Nursing 102 Fundamentals Chapter 15 Vital Signs
When should you assess vital signs?
*On admission, beginning of shift *as specified by physician *every 4 hours routinely * every 5- 15 minutes *if unstable* if the client condition changes *client complains of unusual feeling *medicating for sleep or pain *before during & after blood transfusions *before administering a medicine which will affect vital signs *before calling the physician *after a fall or some other injury * before & after surgery or invasive procedure.
Core temperture
*Warmth of the near center *temperature of deep tissues *relatively constant *ranges 98 degrees to 99.5 degress
Shell Temperture
*Warmth of the skins surface *fluctuates *ranges 96.8 degrees to 100.4 degrees
factors that affect pulse
-Age -Gender -Temperature -Drugs -Excercise -Emotions -Hemorrhage -Posterialn changes -pulmonary conditions
Blood pressure
-cardiac output -peripheral vascular resistance -blood volume -blood viscosity (thickness) -elasticity of arteries -gender(males have higher reading after puberty -ethnicity(African american have a higher blood ) pressure than other races -sympathetic stimulation -daily variation -meds -activity(some may need to increase activity to increase blood pressure.) -heredity -weight -diet(high in salt diet-more fluid-heart works harder to rid of fluid) -smoking(nicotine-vasoconstriction)
Parts of the stethoscope
-earpieces -binaurals -tubing -bell chest piece -diaphram chestpiece
axillary temp
0.9 - 1.0 degrees lower than oral
rectal temp
0.9-1.0 degrees higher than oral
pulmonary conditions, which are diseases causing poor oxygenation such as asthma and chronic obstructive pulmonary disease (COPD)... how can this affect the pulse rate?
increased pulse rate
pulse deficit
ineffiecient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site
normal pulse range for a infant
120-160
polyvinyl tubing
is flexible and 30-45 cm (12 to 18 inches)
obtaining orthostatic blood pressure
laying sitting and standing
normal pulse range for an adult
60-100
normal pulse range for a adolescent
60-90
normal pulse range for a school- ager
75-100
normal pulse range for a preschooler
80-110
normal pulse range for a toddler
90-140
long term exercise conditions the heart, resulting in....
lower rate at rest and quicker return to resting level after exercise
Guidelines for Measuring Vital Signs
Assess vital signs whenever a client enters a health care agency, during a physical assessment, and individually when to assessing a client's condition. A client's needs and condition determine when, where, how, and by whom vital signs are measured. It is important to measure vital signs correctly, understand and interpret the values, communicate findings appropriately, and begin interventions as needed. Use the following guidelines to help you incorporate vital sign measurements into nursing practice: 1. When caring for the client, the nurse is responsible for vital sign measurement. This task may be delegated to nursing assistive personnel (NAP) in stable patients. However, it is the nurse's responsibility to review vital sign measurements, interpret their significance, and make decisions about interventions. 2. Make sure equipment is in working order and appropriate to ensure accurate findings. 3. Select equipment based on the client's condition and characteristics (e.g., do not use a regular adult-size blood pressure cuff for an obese patient). 4. Know the client's usual range of vital signs. Use the client's usual values as a baseline for comparison with findings taken later. 5. Know the client's medical history, therapies, and prescribed medications. Some illnesses or treatments cause predictable vital sign changes. 6. Control or minimize environmental factors that affect vital signs. Measuring the pulse after the client exercises will yield a value that is not a true indicator of the client's condition. 7. Use an organized, systematic approach when measuring vital signs. 8. Collaborate with the health care provider to decide the frequency of vital sign assessment. In the hospital the health care provider orders a minimum frequency of vital sign measurements for each client. After surgery or treatment intervention, vital signs are assessed frequently to detect complications. As a client's physical condition worsens, it is often necessary to monitor vital signs as often as every 5 to 10 minutes. Use vital sign assessment during medication administration as well. For example, the health care provider may order certain cardiac drugs to be given within a range of pulse or blood pressure values. 9. Analyze the results of vital sign measurement. Do not interpret vital sign findings without knowing your client's other physical signs or symptoms and ongoing health status. 10. Verify and communicate significant changes in vital signs. Baseline measurements allow identification and interpretation of changes in vital signs. When vital signs appear abnormal, have another nurse or health care provider repeat the measurement. Inform the nurse in charge or health care provider of abnormal vital signs immediately, document findings in the client's record, and report vital sign changes to nurses working the next shift.
