CHAPTER 11 Vital Signs 1 Mosby items and

Which needs more assessment? 1. 2. 3. 4. Regular sinus rhythm B/P of 120/86 Rectal Temp of 99. 8 Respiratory rate of 30 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 2

What’s most important for an oral temp just after smoking? Rinse mouth with water 2. Place thermometer firmly under tongue 3. Wait 15 minutes to take temp 4. Shake down thermometer 1. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 3

Which is the least accurate site for body temperature? 1. 2. 3. 4. Oral

Which statement by the patient needs further investigation? “I will request pain meds when I can no longer stand the pain” 2. Distraction and imagery techniques help my pain. 3. I need to change my position regularly 1. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 5

Which assessment relates directly to pain? 1. Blood Pressure 100/60 2. Dilated pupils 3. Pulse 80 beats per minute 4. Respirations 14 per minute Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 6

The PT is teaching a client to take a core temperature. Which sites would be used? 1. Skin 2. Mouth 3. Axilla 4. Rectal Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 7

A client having her B/P taken asks, “What does B/P actually represent? 1. It’s the wave of blood created by contraction of the left ventricle of the heart. 2. It’s a measurement of the pressure exerted by the blood as it pulsates through the arteries. 3. It’s a measure of the volume of blood in the cardiac region. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 8

Pulse rate of 140 beats per minute is known as 1. 2. 3. 4.

A pedal pulse site is used to: 1. 2. 3. 4. Determine discrepancies with the radial pulse Identify venous thrombus Determine circulation to the foot. As the primary means of checking heart rate. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 10

You arrive at bedside to take vital signs just after client has had a cup of coffee. What do you do? 1. 2. 3. 4. Ask client to rinse mouth to normalize temp Ask client to not eat, drink, or smoke for 30 min, then take V/S. Take all the V/S except temp…do that later Proceed to take the v/s according to Hospital routine. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 11

Which post surgery patient is in most need of pain meds? Patient with Pulse 120, R 22 , b/p 140/92. 2. “I’m starving and have a dull ache in my back 3. Patient with pulse of 68, R 18 and b/p 100/76 1. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 12

Which B/P in an adult is considered hypertension 1. 2. 3. 4. 110/70 130/80

Vital Signs ► They are called vital signs because they are important. ► They include: § § Temperature Pulse Respirations Blood pressure ► Vital signs and other physiologic measurements can be the bases for problem solving. ► Many facilities have developed a fifth vital sign pain level/comfort level. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 14

Guidelines for Obtaining Vital Signs ► The Psych Tech must be able to do all of the following: § Measure vital signs correctly § Understand interpret the values § Communicate/document findings accurately § Begin interventions as needed Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 15

Oximetry ►A non-invasive device that measures the level of oxygenation in the blood. ► An excellent addition to information received via vital signs. ► Will have a lesson on the operation and values of oximetry in the nursing lab. ► Peg try to get a picture or example Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 16

Temperature ► Many factors can cause body temperature variances. § Environment § Time of day § Patient’s state of health § Activity levels § Stage of monthly menstrual cycle Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 17

Temperature ► Temperature is a relative measure of sensible heat or cold. ► The body strives to maintain a temperature of 98. 6° F (37° C), which is considered normal. ► Normal range is 97° to 99. 6° F (36. 1° to 37. 5° C). ► The hypothalamus helps maintain a balance between heat lost and heat produced by the body. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 18

Temperature ► Two Types of Body Temperature § Core Temperature ►Temperature of the deep tissues of the body ►Remains relatively constant unless exposed to severe extremes in environmental temperature ►Assessed by using a thermometer device § Surface Temperature ►Temperature of the skin ►May vary a great deal in response to the environment ►Assessed by touching the skin Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 19

Temperature ► Temperature measurements are obtained by several methods. § Heat-sensitive patches ►Patch placed on the skin; color changes on the patch indicate temperature readings § Electronic thermometers ►Consist of a rechargeable battery-powered display unit, a thin wire cord, and a temperature processing probe § Tympanic thermometer ►Special form of electronic thermometer; inserted into auditory canal Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 20

Figure 11 -2 (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. ) Disposable, single-use thermometer strip. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 21

Figure 11 -3 (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. ) Electronic thermometer. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 22

Figure 11 -4 (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. ) Tympanic thermometer with probe cover inserted into auditory canal. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 23

Temperature Pyrexia, Febrile, or Hyperthermia § When the temperature is above normal § Fever is actually a body defense; it will destroy invading bacteria. ► Classification of Fevers § Constant: remains elevated consistently § Intermittent: rises and falls § Remittent: temperature never returns to normal until the patient becomes well ► Hypothermia § An abnormally low body temperature Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 24

