Module 7 - Vital Signs - Nursing Kills

Mechanisms of heat loss and production and relating nursing measures to control each: (book and ppt.)

***Heat loss and heat production occur simultaneously.** -RADIATION: loss from body to another cooler source (ie. walls, objects in environment). 85% of the surface area of the human body radiates heat to the environment. ***Patient's position enhances radiation heat loss. ie. standing exposes a greater surface area, and lying in a fetal position minimizes heat radiation. Removing clothing or blankets will promote radiation heat loss. Covering the body with dark, closely woven clothing decreases the amount of heat lost from radiation. -CONVECTION: Transfer of heat away by air movement. Air Currents. ***ie. A fan promotes heat loss through convection and it is increased when moistened skin comes into contact with slightly moving air. A heater would decrease heat loss through convection. -CONDUCTION: loss via direct contact with cooler surface. (ie. ice) ***Accounts for small amount of heat loss. Applying an icepack or bathing a patient with a cool washcloth increases conductive heat loss. Applying several layers of clothing reduces conductive loss. A Body gains heat by conduction when it makes contact with materials warmer than skin temperature. -EVAPORATION: Transfer of heat when liquid is changed to a gas (ie. sweat) ***The body continuously loses heat by evaporation. 600 - 900 mL a day evaporates from the skin and lungs resulting in water and heat loss. When body temp rises, the ant. hyp. signals the sweat glands to release sweat through tiny ducts on the surface of the skin. Sweat evaporates, resulting in heat loss.

Alternative Devices

Automated blood pressure monitors

Heat Loss, Primary site

the skin.

Factors that increase RR (Tachypnea in an adult is a RR> 24 breaths/min.

-AGE: A newborn RR ranges from 30-60 breaths/min -ACTIVITY / EXERCISE: The RR increases due to the increased energy demands placed upon the body. The rate increases to keep up with these energy demands placed upon the body. -ANXIETY: increases rate and depth as a result of sympathetic stimulation -ANEMIA / HEMOGLOBIN FUNCTION: Decreases the hemoglobin, which carries O2, and may increase the RR. -MEDICATIONS: Cocaine and amphetamines, known as "uppers," may increase rate and depth. -ACUTE PAIN: Acute pain may increase rate, but decrease depth. -SMOKING: alters the pulmonary airways causing increased RR, even at rest.

Factors that decrease RR (Bradypnea in an adult is RR < 10 breaths/min)

-AGE: an older adult as a lower baseline RR. An adult's normal range is 12-20 breaths/min. -ACTIVITY: Slower in trained athletes. -MEDICATIONS: Narcotics, sedatives and general anesthetics slow rate and depth.

Factors Affecting Body Temperature

-Age -Exercise -Hormone leve (menopause - vasocontrol) -Circadian Rhythm (Body temp changes during a 24 hour period, 4 PM the highest) -Stress -Environment -Temperature Alterations

Factors that decrease pulse - < 60 bpm

-Age: older adults have a lower baseline rate -Sleeping -Exercise: slower in trained athletes.

Factors that increase pulse - > 100 bpm

-Bleeding: increases pulse when there's inadequate oxygen delivered to the tissues and organs. By the negative mechanism, these receptors send the signals to the brain and thus stimulate the heart to pump faster. -Activity: The heart's compensatory ability attempts to meet the need for increased blood circulation. -Strong emotion: pain, fear, anger, anxiety, and being surprised. -Fever: Increases 10 bpm for each 1*F above normal.

Body Temperature

-Body temperature is the balance between the heat produced in the body and heat loss from the body. -Heat Production - Heat Loss = Body Temperature (physiology of thermoregulation) -Physiological and behavioral mechanisms regulate the balance between heat lost and heat produced - this is known as THERMOREGULATION.

Safety Guidelines for vital signs

-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.

Core temperature vs. Surface temperature (book)

-Core temperature is the temperature of the deep tissues. Temperature-control mechanisms of humans keep the core temp relatively constant. -Surface Temperature varies depending on blood flow to the skin and the amount of heat lost to the external environment. -A consistent body temp measurement from a single site allows you to monitor patterns of your patient's body temperature. -96.8* - 100.4* is the functioning range of body tissues and cells.

