Vital Signs - Chapter 29
State the components that constitute vital signs
Temperature, pulse, BP, RR, Oxygen saturation, pain
3. Identify the nurse's responsibility for vital-sign measurement
- Analyze vital signs and interpret their significance and make decisions about appropriate interventions - Make sure equipment is clean and functional, properly calibrated and for the correct age of the patient being treated - Be familiar with the patients usual range of vital signs which will serve as a baseline for later findings - Know patients medical history, therapies n prescribed medications - Control or minimize environmental factors that affect vital signs - Use organized/systematic approach when taking vital signs to insurance accuracy - Work with health care provider to determine frequency of when vital signs must be taken - Analyze vital sign measurements and incorporate the finding in nursing diagnosis. Be aware of known related s/s and patients ongoing health status - Verify, document, and communicate changes in vital signs. Inform health provider is signs appear abnormal. If normal have another nurse re-measure
Temperature Equipment:
- Electronic thermometer - Tympanic thermometer - Temporal artsy thermometer - Chemical dot re-usable or single use
Temperature measurement sites (locations/Contraindications):
- Oral Advantages: easy access, no position change, comfortable for patient, provides accurate surface for temp reading, reflects rapid change in core temp, reliable for intubated patients Limitations: Causes delay in measurement if patient recently ingested hot/cold fluids, gum or smoked, not for use with patient that had oral surgery, facial trauma, unable to position int out, shaking, chills, or history of seizure, not for infants and small children, confused, unconscious or uncooperative patients, risk for body fluid exposure - Tympanic membrane: Advantages: Easy access, obtained w/o disturbance or moving patient, for patients with tachypnea w/o affecting breathing, accurate reading as ear drum close to hypothalamus, measurement in 2-5 seconds, unaffected by any oral intake (food, smoke, etc), used in infants to reduce heat loss Limitations: variability of measurements more so than any other device, req removal of hearing aids, req disposable sensor cover w/ one size available, cerumen and otitis media will distort reading, not used with patient who had ear surgery, affected by ambient temp devices, difficult to positions for infants, inaccurate because of incorrect positioning - Rectal: Advantages: Argued to be effective when oral cannot be obtained Limitations: Not for patients with anything going on in the perineal area, or have bleeding tendencies, lags behind core temp during temp changes, not for use with newborns, reading influenced by impacted stool, risk for body fluid exposure, embarrassing for patient - Axilla: Advantages: Safe and inexpensive, prove continuous reading, safe n noninvasive, used on neonates Limitations: long measurement time, req cont positioning, measure lags behind core temp during rapid temp changes, not recommended for detecting fever in pants and the young, req exposure of thorax which can result of temp loss in young, affected by exposure to environment, underestimates core temp - Skin: Advantages: inexpensive, prove cont reading, safe, noninvasive, used for neonates Limitations: Measurement lags behind other sites during temperature changes esp during hyperthermia, impaired adhesion by sweat, cannot be used w/ patients allergic to adhesive, affected by environmental temperature - Temporal artery Advantages: easy to access w/o position change, rapid measurement, comfortable w/ no risk of injury to patient or nurse, eliminates need to disrobe, can be used for premature infants, newborns n children, reflects rapid and change in core temp, sensor cover no required Limitations: inaccurate with head covering or hair on forehead, affected by skin moisture such as diaphoresis
Discuss parameters for frequency of vital-sign measurement
1) On admission to health care agency 2) in a hospital care facility on a routine schedule according to a health care providers order or standards of practice of agency 3) when assessing patient during home care visits 4) before, during, and after a surgical or invasive diagnostic procedure 5) before, during and after the administration of medications or applications of therapies that affect cardiovascular, respiratory or temperature control functions 6) Before during and after a transfusion of any type of blood products 7) Before, during and after nursing interventions influencing a vital sign (eg before n after patient pre on bed rest ambulates, before n after patient performs ROM exercises 8) When a patient reports specific symptoms of physical distress 9) When a patients general physical condition changes (loss of conscious etc)
7. Discuss blood pressure c. Factors responsible for deviations of blood pressure
Age, stress, ethnicity, gender, daily variation, medications, activity and weight
5. Discuss pulse a. Physiology of the pulse
Assessing the patients peripheral pulse sites offers valuable data for determining the integrity of the cardiovascular system. An abnormally slow, rapid, or irregular pulse indicates the inability of the heart to deliver adequate blood to the body; a pulse deficit may be present. The integrity of the peripheral pulse indicates the status of blood perfusion to the area distributed by the pulse. Pulses should have rate, rhythm and strength The only ones we count are radial, apical, and carotid all others are palpated but not counted We want to make sure each extremity is oxygenated to we take the pulse
7. Discuss blood pressure
BP reflects the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity and artery elasticity. Your knowledge of these hemodynamic variables help in the assessment of BP alterations. Force exerted on arterial walls How the heart is relaxing
Two types of body temp
Core: temp of deep tissue in body surface: temp of skin info on pp
Measurement of blood pressure
Equipment Auscultation Children on ppt
4. Discuss body temperature d. Terms associated with temperature Temperature alteration