Temperature ► Oral temperature is not obtained in the comatose or disoriented patient or in small infants. ► Rectal temperatures are contraindicated for patients with recent rectal surgery or certain conditions of the perineum. ► Axillary temperature is considered the least accurate method. ► Rectal readings are normally 1° F higher than oral, and axillary readings are 1° F lower than oral. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 25

Auscultating Using the Stethoscope ► When assessing the apical heart rate, the PT uses

Using a stethoscope ► video Mosby items and derived items © 2006, 2003, 1999,

Figure 11 -6 (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. ) Parts of a stethoscope. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 28

Auscultating Using the Stethoscope ► Chestpiece § Diaphragm: circular, flat-surfaced portion of the chest piece covered with a thin plastic disk § Transmits high-pitched sounds created by the high-velocity movement of air and blood § Bell: bowl-shaped chestpiece, usually surrounded by a rubber ring. Transmits low-pitched sounds created by the low-velocity movement of blood. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 29

Pulse ► There is a rhythmic beating or vibrating movement. ► The pulse is the regular, recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts. ► The PT notes the rate, rhythm, and volume of the pulse. ► Adult pulse rate is normally between 60 and 100 beats per minute. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 30

Figure 11 -7 Pulse sites. Mosby items and derived items © 2006, 2003, 1999,

Pulse ► Tachycardia § The pulse is faster than 100 beats per minute. § It may result from shock, hemorrhage, exercise, fever, acute pain, and drugs. ► Bradycardia § The pulse is slower than 60 beats per minute. § It may result from unrelieved severe pain, drugs, resting, and heart block. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 32

Pulse ► Dysrhythmia § Any disturbance or abnormality in a normal rhythmic pattern, specifically irregularity in the normal rhythm of the heart ► Any artery can be assessed for pulse rate, but the radial and carotid arteries are peripheral pulse sites that are easily palpated. ► The radial and apical locations are the most common sites for pulse rate assessment. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 33

Figure 11 -9 (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. ) A, Point of maximum impulse is at fifth intercostal space. B, Assessing apical pulse. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 34

Pulse ► Pulses on both sides of the peripheral vascular system should be assessed. ► Pulses are palpated using the pads of the index and middle fingers; only slight pressure is applied over the artery to avoid obliterating the pulse. ► Apical pulse represents the actual beating of the heart. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 35

Pulse ► When auscultated, the “lubb-dubb” heard represents one cardiac cycle, or heartbeat. ► Pulse deficit: difference between the radial and apical rates; signifies that the pumping action of the heart is faulty. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 36

Figure 11 -8 (From Sorrentino, S. A. [2004]. Mosby’s textbook for nursing assistants. [6 th ed. ]. St. Louis: Mosby. ) Taking an apical/radial pulse. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 37

Respirations ► The taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing. § Internal Respirations ►The exchange of gas at the alveolar level § External Respirations ►Breathing movements that can be observed by the nurse; inspiration and expiration Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 38

Respirations ► Assessment includes the rate, depth, rhythm, and quality. § The normal rate for an adult is between 12 and 20 per minute. ►Tachypnea § Rapid respiratory rate; exercise and fever increase respiratory rate ►Bradypnea § A slow respiratory rate, below 12 per minute § The depth of respiration is determined by the amount of air taken in with inhalation. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 39

Figure 11 -10 Patterns of respirations. Mosby items and derived items © 2006, 2003,

► Assessment Respirations includes the rate, depth, rhythm, and quality. (continued) § The rhythm of respiration should be regular and uninterrupted. ► Dyspnea § Breathing with difficulty ► Apnea § A lack of spontaneous respirations ► Cheyne-Stokes respirations § An abnormal pattern of respiration; alternating patterns of apnea and deep, rapid breathing. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 41

Blood Pressure ► The pressure exerted by the circulating volume of blood on the arterial walls, veins, and chambers of the heart. § Systolic ►The higher number; represents the ventricles contracting § Diastolic ►The second number; represents the pressure within the artery between beats § Pulse Pressure ►Difference between the systolic and diastolic Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 42

Blood Pressure ► Normal blood pressure in the adult is 120/80 mm Hg. ► Hypertension § Sustained elevated blood pressure is above 140/90 mm Hg. ► Hypotension § Blood pressure is below normal. ► Orthostatic Hypotension § A drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when moving from lying to sitting or sitting to Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 43

Blood Pressure ► Sphygmomanometer § A device for measuring the arterial blood pressure § Consists of an inflatable cuff and a gauge § The cuff is inflated around the patient’s arm to compress the artery; then it is slowly deflated while the nurse listens at the brachial artery with a stethoscope and hears pulsating sounds. ►Korotokoff sounds: The first sound heard is the systolic pressure; the point at which the last sound is heard is the diastolic pressure. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 44