How long should the nurse count the heart beat when ascultating the apical pulse?

-If pulse is regular - count for 30 seconds and multiply by 2. -If pulse is abnormal or irregular - count for 1 minute (60 seconds) -note: apical pulse is used more often for assessing irregular pulses. If radial pulse is abnormal or the patient is taking a medication that affects the heart rate, the apical pulse provides a more accurate assessment. -Write down reading.

Patient Conditions not appropriate for Electronic Blood Pressure Measurement.

-Irregular heart rate -Peripheral vascular obstruction (clots, narrowed vessels) -Shivering -Seizures -Excessive tremors -Inability to cooperate -Blood Pressure less than 90 mm hg systolic

Dysrhythmia

-Irregular rhythm of pulse: An interval interrupted by an early or late beat or a missed beat indicates an abnormal rhythm or dysrhythmia. -A dysrhythmia threatens the ability of the heart to provide adequate cardiac output, particularly if it occurs repetitively. -Pulse deficits are often associated with abnormal rhythms - they are the difference between the apical and radial pulse rates.

Why vital signs are important in the nursing assessment. (book)

-Measures of VS indicate the effectiveness of circulatory, respiratory, neural and endocrine body functions. -VS are a quick and efficient way of monitoring a patient's condition or identifying problems and evaluating his or her response to intervention. -VS and other physiological measurements are the basis for clinical decision making.

Guidelines for Measuring Vital signs.

-Measuring is your responsibility -Equipment use; ensure it is working properly -Know patient's usual range and medical Hx -Control environmental factors -Use systematic approach Collaborate to decide frequency -Used for administering medications -Analyze results, identify significant findings -Instruct patient in vital sign assessment -Instruct patient in vital sign assessment

Factors that increase BP. (Hypertension --> 140/90 mm hg)

-Older Adult: will have decreased elasticity of the arteries, which increases peripheral resistance and then increases BP -Men: More have high BP than women the same age. -Women: get high BP after menopause. -Exercise: systolic BP rises during periods of exercise. -Weight: BP higher in people who are obese than those who are thin. (resistance) -Emotional State: Pain, fear, anger, anxiety and surprise raise BP; BP falls back to normal when the situation passes. -Race: High BP more prevalent and more severe in African American men/women. -Blood Volume: Hypervolemia will increase BP

Advantages and disadvantages of using each type of thermometer. check book

-Oral: Pros: Easy, comfortable and accurate. Cons: Can't use after eating or chewing gum, or smoking, after oral surgery, or on an unconscious patient. -Rectal: Advantages: Reliable, core temperature. Cons: Bad with diarrhea, generally uncomfortable, more likely to spread disease. -Axillary: Advantages: Better for kids. Cons:Inaccurate on adults -Tympanic: Advantages: Accurate, shares same arterial blood as hypothalamus, and it's quick. Cons: Bad for people with hearing aids or ear trauma. -Temporal: Advantages: Easy access. Cons: Inaccurate if there's sweat or moisture.

Assessing the Pulse

-Palpation: Middle 2 - 3 fingers used. Pads on fingers are sensitive areas for detecting a pulse. -Auscultation: Stethoscope for auscultating an apical pulse - Good idea to not have clothing. -Doppler Ultrasound: used to hear pulses that are difficult to palpate or auscultate.

Nursing Process and Pulse Determination: (book)

-Pulse assessment determines the general state of cardiovascular health and the response of the body to other system imbalances. -Tachycardia, bradycardia, and dysrhythmias are defining characteristics of many nursing diagnoses: *Activity intolerance. *Anxiety. *Decreased cardiac output. *Deficient/excess fluid volume. *Impaired Gas exchange. *Acute pain. *Ineffective Peripheral Tissue Perfusion.

