Vital Signs - Engage Fundamentals and Potter

Vital Signs – Engage Fundamentals and Potter & Perry book Chapter 29 Objectives • Define terminology related to assessing vital signs. • Identify equipment used for measuring temperature. • Explain the process for measuring temperature. • Explain the process for measuring pulse (central and peripheral). • Identify equipment used for measuring pulse (central and peripheral). • Identify equipment used for measuring respiration. • Explain the process for measuring respiration. • Identify equipment used for measuring blood pressure. • Explain the process of measuring blood pressure. • Identify assessment tools for measuring pain. • Explain the process of measuring pain. • Recognize abnormal findings. • Explain the relationship between vital sign measures. • Describe considerations for documenting vital signs. Vocabulary (1 of 4) • THERMOREGULATION • RADIATION • CONDUCTION • CONVECTION • EVAPORATION • DIAPHORESIS • PYREXIA • FEBRILE • AFEBRILE • HYPERTHERMIA Vocabulary (2 of 4) • VENTILATION • OXYGEN SATURATION • CAPNOGRAPHY • BRADYPNEA • TACHYPNEA • HYPERPNEA • APNEA • HYPERVENTILATION • HYPOVENTILATION • SYSTOLIC Vocabulary (3 of 4) • DIASTOLIC • PULSE PRESSURE • CARDIAC OUTPUT • VISCOSITY • ANTIHYPERTENSIVE MEDICATIONS • HYPERTENSION • HYPOTENSION • ORTHOSTATIC HYPOTENSION • POSTURAL HYPOTENSION • SPHYGMOMANOMETER • KOROTKOFF PHASES Vocabulary (4 of 4) • HEATSTROKE • HEAT EXHAUSTION • HYPOTHERMIA • FROSTBITE • TACHYCARDIA • BRADYCARDIA • PULSE DEFICIT • PULSE SITES • DYSRHYTHMIA What are Vital Signs? Temperature Pulse Respirations Blood Pressure Pain **See chart Box 29-1 in Potter & Perry page 503 for acceptable ranges for adults Pulse Oximetry Copyright © 2017, Elsevier Inc. All Rights Reserved. 7 Body Temperature: Physiology Body temperature: Heat produced - heat lost = body temperature Acceptable temperature range: Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery 96.8° F to 100.4° F or 36° C to 38° C Copyright © 2017, Elsevier Inc. All Rights Reserved. 8 Body Temperature Regulation Body Thermostat = HYPOTHALAMUS- located between cerebral hemispheres Copyright © 2017, Elsevier Inc. All Rights Reserved. 9 HEAT IS LOST BY: Vasodilation Radiation Conduction Convection Evaporation Copyright © 2017, Elsevier Inc. All Rights Reserved. 10 Factors Affecting Body Temperature Age Exercise Hormone level Circadian rhythm Stress Environment Temperature alterations Copyright © 2017, Elsevier Inc. All Rights Reserved. 11 Potential Client Problems Hyperthermia Hypothermia Temperature Alterations Fever (pyrexia) Heat-loss mechanisms are unable to keep pace with excessive heat production Febrile Afebrile Copyright © 2017, Elsevier Inc. All Rights Reserved. 13 Temperature Alterations  Malignant Hyperthermia  Hyperthermia  Heat exhaustion (98.60 – 1040F) Profuse diaphoresis = water and electrolyte imbalance  Heatstroke(>104°F) prolonged exposure to heat overwhelm body’s heat-loss mechanisms  Hypothermia (<950F core) Copyright © 2017, Elsevier Inc. All Rights Reserved. 14 Nursing Process Assessment Sites Thermometers Copyright © 2017, Elsevier Inc. All Rights Reserved. 15 Quick Quiz! 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: 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. Copyright © 2017, Elsevier Inc. All Rights Reserved. 16 • Answer: D • Rationale: The consumption of hot liquids will affect oral temperature readings. Quick Quiz! The nurse would monitor the body temperature most closely/frequently in the care of: A. The client with an infection B. The client who is an infant C. The client who has experienced heat stroke D. The client with a head injury Copyright © 2017, Elsevier Inc. All Rights Reserved. 