NRS 103 Vital Sign Measurements; Cultural Diversity, Pain assessment

NRS 103Vital Signs, Measurements, Cultural Diversity, and Pain assessment Chapters 4,5,6. Asst. Professor: Nancy Sanderson, MSN, RN

MeasurementsHeightWeightHead CircumferenceChildren onlyBody Mass Index

Why Height & Weight?Height & weight reflects a persons general level of healthIn older adults, height & weight coupled with a nutritional assessment determine the cause of and treatment for chronic disease or helps to identify those who have difficulty feeding or other dietary issuesIn children, data is used to assess both growth and developmentWeight also necessary for dosing of medication

3Increased or Decreased HeightIncreasedGigantismDecreasedElderlyMalnutritionDwarfismHypopituitaryAchrondroplastic

4How to Measure HeightHeight (>2 y/o-adulthood)Remove shoes, and outer wear Place back to scale or wallLook straight aheadDocument in centimeters or inches to nearest 1/8 in.Length (< 2y/o)Hold head midline, push down knees until legs are flat.

5Increased or Decreased WeightIncreasedExcess NutritionCushings syndromeFluid retentionDecreasedMalnutritionAcute or Chronic illnessConsider cancerEating DisorderMental Illness

How to Measure WeightWeight (2 y/o-adult)Remove shoes and heavy outer clothing Record in pounds or kilograms (often kg for children)Record to nearest lbWeight (< 2y/o)Check calibration, remove all clothing, stay very close to infant so does not fall.Record to nearest oz in infants and lb or 0.1kg for toddlers

7Why Head Circumference?Assess for brain growth and abnormalitiesMicrocephalyMacrocephalyHydrocephalus

8Head CircumferenceMeasured at birth and each well child visit and then yearly until age 2 years.(Well child visits: 1 wk, & months 1, 2, 4, 6, 9, 12, 15, 18, 24) or if Anterior Fontanel (soft spot) closes around 18 24 monthsCircle tape at widest point and record in centimeters Above pinna or ears and around occipital prominenceMay need to repeat a few times.

9Body Mass Index (BMI)More accurate estimate of body fat than weight alone.Weight (kg)/Height (m) or Weight (lbs)/height (in.) x 703

Underweight40

10BMI: Body Mass IndexMore than than half of U.S. adults are overweight (>25)More than one quarter of U.S. adults are obese (>30)These are risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis, sleep apnea, and some forms of cancerSummary (in a nutshell) Height and Weight needed for BMI Following trends/health statusMeasure head circumference up to the age of 2

Vital signs

Vital Signs5, 6, 7, or 8 VSTemperature (T)Pulse (P)Respiratory Rate (R)Blood Pressure (BP)Pulse OxPainLevel of consciousnessUrine out put

There is a variety of vital signs to be established in an acute care setting. Base line data include measurement of temperature, pulse, respirations, blood pressure and oxygen saturation. Assessing pain is also considered standard baseline data to be collected on all patients and is often included with vital signs. Other measurements may need to be included when calling a physician or discussing care with another health care provider. 14Use of Vital Sign MeasurementsEstablish patients baselineOn admission to health care facilityBefore surgical or invasive diagnostic procedure, transfusion of blood products, administration of medications that affect cardiovascular, respiratory or temperature control functionsMonitor current condition & identify problemsAccording to routine schedule ordered by providerDuring transfusion of blood products, administration of medications that affect cardiovascular, respiratory or temperature control functions-When pts general physical condition changesWhen pt reports nonspecific symptoms of physical distress

15Use of Vital Sign MeasurementsEvaluating Response to InterventionAfter administration of medications for: Pain; Breathing treatments; Blood Transfusions: Chemotherapy; etc. TemperaturePulseBlood pressureRespirationPulse OxPainLevel of consciousness

Guidelines for Nursing PracticeCan delegate, but nurse caring for the patient is responsible for analyzing vital signs & making decisions about interventionsMake sure equipment is functioning and appropriate for the size, age, and condition of the patientKnow each patients:Medical historyPrescribed medications and therapiesBaseline vital signs

17Guidelines for Nursing PracticeKnow the minimum required frequency for obtaining vital sign measurements.Appropriately judge whether more frequent assessments are necessary.Use vital sign measurements to determine indications for medication administrationDocument vital signs and communicate significant changes to healthcare providerDevelop teaching plan to instruct pt/caregiver in vital sign assessment and significance of findings.

