Vital Signs, Lecture 2 CLINICAL
Vital Signs, Lecture 2 CLINICAL NUR 324
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This 12 page Class Notes was uploaded by altaylor10 Notetaker on Friday September 2, 2016. The Class Notes belongs to NUR 324 at University of Alabama - Tuscaloosa taught by Dr. Kaylor in Winter 2016. Since its upload, it has received 2 views. For similar materials see Fundamentals of Nursing Practice in NURSING at University of Alabama - Tuscaloosa.
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Date Created: 09/02/16
Vital Signs 8/26 Clinical Lecture 2 When someone thinks of nursing care, they often think of a nurse checking a patient's vital signs. This activity is an integral part of nursing and health care. Vital signs include: temperature pulse respiration blood pressure oxygen saturation Vital signs are exactly that: Physical signs that are vital to the normal functioning of an individual. Key points to remember: When assessing vital signs: Be systematic. Developing a routine way of practice establishes good habits that will insure that important considerations are not omitted or compromised. Accurately measure and record. Vital signs provide baseline data concerning the condition of the patient on first observation and then progressively throughout the span of care. o This information may be crucial in decisions that are made concerning the implementation of therapeutic care. o This is especially true when the information can be viewed historically over the span of care. o If a person's vital signs begin to deviate from an established baseline, the nurse can further assess the individual to determine the cause of the individual's changing data. o Make sure to document vital signs right away. Make them part of the daily routine and assessment. Vital Signs require critical thinking. Collecting this data is only valuable if the subsequent nursing actions are appropriate. These actions include: o Interpretation o Documentation in the appropriate medical record o Reporting of abnormal values o If a patient is not feeling well, or they don’t look like they feel well, you should check their vital signs. Timing is everything. Follow agency guidelines as to the timing and frequency required for the collection of vital sign information. o There are certain situations where the nurse should always check vital signs, which relies upon critical thinking abilities to determine these situations. o Vital signs should always be checked when a person is admitted to a hospital or enters a clinic situation. This provides that initial, baseline data. o Once care has been initiated, the health care provider will probably order that vital signs be checked every hour, every four hours, or every shift, depending on the stability of the patient. Delegate when appropriate. The collection of vital signs can be delegated to unlicensed assistive personnel as determined by the nurse. o Whenever a procedure is to be done that could result in changes in the patient's condition, the nurse will check vital signs. Situations that are included here are surgical or diagnostic procedures. o If a person's condition changes, the nurse should assess the patient's vital signs. An example of this indicator is of a patient who has gotten out of bed to ambulate to the restroom and faints or feels weak. o Sometimes, the patient may tell the nurse that they cannot describe what they feel, but that they feel strange or different. This also is an indication that vital signs should be evaluated. Temperature Body temperature is a recording of the balance of heat production and heat release by the body. Factors that result in heat production include: o Basal metabolic rate o The amount and rate of muscle activity o The level of thyroid hormones o Sympathetic stimulation o A simple example of heat production in relation to body temperature would be the person who has been exercising. This person's body temperature would probably be temporarily higher than normal limits. The nurse should also remember that many bodily functions are affected by the circadian rhythms. o The body temperature will normally fluctuate approximately one to two degrees F. during a 24 hour period. o These changes result in the persons temperature trends being lowest between 1:00 and 4:00 AM. o The temperature will rise steadily until about 6:00 PM and then decline again until the early morning. o This is a steady pattern that changes very little if at all in response to age, activity level or even shift work. When measuring temperature repeatedly, the same site should be used and compared. Temperature below 96.8 is called hypothermia. Temperature above 100.4 is called hyperthermia, hyperpyrexia, or fever. Anything under this number is not considered a fever. Factors affecting temperature readings: Age: o At birth, the newborn's ability to regulate temperature is immature and can vary greatly based on environmental conditions. This can result in the newborn being too cool or too warm and this being reflected in the infant's temperature reading. o Children may have slightly higher normal temperature ranges until they reach adulthood. o Older adults do not withstand temperature extremes as well as do younger adults. Their normal temperature ranges are narrower than when they were younger. This results in a decreased tolerance to changes in temperature. Exercise: o Physical activity results in increased metabolism and heat production. This will result in a temporary increase in body temperature. o Conversely, the inactive person may have a body temperature at the lower end of the normal range. Circadian rhythms result in the variation in temperature seen during a 24-hour period. Stress: o An increase in body temperature is seen during times of both physical and emotional stress. This is due to the hormonal or neural stimulation. This