Temperature medical terminology

-Pyrexia, hyperthermia and fever all mean an elevation in body temperature -Heat Stroke - a very high fever, over 104*F -Febrile - having a fever; Afebrile - without a fever. -Hypothermia - decreased body temperature below 97*

Characteristics of Respirations:

-Rate: Normal adult rate 12-20 brpm -Abnormal: Tachypnea > 24 brpm. Bradypnea < 12 brpm -Depth: Degree of movement in the chest wall. Described as normal, deep or shallow. -Tidal Volume: Normal inspiration and expiration, or volume of air exchanges, with each breath in an adult is about 500 mL of air. ***sex, age, and height will affect tidal volume. -Rhythm: Regularity of expirations and inspirations. Normally, they are evenly spaced in an adult and irregular in an infant. Irregular respirations in an adult should be reported. -Effort: Assess the chest. Does it expand symmetrically with inspiration (if no, could be pneumothorax or collapsed lung)? Is there retraction of intercostal spaces between the ribs on inspiration (maybe a foreign body obstruction)? Are the respirations diaphragmatic or costal (asthma)? Are accessory muscles used to augment? -Difficulty with breathing is known as Dyspnea.

Character of the pulse

-Rate: the normal HR for an adult is 60-100 bpm. Tachycardic is over 100, bradycardic is under 60. -Rhythm: Pattern of the beats and the intervals between the beats. Equal time should lapse between beats of a normal pulse making a normal rhythm. Irregular rhythm is referred to as dysrhythmia or arrhythmia. -Strength: Strength of the pulse reflects the volume of blood ejected against the arterial wall with each heartbeat. Usually the volume/strength is the same with each heartbeat. look in book levels 1-4. 4: Bounding. 3. Full, or strong. 2.Normal, expected. 1. Diminished or barely palpable. 0: Absent. -Equality: Pulses on both sides of the body should be equal - known as bilateral equality. A pulse in one extremity is sometimes unequal in strength or absent in many disease states. Assess all symmetrical pulses simultaneously except the carotid pulse.

Physiology of Respirations

-Respiratory center is in the brain stem and in the chemoreceptors in the carotid artery and aorta. ***regulated by levels of CO2, O2, and pH in the arterial blood. ***Most important is level of CO2. Elevation of CO2 causes the respiratory control system in the brain to increase the rate and depth of breathing to move out the carbon dioxide. Hypercapnea. -If arterial oxygen levels drop, chemoreceptors signal the brain to increase the rate and depth of ventilation.

Equipment for assessing Blood Pressure

-Stethoscope: The diaphragm is more useful for hearing high-frequency sounds. (Blood pressure and lung sounds). The Bell is more useful for hearing low-frequency sounds. (intestinal sounds and heart murmurs) -Sphygmomanometers: Aneroid - glass enclosed circular gauge containing a needle that registers millimeter callibrations. Mercury - upright tube containing mercury. Pressure created by inflation of cuff moves column of mercury upward against gravity. -Cuff: Be sure it's the correct size. Use index line on cuff. SAFETY ALERT: too large or too small will give an inaccurate read. Too large - BP will be low. Too small - BP will be high)

Sites for assessing peripheral arterial pulses.

-Temporal: over temporal bone of head, above and lateral to eye. -Carotid artery: in the neck. USED: assess this pulse in emergencies. SAFETY ALERT: Light palpate one side at a time to prevent a decrease in O2 to the brain which could cause fainting. -Brachial: Inner aspect of the elbow. USED: most often with infants. -Radial: inner aspect of wrist on thumb side. USED: most often with children and adults. -Ulnar: little finger side of forearm or wrist -Femoral: Below inguinal ligament -Popliteal: behind the knee -Posterior tibial: inner ankle, behind the ankle -Dorsalis pedis: upper surface of the foot. USED: to assess circulation of the feet and legs.