18Vital Signs: Temperature

19Temperature ConversionsConvert Fahrenheit to CelsiusC = (F -32) x 5/9 Convert Celsius to FahrenheitF = (9/5 x C) + 32There are graphs everywhere!

How to MeasureSurface SitesOralAxillaeSkin

Core SitesRectumTympanic MembraneTemporal Artery

21OralOral sublingual site with rich blood supply from carotid arteriesHow to use: Slide probe cover over BLUE tip probe & place in the posterior sublingual pocket with mouth completely closed. After beeps eject probe cover.Ideally wait 20-30 minutes after patient smoked or ingests hot liquids/foods. Advantages: Accurate & convenientDisadvantages: Cannot be used if the patient is unconscious, confused, seizure prone, shaking chills, less than 5 years old, disease/surgery of the mouth, mouth breather, or tachypenic

AxillaryAxillary temperature is 0.9F lower than oral tempTypically used with newborns and unconscious patientsNot recommended for fever in infants or young childrenHow to use:Slide probe cover over BLUE tip probe and place tip into center of unclothed axilla. Lower arm and place across patients chest. If child- hold childs arm next to body Advantages: Safe & accessible for infants & children when environment controlledDisadvantages: Long measurement time. Lags behind core temp during rapid temperature change. Easily affected by the environment.

Rectal TemperatureHigher than oral temps by 0.9 F (average 99.3-99.6F )Infants/Children-Rectal temp higher than adult (100 F)Measures temperature from blood vessels in rectal wallHow to use:Apply gloves, place in Sims position, separate buttocks, & dip probe cover into lubricant. Attach probe with RED tip. Insert lubricated probe cover 1-1.5 inch into rectum. Eject probe cover and wipe probe with alcohol.No Longer recommended in infants or children*!!*Unless a soft flexible temperature probe

Rectal TemperatureAdvantages: Not influenced by eating, drinking, smoking, or ability of patient to hold probe, more accurateDisadvantages: Patient discomfort & time consuming. Lags behind core temp during rapid temperature changes. Contraindicated in pre-term infants, immunosuppressed, and patients with diarrhea or rectal/GI surgery.

Tympanic Higher (1F ) than oral temperature.Senses infrared emissions of the tympanic membraneHow to use:Apply speculum cover. Pull ear up and back for >3y/o & down and back for 100.4 FHypothermia< 96.8 FSevere: < 86.0

30What do the Values Mean?Increased: Fever/HyperthermiaInfection or inflammationTrauma or disease to hypothalamusSpinal cord injuryProlonged exposure to sun/ high temperaturesFluid volume deficitOn medications that decrease bodys ability to lose heat or promote fluid lossHave congenital absence of sweat glands or serious skin disease that impairs sweating

Decreased

31Fever (Afebrile/febrile)Mild temp elevation up to 102.2F (39C) enhances immune systemWhite blood cell production stimulatedBody decreased iron concentration in blood plasma , suppressing growth of bacteriaStimulates interferons, bodies natural virus-fighting substanceProlonged fever weakens patient by exhausting energy stores, increasing oxygen demands and decreasing fluid volumeRisk of Febrile seizures & dehydration in children

32Hyperthermia- Additional S & SSweating/DiaphoresisSkin warm to touchInactivityConfusionExcessive thirstNauseaMuscle crampsVisual disturbancesIncontinence

Increased heart rateDecreased BP

If progressesUnconsciousNonreactive pupilsPermanent neurological damage33What do the Values Mean?Decreased: HypothermiaTrauma or disease to hypothalamusSpinal cord injuryProlonged exposure to cold temperaturesUnintentional exposure to cold (falling through ice at lake)Intentional- surgical to reduce metabolic demands and oxygen requirements

34Hypothermia- Additional S & SSkin cool to touchVoluntary muscle contractionShiveringMemory lossPoor judgmentDecreased heart rateDecreased respiratory rate

Decreased blood pressureSkin cyanotic

If progressesCardiac dysrhythmiasLoss of consciousnessUnresponsive to painful stimuli