can be seen in situations where the person is very anxious about the experience of hospitalization. Environment: o This is seen in examples such as hypothermia when someone is exposed to extremely low temperatures during a snow storm or extremely high temperatures during the summer months. o Temperature is a balance between heat production and heat loss. When external factors overwhelm the body's ability to compensate, the body temperature will go outside the normal range. Hormone levels are responsible for changes in body temperature. o These changes may be helpful indicators when someone wants to time ovulation for the purpose of becoming or avoiding becoming pregnant. o During the time of menopause, the woman may also experience changes in body temperature. Hot flashes are periods of intense heat and sweating due to the loss of control of heat regulating mechanisms during this time. Conditions that affect heat loss: There are four main mechanisms for heat loss (see Potter & Perry). o Conduction: the transfer of heat from one object to another with direct contact. This occurs when a person touches or lies on a colder object such as an infant being placed on a cold metal scale after birth. Babies can get cold extremely quick. o Convection: the loss of heat due to the movement of air across the person. Modern air-conditioning vents that direct cool air into a room may result in this event. o Radiation: the transfer of heat from the surface of one object to the surface of another. People lose a large amount of heat to surrounding structures in this manner. Many students are surprised to learn that it is not necessary to touch this colder object to lose heat. o Evaporation: the transfer of heat when a liquid on the body is changed to a gas. Examples: The newly born infant that is not properly dried after birth. They will get cold extremely fast and it can be detrimental. The person who receives a bedbath without being properly dried. The elderly person who is having their posterior chest prepped with a disinfectant solution prior to a procedure. Applying room temperature water on patient is actually really cold. Methods for temperature measurement: Site selection requires the nurse to consider not only the person's preference, but more importantly the most accurate site for the recording. When documenting temperature make sure to document the specific site. Oral site: most frequently used and is preferred in most situations. o Used if the person is able to keep the thermometer safely in place for the required length of time. o Examples where this may not be possible include persons who are confused, uncooperative, or those with physical conditions that would prevent the mouth from remaining closed for the required length of time. o Do not use oral site if patient is drinking coffee, soup or iced tea. o ^ Always ask if they have had something to eat or drink within the last couple of minutes. Axillary sites: may be used when the oral route cannot be used. o When documenting, record the temperature that was measured, and specify “Ax” o When interpreting the documented measure, add one degree Tympanic site: quick and accurate site for core temperatures. o Frequently used with children and in clinics and offices. o When documenting, record the temperature that was measured, and specify “T” o When interpreting the documented measure, add one degree Rectal site: provides accurate information of core temperature. o When documenting, record the temperature that was measured, and specify “R” o When interpreting the documented measure, subtract one degree o This site is least preferred due to the embarrassment of the patient; it has traditionally been used with infants. o The rectal site would not be chosen if there has been recent rectal surgery, or rectal abscesses; there is always a risk of damage to the rectal tissues. o MENTALLY add and subtract degrees. Always document the exact number. o Make sure to look at the color of the thermometer- may be different for different sites. Elevated temperatures: The clinical appearance of hyperpyrexia (fever) or hyperthermia is of clinical significance. Its presence can signal important changes in the body or attempts to fight infection. It occurs when the heat-losing mechanisms of the body are outpaced by the mechanisms of heat production. The body temperature will rise above the upper range of normal. Fever is one of the body's important defense mechanisms, as it plays a role in enhancing the body's immune system. The response to fever in a clinical setting will depend on the degree of rise, the suspected cause, and the duration. Abnormal rises in temperature should always be recorded and reported. Common patterns of fever include: o A continuous or sustained fever: The significant characteristic in this pattern is that the fever is a persistent elevation that lasts over 24 hours. o An intermittent fever will have normal readings with spikes of fever interspersed between normal readings. o A remittent fever will have rises and falls as the intermittent fever, but the lower readings will not return to normal ranges. o A relapsing fever will be exhibited when the person has periods of normal and abnormal temperatures. These periods may last longer than 24 hours. Conditions Causing Fever: different types of conditions that cause an elevation in body temperature will require different responses to bring the temperature under control and back to the normal range. The many conditions that cause fever can be grouped into three main categories: Conditions that result in increased heat production. Example: infection o The body attempts to defend itself against infection by increasing the activity of the immune system. Conditions that prevent heat loss. Example: heat stroke. (Outside cutting grass all day) o The heat-regulating mechanisms shut down, and the