Upload
louise-tyler
View
216
Download
1
Tags:
Embed Size (px)
Citation preview
VITAL SIGNS
Professor Blakey
NUR302
Vital Signs• Temperature • Pulse • Respirations• Blood Pressure• Health Status• Changes• Accuracy, Responsibility
Vital Signs
• When are they reported?
• When are they recorded?
Temperature
Sites:
Oral-
Taken routinely
Taken per MD order
Taken when fever is suspected
Oral Temperature
• Contraindicated with
• Unconscious patient
• Disorders of mouth
• Recently had fluids/smoked
• Wait 15 minutes
• Receiving nasal oxygen
Temperature• Rectal
• When?
• Assessing most accurate temp
• Alternative to oral site
Rectal Temp• Contraindicated with:• Newborns, small children• Diarrhea• Rectal surgery• Rectal disease• Concern re: vagus nerve
stimulation• Neurological disease
Axillary Temperature• When?
• Unable to use oral or rectal
• Newborn
• Contraindications:
• Axillary/Arm disorders
• After bathing
Normal Values
• Average values may vary 1 degree F higher or lower
F/ C• Oral- 98.6/ 37
• Rectal- 99.5/ 37.5
• Axillary- 97.6/ 36.5
Factors Affecting Temp• Circadian Rhythm (24 hours)
Predictable fluctuations-
Temp 1-2 degrees lower in early morning
Temp peaks late afternoon (4-7 pm)
Factors Affecting Temp• Age- very young and old
affected
• Gender- women
Progesterone at ovulation increases temp 0.5-1 degree
Environmental
Factors Affecting Temp• Hypothermia- low body temp
• Hyperthermia- high body temp
• Fever
Loss of appetite, headache, flushed, malaise
Severe- dehydration, alt urine output, seizures, lyte imbal
Reducing Fever• Cooling the body
• Increase fluids
• Monitor intake
• Monitor labs
• Antipyretics
• Antibiotics
Pulse• Normal range- 60-100
• Tachycardia- more than 100• Causes-• Decreased blood pressure• Elevated temp• Decreased oxygen• Heat, Pain, Medicatioins
Pulse• Bradycardia- less than 60• Caused by:• Slower in men• Thin person• Sleep• Hypothermia• Aging• Medications
Pulse Strength(Amplitude)
• 0- Absent
• 1+- Thready
• 2+- Weak
• 3+- Normal
• 4+- Bounding
• What would be reported?
Pulse Sites• Temporal (Temple)• Carotid (Neck)• Brachial (Bend of arm)• Radial- used frequently/palpate (Wrist)• Femoral (Groin)• Popliteal (Behind knee)• Posterior tibial (Inner ankle)• Dorsalis pedis (Top of foot)• Apical- used frequently/ auscultate (heart)
PulseEquipment
• Hands
• Doppler
• Stethoscope
Respirations• Ventilation
• Inspiration
• Expiration
• Normal rate- Adults 12-20 breaths per minute
Respirations• Patterns of Respiration
• Normal- 12/20 per minute
• Tachypnea- more than 24/min
(fever, anxiety, resp disease)
• Bradypnea- less than 10/min
(meds, brain injury)
Respirations• Hyperventilation- increased rate
and depth (Kussmaul’s)• Hypoventilation- decreased rate
and depth-narcotics/anesthesia
• Cheynes-Stokes- alt. deep/rapid with apnea
• Biot’s- erratic depth and apnea (brain injury)
RespirationsTerms
• Apnea- No breathing
• Dyspnea- Difficulty breathing
• Orthopnea- Breathing sitting upright
Factors Affecting Respirations
• Age- decreases with older age• Gender- males- diaphragmatic• Exercise- increases respirations• Disease- brain injury• Anemia- increases respirations• Anxiety- increases respirations• Medications- narcotics lower;
amphetamines- increases• Acute pain- increases
Respirations• Assessing:
Observation
(Other monitoring devices)
Blood Pressure• Systolic blood pressure-
contraction of ventricles (Highest pressure on arterial walls)
• Diastolic- relaxation (lowest pressure)
• Pulse pressure (PP)-
Systolic- Diastolic= PP
Blood PressureValues
• Normal- <120/ <80
• Prehypertension- 120-139/80-80-89
• Stage 1- 140-159/ 90-99
• Stage 2- >160/>100
Blood Pressure• Hypertension-
Sustained, above normal
Primary/essential HTN- no causeSecondary HTN- known etiology
Risk factors- Hx, obesity, smoking, sedentary, stress, diet
Blood Pressure• Hypotension- below normal B/P
• Orthostatic hypotension- Postural hypotension; weakness/ fainting when standing (esp when on prolonged bedrest)
Blood Pressure• Korotkoff Sounds:
Phase I- first faint clear tapping
Phase II- Swishing
Phase III- Distinct loud sounds
Phase IV- Muffling sounds
Phase V- Last sound
Blood PressureAssessment Sites
• Brachial Artery B/P Do not take in arm with IV, side
of mastectomy, AV shunt Popliteal Artery B/P
Systolic may be higher
Palpating B/PSystolic
Blood Pressure• False lows:• Releasing valve rapidly• Not pumping cuff high enough• Using faulty equipment• Did not insert earpieces correctly• Cuff too wide• Looking at meniscus above eye
level
Blood Pressure• False Highs:
• Cuff is not calibrated
• Looking at meniscus below eye level
• Cuff is too narrow
• Releasing valve too slowly
• Reinflating cuff during auscultation
Pain- the 5th Vital Sign
• Factors Affecting Pain:• It is what the patient says it is• Culture• Ethnicity• Gender• Age• Support of Others• Anxiety• Past experiences
Pain• JCAHO standards• Right to assessment and management• Ongoing assessment• Recorded• Policies and procedures• Pain must be managed• Education must be provided• Discharge planning includes pain mgt• Monitor effectiveness of mgt
Pain Assessment• Patient’s description• Duration• Location• Quantity/ Intensity• Quality• Chronology• Aggravating factors• Alleviating factors• Physiologic indicators of pain• Behavioral responses• Effect on activities and lifestyle
PainRating (p. 1384)
• Simple descriptive Pain Distress Scale
• Numeric Pain Scale
• Visual Analog Scale
• Wong-Baker Faces