35You have delegated vital signs to assistive personnel. The assistant informs you that the client has just finished a bowl of hot soup. The nurses most appropriate advice would be to: A. Take a rectal temperature.B. Take the oral temperature as planned.C. Advise the client to drink a glass of cold water.D. Wait 30 minutes and take an oral temperature.32 - 36

36Vital Signs: Pulse

Pulse BasicsPulse is the palpable bounding of blood flow created by ejection of blood into the aorta. Peripheral pulses felt by palpating arteries lightly against underlying bone or musclesProvides clinical data regarding the hearts pumping action (cardiac output)Cardiac output = heart rate x stroke volumeAbnormally slow, rapid, or irregular pulse alters CO

Pulse BasicsChanges in pulse rate caused by:Heart disease/dysrhythmias (decreased CO)AgeExercisePositions changesFluid balance (i.e. hemorrhage)MedicationsTemperatureSympathetic stimulation

39Radial & Carotid Pulse SiteRadialPlace patients forearm straight alongside body or across lower chest or abdomen. If sitting bend elbow at 90and supportPlace pads of first 2-3 fingers in groove along thumb side (radius) CarotidPlace pads of first 2-3 fingers along medial edge of sternocleidomastoid muscle in neck

Radial & Carotid Pulse SitesRate (beats/minute)If pulse is regular then count for 30 seconds and multiply by 2. If pulse irregular or weak count for 1 minute at apical siteNormal RangeAdult 60-100 bpmInfants/Children (less than or 2 years of age: apical pulsebrachial in BLS)Adults Abnormal> 100 bpm = Tachycardia< 60* bpm = Bradycardia (*exception: extreme athletic person)

Radial & Carotid Pulse SitesRhythmNormalRegularSinus Arrhythmia in children Irregular/DysrhythmiaRegularly irregularIrregularly irregular

42Radial & Carotid Pulse SitesStrength (Amplitude)NormalStrong (2+)AbnormalWeak or thready (1+)Bounding (3+)EqualityRadial: Assess on both sides to determine if equalCarotid: Never palpate simultaneously. Only one at a time.

43Apical Pulse SiteListen to the Apical heart soundAlthough called pulse you want to listen w/stethoscopeAuscultate with stethoscope & assess rate & rhythm1 full minuteIf you feel an irregular pulse when feeling radial pulse (bounding, weak, irregular, or skipped beats Any child less than 2 years old

44Apical Pulse SiteAuscultation of heart soundsOften used when:Heart rate is irregularPeripheral pulse is weakPatient taking medication that affects pulse ratePatient is < 2 y/o

45 You notice that a teenager has an irregular pulse. The best action you should take includes: A. Read the history and physical.B. Assess the apical pulse rate for one full minute.C. Auscultate for strength and depth of pulse.D. Ask if the client feels any palpations or faintness of breath.32 - 46

46Vital Signs: Respiratory Rate

Respiratory RateAssess breathing pattern.Observe chest wall expansion and bilateral symmetrical movement of thorax.Assess the rate, depth, and rhythm of each breath.Count for 30 seconds & multiply by 2 if regular patternIn infants watch abdomen and count full minute

So Patient isnt aware. . . Ask patient to move arm over chest and as you count the radial pulse you actually count the respirationsQuestionYou are counting respirations in a male patient you notice his chest is not moving much, but his abdomen has movement with each respiration this is:A. A symptom of severe respiration problemsB. Normal diaphragmatic breathingC. You need to notify the doctorD. A & C

50Vital Signs: Blood Pressure

Blood PressureSystolic: force of pressure in the walls of the arteries when the (L) ventricle contractsDiastolic: force of pressure on walls of arteries when the heart is fillingPhysiological factors controlling BP:Cardiac outputPeripheral vascular resistanceVolume of circulating bloodViscosityElasticity of vessel walls

Blood Pressure

Blood PressureAllow patient to sit for 5 minutes with feet flat on floor and legs uncrossed. Allow 30 minutes if just smoked or consumed caffeine.Select appropriate cuff size (see W & G pg. 34)Width of the bladder should cover 40% of the upper armLength of the bladder should be about 80% of upper arm (almost long enough to encircle the arm)Cuff too small, the BP will be falsely elevatedCuff too large, the BP will be falsely lowered