18  Correct Answer : D  All of the clients depicted would need to have their temperatures monitored closely. However, a client with a head injury may have damage to the hypothalamus and therefore loss of global thermoregulation. The temperature of this client would need to be monitored more frequently. Pulse  Pulse  Rhythmic expansion of an artery produced when blood is forced into it by the contraction of the heart. Palpable bounding of blood flow noted at various points on the body (pulse sites)  The indicator of circulatory status  Pulse rate  Number of pulsing sensations in 1 minute (60-100 BPM)  Cardiac Output = HR X Stroke Volume of ventricle Copyright © 2017, Elsevier Inc. All Rights Reserved. 20 Assessment of Pulse Sites: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis Use of stethoscope Copyright © 2017, Elsevier Inc. All Rights Reserved. 21 Assessment of Pulse (Cont.) Character of the Pulse Rate Rhythm Strength (Quality) Copyright © 2017, Elsevier Inc. All Rights Reserved. 22 TECHNIQUE for Palpation of Pulses Feel over BONY area DO NOT use thumb Use 2-3 fingers DO NOT squeeze Count 30 seconds if regular x 2  Note Rate, Rhythm, Quality  If irregular, count for 1 full minute or take apical pulse for 1 minute.      Copyright © 2017, Elsevier Inc. All Rights Reserved. 23 APICAL-RADIAL PULSE and PULSE DEFICIT  Requires 2 nurses  1 nurse counts apical heart rate  1 nurse counts radial pulse  BOTH count during the same 60 seconds  1 nurse acts as timekeeper for both nurses Copyright © 2017, Elsevier Inc. All Rights Reserved.  Count apical-radial pulse  The difference is the PULSE DEFICIT  Apical pulse will always be the same or higher than the radial pulse if both are counted correctly  If the radial pulse is higher, one or both nurses counted incorrectly 24 Factors affecting Pulse Rate Developmental stage Gender Disease Thyroid Pulmonary Exercise Drugs Fever Hemorrhage Stress Postural Changes Copyright © 2017, Elsevier Inc. All Rights Reserved. **See Potter & Perry Table 29.5 Factors Influencing Heart Rate page 515 25 Potential Client Problems Activity Intolerance Anxiety Deficient/excess fluid volume Acute Pain Impaired gas exchange Decreased Cardiac Output Ineffective peripheral tissue perfusion Quick Quiz! 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. Copyright © 2017, Elsevier Inc. All Rights Reserved. 27 • Answer: B • Rationale: If you detect an abnormal rate while palpating a peripheral pulse, the next step is to assess the apical rate. Respiration 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. Copyright © 2017, Elsevier Inc. All Rights Reserved. 29 Movements During Breathing Mechanics of breathing Copyright © 2017, Elsevier Inc. All Rights Reserved. 30 Assessment of Ventilation  Easy to assess Respiratory rate: breaths/minute 12 – 20 breaths/minute for adult = eupnea <12 bpm = Bradypnea > 20 bpm = Tachypnea Ventilatory depth (degree of excursion or movement in chest wall): deep, normal, shallow Ventilatory rhythm (interval between breaths): regular/irregular Copyright © 2017, Elsevier Inc. All Rights Reserved. 31 Assessment of Diffusion and Perfusion Measure oxygen saturation of the blood using a pulse oximeter 95 – 100% Copyright © 2017, Elsevier Inc. All Rights Reserved. 32 Influential Factors  Exercise  Acute Pain  Anxiety  Smoking  Body Position  Medications  Neurological Injury  Hemoglobin **See Potter & Perry Box 29.6 pg 517  Age  Temperature Copyright © 2017, Elsevier Inc. All Rights Reserved. 33 Potential Client Problems Activity Intolerance Ineffective Airway Clearance Anxiety Ineffective Breathing Pattern Impaired Gas Exchange Acute Pain Ineffective Peripheral Tissue Perfusion Quick Quiz! 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. Copyright © 2017, Elsevier Inc. All Rights Reserved. 