38° C (100.4° F)
with little fluctuation
Intermittent
Fever spikes interspersed
with usual temperature levels
Remittent
Fever spikes and falls without
a return to normal temperature levels
Relapsing
Periods of febrile episodes and periods with acceptable
temperature values
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Nursing Process and Temperature
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Assessment
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Sites: advantages and disadvantages
• Core and surface
Thermometers
• Electronic: oral, axillary, rectal, tympanic membrane,
temporal artery
• Disposable: oral, axillary, rectal
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Fahrenheit or Celsius scale
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Electronic Thermometer
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Temporal Artery Thermometer
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Chemical Dot Thermometer
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Quick Quiz!
1.You have delegated vital signs to assistive
personnel. The assistant informs you that the
patient has just finished a bowl of hot soup. The
nurse’s most appropriate advice would be to
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A. Take a rectal temperature.
B. Take the oral temperature as planned.
C. Advise the patient to drink a glass of cold
water.
D. Wait 30 minutes and take an oral temperature.
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Nursing Process: Temperature
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Diagnosis
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Risk for imbalanced body temperature
Hyperthermia
Hypothermia
Ineffective thermoregulation
Planning
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Nursing Process: Temperature
(cont’d)
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Implementation
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Health promotion
• Consider activity, environment, and clothing.
Acute care: treat pyrogen, antipyretics
• Heatstroke
• Hypothermia
Restorative and continuing care
Evaluation
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Get patient’s perspective, compare actual with
expected outcomes, and determine whether goals
were met.
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Pulse Physiology and Regulation
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Pulse = Palpable bounding of blood flow
noted at various points on the body
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Pulse rate = Number of pulsing sensations in
1 minute
Electrical impulses originate from the
sinoatrial (SA) node.
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The indicator of circulatory status
Cardiac output, heart rate, stroke volume
Mechanical, neural, and chemical factors
regulate ventricular contraction and stroke
volume.
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Assessment of Pulse
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Sites: temporal, carotid, apical, brachial,
radial, ulnar, femoral, popliteal, posterior
tibial, and dorsalis pedis
Use of stethoscope
Character of pulse: rate, rhythm, strength,
and equality
Nursing process and pulse determination
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Parts of a Stethoscope
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Use of a Stethoscope
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Pulse Character
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Rate
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Rhythm
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Apical rate: ID S1 and S2, “lub”+“dub” = 1
heartbeat
Lub-dubs per minute = Rate
Bradycardia
Tachycardia
Pulse deficit = Difference between radial and
apical pulse rates
Dysrhythmia: regularly or irregularly irregular
Strength: 4+, 3+, 2+ (normal), 1+, 0
Equality
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Nursing Process and Pulse
Determination
Activity
intolerance
Anxiety
Fear
Decreased
cardiac output
Deficient/excess
fluid volume
Impaired gas
exchange
Hyperthermia
Hypothermia
Acute pain
Ineffective peripheral tissue perfusion
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Quick Quiz!
2. You notice that a teenager has an irregular
pulse. The best action you should take
includes
A. Reading the history and physical.
B. Assessing the apical pulse rate for 1 full minute.
C. Auscultating for strength and depth of pulse.
D. Asking whether the patient feels any palpitations
or faintness of breath.
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Respiration
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Ventilation = Movement of gases into and out
of the lung.
Diffusion= Movement of oxygen and carbon
monoxide between alveoli and red blood
cells.
Perfusion = Distribution of red blood cells to
and from the pulmonary capillaries.
Physiological control; hypoxemia
Mechanics of breathing; eupnea
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Movements During Breathing
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Assessment of Ventilation
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Easy to assess
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Respiratory rate: breaths/minute
Ventilatory depth: deep, normal, shallow
Ventilatory rhythm: regular/irregular
Diffusion and perfusion
Arterial oxygen saturation
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Case Study (cont’d)
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Miguel continues to take Ms. Coburn’s vital
signs.
Ms. Coburn’s respiratory rate is 14 breaths
per minute, and her pulse is 86 beats per
minute.
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Factors Influencing Character of
Respirations
Exercise
Acute pain
Anxiety
Smoking
Body position
Medications
Neurological injury
Hemoglobin function
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Alterations in Breathing Pattern
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Bradypnea
Tachypnea
Hyperpnea
Apnea
Hyperventilation
Hypoventilation
Cheyne-Stokes respiration
Kussmaul’s respiration
Biot’s respiration
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Assessment of Diffusion and
Perfusion
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Measurement of arterial oxygen saturation
(SaO2), the percent of hemoglobin that is
bound with oxygen in the arteries
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Usually 95% to 100%
Pulse oximeter
• Probes: digit, earlobe, disposable
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Pulse Oximeter
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Nursing Process and Respiratory
Vital Signs
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Nursing diagnosis
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Activity intolerance
Ineffective airway clearance
Anxiety
Ineffective breathing pattern
Impaired gas exchange
Acute pain
Ineffective peripheral tissue perfusion
Dysfunctional ventilatory weaning response
Planning, interventions, evaluation
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Quick Quiz!