Analyzing Vital Signs

-The nurse needs to look at the relationship of the vital hands to each other, to previous findings, and to other assessment data. -If the temperature is abnormal, first, reassess the temperature. -If the temperature remains abnormal, the nurse should document and notify the HCP. ***Always look at trends and assess any breaks from the trends. What was happening a the time of the break?***

Procedure for assessing Respirations

-Unobtrusively observe the patient's respirations while seeming to be involved in another activity. (they will breath faster if they know you're counting) -Count the rate for 30 sec unless otherwise indicated. -Wash hands if contact made with the patient or furnishings in the room. -Document and report abnormalites

When to Measure Vital Signs?

-Upon admission to any healthcare facility--establish their baseline. -On a routine schedule - every 4 hours but can do it as often as you feel is necessary. Don't miss them, always document, communication with the other nurses. -Any time there is a change in the patient's condition. -Before, during, and after surgical or invasive diagnostic procedures; blood transfusions. -Before and after activity that may increase risk. -Before administering medications that affect cardiovascular or respiratory functioning. -- narcotics, benzos, especially IV, even if they're already on them.

Neural and Vascular control of Thermoregulation (book)

-When nerve cells in the anterior hypothalamus become heated beyond the set point, impulses are sent out to reduce body temperature. MECHANISMS OF HEAT LOSS: Vasodilation - body redistributes blood to surface vessels to promote heat loss. -If the posterior hypothalamus senses that body temperature is lower than the set point, the body initiates heat-conservation mechanisms. MECHANISMS OF HEAT CONSERVATION: Vasoconstriction. Blood vessels narrow to reduce blood flow to the skin and extremities. --Compensatory is stimulated through voluntary muscle contraction and muscle shivering.

Factors that decrease BP (hypotension -- < systolic of 90 mm hg)

-Women: Lower BP than men of the same age until menopause. -Exercise: lower in trained athletes -Body Position: BP tends to lower in prone or supine position than sitting or standing. -Orthostatic hypotension (postural hypotension): drop in SBP > 20 or DBP > 10 within 3 min of standing. S&S = dizziness, diaphoresis, blurred vision. -Blood Volume: Hypovolemia will decrease BP

Assessment of the Pulses: (book)

-You can assess any artery for pulse rate, but you typically use the radial artery b/c it's easy to palpate. -Because the heart continues delivering blood through the carotid artery to the brain as long as possible, when a patient's condition suddenly worsens, the carotid site is recommended for quickly finding and assessing the pulse. -When cardiac output declines significantly, peripheral pulses weaken and are difficult to palpate. -When a patient takes medication that affects the HR, the apical pulse provides a more accurate assessment of heart function. -Assessment of the radial pulse includes measuring the rate, rhythm, strength, and equality. When auscultating an apical pulse, assess rate and rhythm only. -You assess other peripheral pulses when conducting a complete physical, when surgery or treatment as impaired blood flow to a body part, or when there are clinical indications pf impaired peripheral blood flow.

Blood Pressure

A measure of the pressure exerted by the blood on the walls of an artery as it flows through the arteries.

Pulse

A wave of blood created by contraction of the left ventricle of the heart. Ventricles pump. The heart is a large pump that forces blood to enter the arteries with each heartbeat, causing pressure pulses or pulse waves.

Physiology of Blood Pressure

BP = CO x R -Cardiac Output: the volume of blood pumped by the heart during one minute. -Resistance: resistance of blood flow determined by the tone of vascular musculature and diameter of blood vessels.

Sites for Assessing Blood Pressure

Brachial is the most common. Alternatives sites: lower extremities - popliteal artery behind the knee.

Physiology of the Pulse

CO = SV x HR -Stroke Volume: amount of blood that enters the arteries with each ventricle contraction. Normally heart empties about 70% of its volume with each contraction. That is about 70 mL of blood in an adult. -Cardiac Output: volume of blood pumped by the heart in 1 minute. In an adult: ~5000 mL/min. -Heart Rate: beats per minute -Average 4 - 8 L/ min

Potential causes of a BP error:

High reads: reflating the bladder of the cuff during auscultation - deflate all the way then try again. Applying too narrow a cuff. Releasing the valve too slowly (causes discomfort or pain). Low reads: Noise in environment - hard to hear. Releasing the valve to quickly (miss first pump). Applying too wide a cuff. Failing to pump the cuff 30 mm hg.