(emotions) acute pain and anxiety increase sympathetic stimulation, affecting heart rate in what way?
increased pulse rate
(hemmorrhage) loss of blood increased sympathetic stimulation. how does this affect the heart rate
increased pulse rate
(meds) positive chronotropic medications such as epinephrine. how can this affect the heart rate?
increased pulse rate
how can standing or sitting affect the heart rate ?
increased pulse rate
how would short term exercise effect your client prior to assessing vitals?
increased pulse rate
dysrythmia
alters cardiac function, particulary if it occurs repetitively
site used to auscultate the apical pulse.located fifth intercostal space at left midclavicular line
apical pulse site
if abnormal rate is detected while palpating the peripheral pulse the next step is to...
assess the apical rate
oral temp
average 98.6 degrees
sites for bp assessent
mostly assessed over the brachial artery avoid dialysis shunts are with iv mastectomy arm or fractured arm can check on lower extremity
site used to assess upper extremity blood pressure used during infant cpr. located groove between biceps and triceps muscles at antecubital fossa
brachial pulse site
easily accessible site used in patient with physciological shock or during adult cpr when othe sites are not palable. located along medial edge of sternocliedomastoid muslce in neck
carotid pulse site
(emotions) unrelieved sever pain increased parasympathetic stimulation, affecting heart rate, relaxation. how can this affect the heart rate ?
decreased pulse rate
A client that has a consistent exercise regimen could possibly have what type of pulse rate?
decreased pulse rate
how can lying down affect the heart rate?
decreased pulse rate
negative chronotropic medications such as digitals , beta-adrenergic blocker. how can this affect the heart rate?
decreased pulse rate
hypothermia can do what to the heart rate?
decreases pulse rate
Body Temperature
difference between the amount of heat produced by body processes and the amount of heat lost to the external environment.
hypotension
dizziness chest pain confusion pallor increased heart rate decreased urinary output skin is clammy
documentation of the blood pressure
document vitals on graphic sheet in nurses note should always be reported to the physician may be recorded on MAR when appropriate blood pressure is expressed as a improper fraction
pg 280 to finish
dorsalis pedis pulse site
pain or fear can cause
elevated blood pressure
factors influencing pulse rate
excercise temperature emotions medications hemorrhage psotural changes pulmonary conditions
sites used to assess character of pulse in patient with physiological shock or during cpr when other pulses are not palpable; assess status of circulation to leg
femoral pulse site
factors that increase heart rate involving temperature
fever, heat , hyperthermia
risks for orthostatic hypostension
fluid volume deficit -decreased blood volume -dehydration -recent blood loss ex. getting up from lying to standing causing dizziness and light headedness prolonged anemia antihypertensive meds
blood pressure
force exerted against the arterial wall the pulsing blood under pressure from the heart
pulse rate assessment often reveals variations in?
heart rate
assess apical pulse by listening for?
heart sounds
systolic pressure
pressure within arterial system when heart contracts contracting 90-139 mmhg
diastolic pressure
pressure within the arterial system when heart replaced and filled with blood relaxed 60-89 mm hg
common site used to assess character of pulse peripherally; assesses status of circulation to hand, located radial or thumb side of forearm at wrist
radial pulse site
orthostatic hypotension
referred to as postural hypotension sudden drop in pressure within 3 min of standing complains of light headedness or dizziness
before measuring a pulse you should?
review your client's record to obtain baseline rate for comparison.
equipment needed for bp
sphygmomanometer calibrated instrument mercury or aneroid cuff stethoscope ear tips should be positioned downward and forward with ear
hypertension
systolic bp less than or equal to 140 mm hg dialsto anxiety obesity heredity CVA vascular disease heart failure smoking high salt intake systolic below normal value may indicate and inefficient heart, shock, hemorrhage, or side effects from drugs
a client with a pulse rate over 100 beats per minute. what is that client experiencing
tachycardia
Factors of Vital Signs
temperature of the environment, physical exertion, and the effects of illness cause vital signs to change, sometimes outside the acceptable range.
Vital Signs
temperature, pulse, respiration, blood pressure (BP), oxygen saturation, and pain.
easily accessible site used to assess pulse in children. located over temporal bone of the head, above and lateral to the eye
temporal pulse site
bell
transmits low-pitched
pulse rate varies with clients age. true or false
true
site used to assess status of circulation to ulnar side of hand ; used to perform allen's test. located ulnar side of forearm at wrist
ulnar pulse site
sthethoscope
used to auscultate
korotkoff sound
vibration of the blood within the arterial wall sound heard with stethoscope as cuff is being deflated