40%Blood PressurePlace arm at heart levelPalpate brachial artery and apply cuff to bare arm 1 inch above antecubital space with arrow over brachial arteryPalpate the radial pulse & inflate cuff until unable to palpate the radial pulse. Read this pressure on the manometer & add 30 mmHg to it.Deflate the cuff & wait 15-30 seconds

Blood PressurePlace the diaphragm lightly over the brachial arteryInflate the cuff rapidly to the level just determined, and then deflate it slowly at a rate of about 2-3 mm Hg per second. If you deflate too slowly, you can cause congestion that falsely increases the blood pressure.Too fast falsely decreased readingNote the level at which you hear the sounds of at least two consecutive beats. This is the systolic pressureContinue to lower the pressure until the sounds disappear. This is the diastolic.Read both the systolic and diastolic levels to the nearest 2 mm Hg.

What makes the sounds?

16012011078Recording Blood PressureSystolic/DiastolicRecord what arm the BP was taken onBlood pressures can normally vary 5-10 mm Hg in different arms. Subsequent BPs should be checked in the arm that has the higher value.>10-15mmHg suggests arterial compression or obstruction on side with lower pressure

Blood Pressure ClassificationNormal100

Hypotensive92% in Colorado May place clip on:FingerToeNoseEarlobeInclude the use of any type of oxygen equipment, including route and flow rate

66Summary: Vital signs are one of the most important assessment you can do! Should be done after introduction and getting history (Do first if EMERGENCY)Retake per orders or if patient shows signs of going downhill.

67The often forgotten VSPain Assessment

PainThe assessment of pain is based primarily on subjective data gathered from the patientUse your OLDCARTS/OPQRST in gathering information http://www.ems1.com/ems-products/education/tips/475522-Refining-OPQRST-as-an-Assessment-Tool/Pain intensity / rating scale is a good tool to use in assessing painWhat is the patients acceptable level of painFind out if the pain is newFind out what helps or relieves the painPharmacologicNon - pharmacologic

69Physiology of Pain Perception

70Things to remember!!!Pain is subjectiveDifferent cultures will report differentlySubjective The patients own wordsObjective What you see and can chartCryingRigidIncrease BP71Standards for Pain AssessmentCriteria for accreditation for hospitals Joint Commission has set a standard that patients have the right to appropriate assessment and management of pain. The standard includes:Initial assessment and regular assessment of pain, taking into account personal, cultural, ethical and spiritual beliefs.Education of all relevant health care personnel in pain assessment and management.Education of patients and families regarding their roles in managing pain, potential limitations, & adverse effectsof pain treatments.

Pg. 60 W & G McGill Pain Questionnaire73OPQRST PAIN ASSESSMENTOnset: Did your pain start suddenly or gradually get worse and worse? This is also a chance to ask, What were you doing when the pain started? Provokes or Palliates: Instead of asking, What provokes your pain? use real, casual words. Try, What makes your pain better or worse?Quality: Asking, Is your pain sharp or dull? limits your patient to two choices, when their pain might not be either. Instead ask, What words would you use to describe your pain? or What does your pain feel like?Radiates: This is another chance to use real, conversational words during assessment. Asking, Does your pain radiate? sounds silly and pompous to the patient. Instead use this question, Point to where it hurts the most. Where does your pain go from there?Severity: Remember, pain is subjective and relative to each individual patient you treat. Have an open mind for any response from 0 to 10. Time: This is a reference to when the pain started or how long ago it started.

FLACC

75Acute Pain BehaviorsGuardingGrimacingRubbing/splinting of body partsStillnessRestlessness/reduced attention spanAvoidance of social contact or conversationRefusing to eat, nausea, vomitingVocalization (i.e. moaning, crying)Agitation/striking outDiaphoresisChange in vital signs ( Pulse, Resp, BP) PAIN IS A CULTURALLY EXPRESSED PHENOMENON 76Summary: Pain assessment is the most under assessed VSPain is culturally dependent and subjectiveSeveral tools to help you assess painChildren in the hospital for surgery or accident this is probably their worse pain77