Febrile: During this phase WBC production is stimulated. The chills subside and the person feels warm and dry. Shivering is bad in the elderly or old people because they expend too much energy Afebrile: when the fever breaks Pyrexia: AKA Fever, occurs when heat-loss mechanisms are unable to keep pace with heat production, resulting in an abnormal rise in body temperature Hyperpyrexia: fever with an extreme elevation of body temperature greater than or equal to 41.5 °C (106.7 °F) Hyperthermia: temperature greater than 37.5-38.3 °C (99.5-100.9 °F), depending on the reference used, that occurs without a change in the body's temperature set point. Hypothermia: temperature below 35.0 °C (95.0 °F). With this method it is divided into degrees of severity based on the core temperature. Heat exhaustion v heat stroke Frost bite
4. Discuss body temperature b. Methods of temperature control
How heat is lost within the body - The hypothalamus controls the body's temp like a thermostat - Heat is produced in the body during rest, voluntary movements, involuntary shivering and non shivering thermogenesis (in neonates) - Heat loss occurs via radiation( xfer of heat from object to another w/o touching), conductions(xfer of heat w direct contact), convection(xfer of heat by air movement) and evaporation(transfer of heat when liquid changes to gas) diaphoresis (sweating) - Skin: Heat travels from blood, to blood vessels walls to surface of skin and heat is lost *add examples
4. Discuss body temperature Equipment
Methods of temp assessment: - Thermometers - Electronic Thermometers - Chemical dot thermometers - Temperature sensitive patch or tape
5. Discuss pulse e. Characteristics of pulse Rhythm Amplitude
Normally a regular interval occurs between each pulse or heartbeat. an interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm (dysrhythmia) Dysrhythmia threatens the hearts ability to perform cardiac output. To identify it you palpate an interruption in a successive pulse wave or osculate an interruption between heart sounds. Pulse character on pp
Pulse deficit
Pulse deficit When a pulse deficit is assessed between the apical and radial pulses, the volume of blood ejected from the heart may be inadequate to meet the circulatory needs of the tissues and intervention may be required. To assess for pulse deficit the nurse and a second health care provider assess a peripheral pulse rate and the apical pulse rate simultaneously and compare measurements Pulse deficient should be 2 not greater than 7
6. Discuss respirations a. Physiology of respirations
Respiration is the mechanisms the body uses to exchange gases between the atmosphere and blood and the between the blood and cells. It involves: ventilation: movement of gases in and out of lungs diffusion: movement of oxygen and CO2 between alveoli and RBC and perfusion: distribution of RBC to and from the pulmonary capillaries The accurate assessment of respirations depends on the recognition of normal thoracic and abdominal movements During quiet breathing the chest wall gently rises and falls. Contraction of the muscles in the neck and shoulders is not visible The diaphragmatic movement causes the abdominal cavity to rise and fall slowly The objective measurement of respiration includes respiratory rate (varies w age, declines with age) ventilatory depth( assessed by observing the degree of movement in chest wall, resp is shallow when small amount of air passes lungs) and ventilatory rhythm ( breathing pattern determined by observing chest and abdomen) internal resp: gas change on alveolar level external resp: breathing that can be observed by nurse
Nursing diagnosis
Risk for imbalanced for imbalance info on body temp
7. Discuss blood pressure a. Terms associated with blood Systolic pressure Diastolic pressure Pulse pressure Hypertension Hypotension Orthostatic (postural) hypotension
Systolic pressure The peak of maximum pressure when ejection occurs Diastolic pressure When the ventricles relax the blood remaining in the arteries exert a minimum diastolic pressure. This is the minimal pressure exerted against the arterial wall at all times Pulse pressure The difference between the systolic and diastolic pressure. For a BP of 120/80 the pulse pressure is 40 Hypertension An alteration in BP. The most common which is often asymptomatic. One elevated measurement does not qualify as a diagnoses. If a high reading is measured the patient should return w/in two months Hypotension When the systolic BP falls to 90 mm Hg or below Associated with skin pallor, mottling, calmness, confusion, increased HR or decreased urine Orthostatic (postural) hypotension When normotensive person develops symptoms and low BP when rising to an upright position. Detected w/in a min of standing most times
5. Discuss pulse c. Terms associated with pulse
Tachycardia Abnormally elevated HR, above 100 beats/min in adults Bradycardia Slow rate below 60 beats/mins adults
5. Discuss pulse g. Apical-radial pulse assessment Method Indications
The apical and radial locations are the most common sites for pulse assessment. You can show patients how to monitor their own pulse via radial pulse. If radial pulse is absent or intermittent resulting from dysrhythmia or if it is inaccessible because of dressing or cast assesses the apical pulse The apical pulse provides a more accurate assessment of heart function. The brachial or apical is the best for assessing infants or young child's pulse
4. Discuss body temperature Expected values at each location
Usually between 36C(96.8F) and 38C(100.4F) but varies depending on site measured Oral/ Tympanic: 37degrees C(98.6F) Rectal: 37.5C(99.5F) Axillary: 36.5C(97.7F) Temp is know measured in Celsius
4. Discuss body temperature a. How temperature is regulated
a. How temperature is regulated Body temp is regulated by the following mechanisms: - Neural and vascular By the hypothalamus - Heat production a by product of metabolism shivering non shivering thermogenesis - Heat loss radiation, conduction, convection, evaporation, diaphoresis (sweating) - Skin preserves temp via insulation on the body - Behavioral control Individuals can control temp by the degree of the top, the persons ability to sense temp, persons thoughts or emotions, persons mobility. IF a person is unable to control these they will not be able to control temp
Factors affecting temperature
age, hormone look on pp
7. Discuss blood pressure b. Factors responsible for maintaining blood pressure
cardiac output, peripheral vascular resistance, blood volume, blood viscosity and artery elasticity
Interventions to reduce fever
info on pp Increase fluid intake
Nursing diagnoses for pulses
on pp
Alternate places to take blood pressure
on ppt
Nursing Diagnoses
on ppt
Nursing interventions
on ppt - incomplete Assess/monitor Respirations quality, rate, pattern, depth and breathing