3. A postoperative patient is breathing rapidly.
You should immediately
A. Call the physician.
B. Count the respirations.
C. Assess the oxygen saturation.
D. Ask the patient if he feels uncomfortable.
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Arterial Blood Pressure
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Force exerted on the walls of an artery by
pulsing blood under pressure from the heart
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Systolic = Maximum peak pressure during
ventricular contraction
Diastolic = Minimal pressure during ventricular
relaxation
Pulse pressure = Difference between systolic
and diastolic pressures
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Physiology of Arterial Blood Pressure
Factors affecting arterial blood pressure:
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
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Factors Influencing Blood Pressure
Age
Stress
Ethnicity
Gender
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Factors Influencing Blood Pressure
(cont’d)
Daily variation
Medications
Activity, weight
Smoking
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Case Study (cont’d)
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Ms. Coburn’s blood pressure is 164/98 mm
Hg. Ms. Coburn asks whether this means she
is healthy.
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Blood Pressure Cuff Size Guidelines
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Hypertension versus Hypotension
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Hypertension
 More common than
hypotension
 Thickening of walls
 Loss of elasticity
 Family history
 Risk factors
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Hypotension
 Systolic <90 mm Hg
 Dilation of arteries
 Loss of blood
volume
 Decrease of blood
flow to vital organs
 Orthostatic/postural
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Case Study (cont’d)
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Miguel responds, “Ms. Coburn, your blood
pressure is pretty high right now. After you
see the nurse practitioner today, I am going
to take your blood pressure again.
We are also going to talk about the changes
you can begin to make to help you be
healthier and feel better.”
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Measurement of Blood Pressure
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Equipment
Auscultation
Children
Ultrasonic stethoscope
Palpation
Lower extremity
Electronic blood pressure
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Sphygmomanometer
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Alternate Methods of Measuring
Blood Pressure
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Patient Conditions Not Appropriate for
Electronic Blood Pressure Measurement
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Irregular heart rate
Peripheral vascular obstruction (e.g., clots,
narrowed vessels)
Shivering
Seizures
Excessive tremors
Inability to cooperate
Blood pressure less than 90 mm Hg systolic
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Patient Measurement of BP
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Benefits
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Detection of new problems (prehypertension)
Patients with hypertension can provide to their
health care provider info about patterns of BP.
Self-monitoring helps adherence to therapy.
Disadvantages
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Improper use risks inaccurate readings.
Unnecessary alarming of patient
Patients may inappropriately adjust medications.
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Nursing Process and Blood Pressure
Determination
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Assessment of blood pressure and pulse
evaluates the general state of cardiovascular
health.
Hypertension, hypotension, orthostatic
hypotension, and narrow/wide pulse
pressures are defining characteristics of
certain nursing diagnoses.
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Case Study (cont’d)
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After caring for Ms. Coburn, Miguel sees the need to
educate Ms. Coburn about the different types of vital
signs.
Miguel determines that the priority is to focus on
hypertension and ways to prevent or control elevated
BP. He states, “We need to watch your blood
pressure closely over the next few weeks. In the
meantime, remember, you decided that you are going
to walk for at least 15 minutes 3 days a week; you
are also going to try to eat foods with less salt and
think about not smoking anymore.
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Quick Quiz!
4. When assessing the blood pressure of a
school-aged child, using an adult cuff of
normal size will affect the reading and
produce a value that is
A. Accurate.
B. Indistinct.
C. Falsely low.
D. Falsely high.
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Health Promotion and Vital Signs
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Monitor vital signs.
Include age-related factors.
Include environmental and activity factors.
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Case Study (cont’d)
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Ms. Coburn has purchased an electronic
blood pressure device for home use.
What evaluation strategies would you
suggest for Miguel to use with Ms. Coburn?
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Recording Vital Signs
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Record values on electronic or paper graphic.
Record in nurses’ notes any accompanying or
precipitating symptoms.
Document interventions initiated on the basis
of vital sign measurement.
If a vital sign is outside anticipated outcomes,
write a variance note to explain, along with
the nursing course of action.
In the nurse’s variance note, address
possible causes of a fever.
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Safety Guidelines for Skills
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Cleaning devices between patients
decreases the risk for infection.
Rotating sites during repeated measurements
of BP and pulse oximetry decreases the risk
for skin breakdown.
Analyze trends for vital signs, and report
abnormal findings.
Determine the appropriate frequency of
measuring vital signs based on the patient’s
condition.
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