Oral temp: quick how-to and safety alert

Insert thermometer under the tongue, in the posterior sublingual pocket. SAFETY ALERT: wait 15-30 min if patient has . been smoking, eating hot/cold food or fluids, or chewing gum.

Temperature Ranges

Normal: -Adults 96.8* - 100.4*, oral Variations: -Rectal temperature is usually 1* higher than oral -Axillary temperature is usually 1* lower than oral

Blood Pressure Levels:

Normal: < 120/80 Prehypertension: 120-139 / 80-89 Hypertension Stage 1: 140-159 / 90-99 Hypertension Stage 2: 160 or higher / 100 or higher Emergency care needed: Higher than 180 / Higher than 110

Tympanic temp: quick how-to and safety alert

Place into patient's ear canal with pinna pulled up and back (ear temp). The tympanic temp is the core temp, which is the operating temp of deep structures (ie. the liver). Children like this b/c it only takes a few seconds. SAFETY ALERT: not used with patients who have drainage from the ear. Ear wax does not effect temp.

Axilla temp: quick how-to and safety alert

Place thermometer in center of axilla. SAFETY ALERT: used with newborns to avoid perforating the wall of the rectum. Axilla must be dry.

Respirations: Expiration <--> Inspiration

Respiration is the act of inspiration (breathing in) and expiration (breathing out), supply oxygen to the body cells and removing CO2 from the body cells.

Systolic and Diastolic Pressure

Systolic pressure: The pressure of the blood as a result of contraction of the ventricles, that is the pressure of the height of the blood wave. Diastolic Pressure: pressure when the ventricles are at rest. Diastolic pressure in the minimal pressure exerted against the arterial walls at all times.

Pulse Terminology

Tachycardia: increased heart rate - over 100 bpm. Usually occurs when sympathetic nervous system is stimulated. Bradycardia: Decreased heart rate - below 60 bpm. Usually occurs when parasympathetic nervous system is stimulated.

Physiology of the body Temperature: What regulates our body temperature?

The HYPOTHALAMUS acts as a central thermostat, receiving input from sensors that detect HOT or COLD temperatures and initiates body responses mainly in the cardiovascular system via vasoconstriction or vasodilation that decrease heat production and increase heat loss.

Heat Production - primary source, stimulated by (ppt)

The Primary source of heat production ( muscles? ex. of heat production is shivering) is a by-product of METABOLISM. Metabolism is increased by exercise, cold environments, hyperthyroidism, etc.

What are Vital Signs?

The VS are an important part of the nursing assessment in any clinical setting, even if they are delegated, b/c a change in the VS might indicate a change in health. -Temperature (T) -Pulse (P) -Respiration (R) -Blood Pressure (BP) - Oxygen Saturation - Pulse Oximetry (SpO2)* (discussed more in module 8)

Behavioral Control of thermoregulation

The ability of a person to control body temp depends on: 1. The degree of temperature extreme 2. The person's ability to sense feeling comfortable or uncomfortable 3. Thought processes or emotions 4. The person's mobility or ability to remove or add clothes **Individuals are unable to control body temperature if any of these abilities is lost.

Pulse Pressure

The difference between the systolic and diastolic pressure. PP = SP - DP High PP could be at risk of MI Low PP - respiratory or cardiac failure.

Peripheral Arterial Pulses

These arteries are located near the surface of the body. The pulse can be detected in any of these sites by light palpation.

Apical Pulse Location and Rate

When assessing the apical pulse, the nurse should place the stethoscope between the 5th intercostal space and midclavicular line (about 3 inches to the left of the mid sternal line) and slightly below the nipple line.

Rectal temp: quick how-to and safety alert

With lube insert thermometer 1.5 inches into the rectum. SAFETY ALERT: not used in newborns, children with diarrhea or anyone with rectal disease or rectal surgery. It can cause bradycardia by stimulating the vagus nerve so usually not used for patients with heart disease or surgery. Do not use on someone with heart rate lower than 60 bpm.