35 • Answer: C • Rationale: Shortness of breath is an indicator of hypoxemia. Assessing the oxygen saturation will let the nurse know if the patient’s breathing status is a result of hypoxemia. Blood Pressure  Force exerted on the walls of an artery by pulsing blood under pressure from the heart Systolic = Maximum peak pressure during ventricular contraction Diastolic = Minimal pressure during ventricular relaxation  Unit of measurement: mm Hg  Recorded as a ratio Example: 120/80 mm Hg  Pulse pressure = Difference between systolic and diastolic pressures Copyright © 2017, Elsevier Inc. All Rights Reserved. 37 Physiology of Arterial Blood Pressure Factors Affecting Arterial Blood Pressure Cardiac output Peripheral resistance Blood volume Viscosity Elasticity Copyright © 2017, Elsevier Inc. All Rights Reserved. 38 Factors Affecting Blood Pressure Age Daily Variations Ethnicity Medications Stress Activity, weight Gender Smoking Categories of BP in Adults  Acceptable = <120 mm Hg Systolic and <80 mm Hg Diastolic  Elevated = 120 – 129 mm Hg Systolic and <80 mm Hg Diastolic  Hypertension Stage 1 = 130-139 mm Hg Systolic and 80 – 89 mm Hg Diastolic  Hypertension Stage 2 = > or = 140 mm Hg Systolic and > or = 90 mm Hg Diastolic Hypertension “Silent Killer” Importance of Taking Blood Pressure Medication Diet Modifications Exercise Antihypertensive Medications Diuretics Beta blockers Vasodilators Calcium Channel blockers ACE inhibitors ARBs – Angiotensin-II Receptor blockers **See Potter & Perry Table 29.9 Antihypertensive Medications page 521 Hypotension Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs Orthostatic/postural Copyright © 2017, Elsevier Inc. All Rights Reserved. 43 Measurement of Blood Pressure Equipment Sphygmomanometer Aneroid manometer Occlusive cuff with inflatable bladder Pressure bulb with release valve Copyright © 2017, Elsevier Inc. All Rights Reserved. 44 Measurement of Blood Pressure Auscultation Ultrasonic stethoscope or Doppler Palpation (systolic pressure) Copyright © 2017, Elsevier Inc. All Rights Reserved. 45 Reasons to not take Blood Pressure in an Arm Dialysis Graft or Fistula Mastectomy on that side Pacemaker on that side IV Fluids - ….. Paralyzed side in a stroke patient Measurement of Blood Pressure (Cont.) Lower-extremity blood pressure Electronic blood pressure devices Copyright © 2017, Elsevier Inc. All Rights Reserved. 47 Pulse Pressure Pulse pressure is the difference between the upper and lower numbers of your blood pressure. This number can be an indicator of health problems before you develop symptoms. Your pulse pressure can also sometimes that you’re at risk for certain diseases or conditions.  Pulse pressures of 50 mmHg or more can increase your risk of heart disease, heart rhythm disorders, stroke and more. Higher pulse pressures are also thought to play a role in eye and kidney damage from diseases like diabetes. Potential Client Problems  Hypotension, hypertension, orthostatic hypotension, and narrow or wide pulse pressures are defining characteristics of certain nursing diagnoses, including the following:  Activity Intolerance  Anxiety  Decreased Cardiac Output  Deficient/Excess Fluid Volume  Risk for Injury  Acute Pain  Ineffective Peripheral Tissue Perfusion 49 Pain Scales 50 Pain Severity 0 No Pain 1-3 Mild Pain 4-6 Moderate Pain 7-10 Severe Pain Health Promotion and Vital Signs Monitor vital signs. Include age-related factors. Include environmental and activity factors. 52 Recording Vital Signs Record values (electronic in computer). 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 53 course of action. Safety Guidelines for Nursing Skills 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. 54