Figure 11 -11 (From Sorrentino, S. A. [2004]. Mosby’s textbook for nursing assistants [6 th ed. ]. St. Louis: Mosby. ) Aneroid manometer and cuff. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 45

Figure 11 -12 (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. ) Wall-mounted aneroid sphygmomanometer. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 46

Figure 11 -17 Electronic sphygmomanometer. Mosby items and derived items © 2006, 2003, 1999,

Figure 11 -14 (From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. ) Doppler stethoscope over brachial artery to measure blood pressure. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 48

Figure 11 -13 (From Potter, P. A. , Perry, A. G. [2005]. Fundamentals of nursing. [6 th ed. ]. St. Louis: Mosby. ) The sounds during blood pressure measurement can be differentiated into five Korotkoff phases. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 49

Blood Pressure ► Assessment Extremities of Blood Pressure in the Lower § Occasionally, the upper extremities may be inaccessible, so blood pressure must be measured in the lower extremities. § The popliteal artery, located behind the knee, is the site for auscultation. § The cuff must be wide and long enough to allow for the larger girth of the thigh and is positioned with the bladder over the posterior aspect of the midthigh. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 50

Figure 11 -15, A (A, From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. ) A, Lower-extremity blood pressure cuff positioned above popliteal artery at midthigh. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 51

Figure 11 -15, B (A, From Elkin, M. K. , Perry, A. G. , Potter, P. A. [2004]. Nursing interventions and clinical skills. [3 rd ed. ]. St. Louis: Mosby. ) B, Location of the popliteal artery and placement of the cuff. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 52

Blood Pressure ► Automatic Measurement Devices § Many automatic devices can determine blood pressure automatically. § Once the cuff is applied, the nurse can program the device to obtain and record blood pressure readings at preset intervals. ► Self-Measurement § Portable home devices § Stationary automated machines Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 53

Height and Weight ► Helps assess normal growth and development ► Aids in proper drug dosage calculation ► May be used to assess the effectiveness of drug therapy, such as diuretics ► Significant loss of weight may be a sign of an underlying disease Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 54

Height and Weight ► Height § Patient should remove shoes and stand erect. § A measuring stick or tape may be attached vertically to the weight scales or wall. § Standing scales may have a metal rod, which is attached to the back of the scale and swings out over the top of the patient’s head. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 55

Height and Weight ► Weight § Types of scales ►Standing scales ►Chair scales; lift scales § Used for patients who cannot stand § Patients should be weighed at the same time of day, on the same scale, and in the same type of clothing to allow an objective comparison of subsequent weighing. § Patient should void before weighing. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 56

Figure 11 -18 (From Sorrentino, S. A. [2004]. Mosby’s textbook for nursing assistants. [6 th ed. ]. St. Louis: Mosby. ) Types of scales. A, Standing scale. B, Chair scale. C, Lift scales. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 57

When Vital Signs Are Assessed ► Temperature, pulse, respirations, and blood pressure are usually assessed at the same time at set intervals. ►A set of vital signs is taken when the patient is admitted to the facility and then as prescribed by the physician or as policy dictates. ► Example: every 4 hours; once a shift; weekly Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 58

When Vital Signs Are Assessed ► The more ill the patient, the more frequently vital signs are taken. ► Vital signs are interrelated. § A rise in temperature of 1° F may cause an increase in pulse rate of 4 beats per minute. § Respiratory rate and blood pressure readings increase with a rise in temperature. § Blood pressure falls because of hemorrhage, the pulse and respirations increase and the temperature usually decreases. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 59

Recording Vital Signs ► Graphic Flow Sheet § Used for charting vital signs § R indicates a rectal temperature § Ax indicates an axillary temperature § Blood pressures are always written with the systolic first and the diastolic beneath. ►Example: 120/80 § Apical pulse is indicated with an “ap” after next to the number. ►Example: 78 ap Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 60

Recording Vital Signs ► Any abnormal findings are reported to the nurse-manager or physician immediately. ► Any accompanying or precipitating signs and symptoms such as chest pain, vertigo, shortness of breath, flushing, and diaphoresis should be recorded as well. ► The nurse documents any interventions initiated as a result of vital sign measurement, such as tepid sponging. Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 61

Nursing Process ► Assessment § Normal daily fluctuations § Factors likely to interfere with accuracy of vital sign reading § Medications that may influence vital signs § Factors that influence vital signs § Conditions that precipitate fever, such as infections § Pertinent laboratory values § Previous baseline vital signs from patient’s Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 62

Nursing Process ► Nursing Process § Fluid volume deficient § Hyperthermia § Hypothermia § Body temperature, risk for imbalance § Gas exchange, impaired Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby, Inc. Slide 63