body is unable to decrease its temperature as it normally would. Conditions that result in elevated body temperature. Example: head injury o The centers of the central nervous system that control the heat- regulating function of the body are compromised and do not function properly. Conversion of Temperature: C = (F - 32) x 5/9 F = (9/5 x C) + 32 Pulse The pulse is the palpation of the wave of blood flow as it is ejected from the heart with contraction. As the heart contracts the blood leaves the heart and enters a continuous circuit. The blood supplies needed oxygen and nutrients to tissues, which is essential to the functioning of the body. Thus, a normal pulse is one of those essential signs of life, or vital signs. When checking the pulse, it is best to check for one full minute and record. If necessary, the pulse may be checked for a shorter time and multiplied accordingly. o Example: If the pulse is counted for 30 seconds, multiply by 2. Pulse Assessment can be delegated to assistive personnel if the patient is considered stable. Four main qualities of Pulse Assessment: Rate: the number of times in one minute that the heart pumps out the blood. o Normal pulse range for an adult is 60 to 100 beats per minute (bpm). A pulse less than 60 beats per minute is called bradycardia A pulse higher than 100 beats per minute is called tachycardia o Rate will vary with age: a newborn infant’s rate will be in a normal range between 120 and 160 bpm. o If the patient has been active, allow them to sit and rest for 5-10 minutes prior to assessing to allow the pulse rate to return to baseline. * Rhythm: The rhythm refers to the interval between each beat, which should be regular. o Since the wave of blood flow that we call a pulse is dependent on the heart activity, it is expected that the timing of the events of cardiac compression and relaxation in a regular pattern. If the interval varies enough to be detected by palpation of the pulse, it is said to be an irregular rhythm. Strength: refers to the force of the wave of blood ejected from the heart, which is expected to be approximately the same force with each beat. o A variety of terms are used to describe the strength of the pulse, but the most common are absent (0), weak or thready (1+), normal (2+), and full or bounding (3+). o The pulses at comparable sites, i.e. right and left femoral, should be equal in strength. If there are differences noted, this fact should be reported. This finding may indicate a blockage of blood flow to the area. Location: Pulse sites are those points located throughout the body where the pulse may be palpated. o Locate each pulse site on yourself or a partner. Remember to use your fingertips, not your thumb to locate these sites. Temporal Carotid Apical: Most reliable to assess cardiac function Brachial Radial-lower hand Ulnar Femoral Popliteal Posterior tibialis Dorsalis pedis o The apical or brachial is recommended for infants and young child assessment. Arrhythmia: If a pulse rate lacks the normal, regular rhythm, an arrhythmia of some type is present and further investigation may be needed. When assessing an irregular rhythm, compare the apical and radial pulses simultaneously to determine if a pulse deficit exists. A pulse deficit exists when the radial pulse is slower than the apical pulse. o This happens because ineffective contractions fail to send pulse waves to the periphery. o A pulse deficit should be reported to the health care provider. o Two individuals are needed to assess for a pulse deficit; one person to assess the apical pulse and one to assess the radial pulse simultaneously. Factors affecting pulse rate: Exercise: will initially increase the heart rate in an effort to bring increased amounts of oxygen-laden blood to the tissues. o The pulse rate of athletic individuals will be less than an individual in similar condition. Fever and heat: will result in an increase in the pulse as the body attempts to bring warmer blood to the body surface in an attempt to reduce body temperature. Need for oxygen: will result in this increase in the pulse rate. If brain needs oxygen it’s going to need more blood-containing O2, therefore increasing pulse rate. Medications: may either increase or decrease the pulse rate. o For these medications, it is an important nursing action to evaluate the pulse prior to the administration of those medications. Acute loss of blood: will result in an increase in the pulse rate. Age Position Changes Fluid balance Sympathetic stimulation Respirations The action of respiration allows the body to bring in needed oxygen and give off the waste product carbon dioxide. Any condition or activity that increases this need may result in an increased respiratory rate. Respirations are always documented as breaths per minute. Because breathing is not a conscious activity, don’t tell the patient you are about to count respirations. Calling attention to the activity often makes the patient unconsciously alter their rate or pattern of breathing. Respiration assessment can be delegated to assistive personnel as long as the patient is stable. Qualities of Respiratory Assessment: Rate: The normal range is 12-20 breaths per minute o Respirations less than 12 are called bradypnea. o Respirations greater than 20 are called tachypnea. o *NOTE: There is a discrepancy in texts; Potter & Perry states the normal adult respiratory rate as 12-20, whereas Jarvis states the normal adult respiratory rate as 10-20. For the purposes of this class —in discussions, exams, and clinical activities-- we will use the 12-20 range, although for bradypnea, clinical action is not indicate until a respiratory rate is less than 10. Depth: o In hyperpnea, there is an increase in the depth of the respiration, which is seen in situations such as exercise. o When respirations cease for at least several seconds, apnea is said to have occurred. o If both rate and depth of respirations increase, hyperventilation is occurring. o If both rate and depth decrease, the term is known as hypoventilation. Rhythm: If regular, respirations may be assessed for 30 seconds and multiplied by 2. If irregular, respirations should be assessed for one full minute. * Conditions affecting Respirations: Consider the pathophysiology of each of these conditions and determine if the respiratory rate would be increased or decreased: Chest wall pain Anemia Pneumothorax Emphysema Neuromuscular diseases Individual or environmental factors: o Exercise, acute pain, anxiety, and smoking (increase respiratory rate) o Brainstem injury may result in a drop in the respiratory rate o Body position change may increase or decrease the rate depending on the nature of the change. o Medications may decrease the respiratory rate Oxygen saturation: used to evaluate the diffusion and perfusion of oxygen in tissue (also known as checking someone's "sat level.") Uses a small machine called a pulse oximeter that is non-invasive and usually involves a clip-on device that is placed on the person's finger. Normal arterial saturations are between 92 and 100%. There are conditions, such as chronic lung disease, that would prevent saturation levels from reaching normal. Blood Pressure Blood pressure measurements are among those vital signs that are evaluated upon admission and routinely during the course of treatment. Can be checked at anytime. Blood pressure assessment greatly depends on an understanding of the following: o BP=CO x PVR o Cardiac Output (CO) =Heart Rate (HR) x Stroke Volume (SV) o Peripheral Vascular Resistance (PVR) is the resistance to blood flow determined by the tone of vascular musculature and diameter of the blood vessels. Blood Pressure is the force exerted on the walls of an artery by the pulsating blood under pressure from the heart. o The systolic pressure is the sound of the highest force of the wave of blood as it is pushed from the heart. This is when ejection of the blood occurs. o The diastolic pressure is the measure of the lowest pressure. This compares with the resting point. This is when relaxation of the ventricles occurs. Optimal BP: 120 or </ 80 or < Normal 90-140/60-90 o Hypertension (HTN) occurs when the SBP>140 or the DBP > 90 o Hypotension occurs when the SBP < 90. This may be due to vasodilation, hemorrhage, or other decrease in CO o Orthostatic hypotension: occurs when a drop of BP of 10-20 mmHg with position change. This may be due to: hypovolemia, medications, anemia, abnormal electrolytes There is always some pressure in the vessels. The difference between the two (systolic and diastolic) pressures is called the pulse pressure and represents the stroke volume of the heart. When the nurse evaluates the blood pressure (BP), they can assess several points of information: o Efficiency of the heart as a pump: If the heart is not pumping effectively, blood will leave the heart and be sent to the periphery as it should and blood "backs-up" in the circulatory system. o Elasticity of vascular walls: If the walls of the arteries are not flexible, the pressure is higher because the walls of the vessels do not "give" with the pulse. o Blood volume: If a person has lost a great amount of blood, there is less volume of blood in the vessels to exert pressure. o Resistance to blood flow found in the peripheral vasculature: If there is resistance to the flow of blood in the periphery, the pressure increases. Factors affecting Blood Pressure: Medications that cause vasoconstriction or vasodilation will result in changes in the person's blood pressure. Medications have the potential to have a profound effect on the blood pressure. Age: As we age, there may be a gradual rise in our BP. Stress: accompanied with continual tension may cause an increase after time. Ethnicity: BP is often higher in blacks than in whites. o This is important to remember as screening may need to begin earlier in blacks and health teaching may need to be stressed earlier and more often. Diurnal variation: Individuals may see a peak and trough phenomenon where their blood pressure is lower upon awakening and higher at the completion of a busy day. Exercise will cause a temporary increase in BP, but long-term exercise will improve the cardiovascular system and should result in a decrease in blood pressure. Weight is also an important indicator; over-weight individuals are more likely to have an increased blood pressure than their counterparts whose weights are within normal range. Equipment Needed for Blood Pressure Assessment: Sphygmomanometer, Stethoscope, Appropriate size cuff o Cuff bladder should encompass 80% of adult arm and 100% of child arm. Korotkoff Sounds: the sounds heard when blood pressure is being auscultated 1 Sound: Corresponds to systolic BP nd 2 : blowing, whoosing sound due to turbulence of blood flow 3 : crisper, more intense tapping th 4 : muffled, low pitch as cuff deflates as cuff pressure falls below vessel pressure 5 sound: Corresponds to diastolic BP in adults and adolescent Ausculatory gap: associated with an increased BP, this finding occurs when the sound disappears then returns—may be as much as 40mmHg** be sure to inflate cuff 30mmHg above the pressure at which the radial pulse was last palpated. Locations for Blood Pressure Assessment: Upper arm/ AC Brachial* Lower arm/ Radial Thigh/Popliteal (SBP may be 10-40mmHg higher than brachial) AVOID these locations: o No BP in same side as Mastectomy (both old and new) o No BP in same side as dialysis shunt o Surgery, Trauma, CVA o Congenital malformations Try to avoid IV’s if possible. Sometimes it’s impossible to avoid IVs if they have one in each arm. If patient is active, allow to rest 5-10 minutes before assessing BP. *
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