Chapter 32 Vital Signs NRS 102 Mosby items

General Survey Physical appearance Age Ø Sex Ø Level of consciousness Ø Skin color

General Survey Body structure Stature Ø Nutrition Ø Symmetry Ø Posture Ø Position Ø Body build, contour Ø Mobility Gait Ø Range of motion Ø Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

General Survey Behavior Ø Ø Ø Facial expression Mood and affect Speech Dress Personal

Guidelines for Measuring Vital Signs Establish a baseline for future assessments. Be able to understand interpret values. Appropriately delegate measurement. Communicate findings. Ensure equipment is in working order. Accurately document findings. Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Body Temperature Physiology Body temperature: Heat produced Ø Heat lost Ø Temperature range: Ø 98. 6° F to 100. 4° F or 36° C to 38° C Temperature sites: Ø Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Body Temperature Regulation Neural and vascular control Heat production Heat loss Skin temperature regulation Behavioral control Thermoregulation Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Factors Affecting Body Temperature Age Exercise Hormonal level Circadian rhythm Environment Temperature alterations Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Abnormal Body Temp Hypothermia Heat loss during prolonged exposure to cold Classified by core temp (mild-severe) May be intentional (surgery) Early signs- uncontrolled shivering, loss of memory, poor judgment Later signs- Cyanosis, decreased VS, cardiac dysrhythmias, loss of consciousness Frostbite- body exposure to subnormal temps Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Abnormal Body Temp Hyperthermia Elevated body temp related to body’s inability to promote heat loss or reduce heat production Heatstroke- prolonged exposure to sun or high environmental temp. Heat depresses hypothalamus function Heat Exhaustion- profuse diaphoresis result in fluid & electrolyte loss Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate

Nursing Process and Temperature Assessment Diagnosis Planning Implementation Evaluation Mosby items and derived items

Pulse, Physiology, and Regulation The indicator of circulatory status Electrical impulses originate from the sinoatrial (SA) node. Cardiac output, heart rate, stroke volume Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume. Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Assessment of Pulse Sites Use of stethoscope Character of pulse Nursing process and pulse

Knowledge check! Which patient would be most likely to present with a pulse rate that is lower than normal? A. A 70 -year-old telephone salesman presenting with dehydration. B. A 20 -year-old runner who had surgery 4 days ago for a fractured leg. C. A 67 -year-old who presented with an exacerbation of his COPD Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 18

Respiration Ventilation Diffusion Perfusion Physiological control Mechanics of breathing Mosby items and derived items

Assessment of Ventilation Easy to assess Respiratory rate Ventilatory depth Ventilatory rhythm Diffusion and perfusion Arterial oxygen saturation Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 20

Assessing Respirations Assessing rate- observe full inspiration & expiration Assess for full minute Normal adult 12 – 20 breaths/minute Varies with age, rate declines throughout life Apnea Monitor Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 21

Normal & Abnormal Respirations Eupnea- normal respirations Bradypnea- abnormally slow < 12 Tachypnea- abnormally fast >20 Hyperpnea- labored, after exercise Hyperventilation/Hypoventilation Cheyne-Stokes Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 22

Nursing Process and Respiratory Vital Signs Measurements include: Ø Respiratory rate, pattern, depth, Sp. O 2, ventilation, diffusion, perfusion Nursing diagnosis Interventions Planning Evaluation Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 23

Arterial Blood Pressure and Physiology Force exerted on walls of an artery Systolic and diastolic Cardiac output Peripheral resistance Blood volume Viscosity Elasticity Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 24

Factors Influencing Blood Pressure Age Stress Ethnicity Gender Daily Variation Medications Activity, weight Smoking Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 25

Hypertension and Hypotension Hypertension Hypotension Ø More common than Ø 90 mm Hg hypotension Ø Thickening of walls Ø Loss of elasticity Ø Family history Ø Risk factors Ø Dilation of arteries Ø Loss of blood volume Ø Decrease of blood flow to vital organs Ø Orthostatic/postural Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 26

Factors controlling Blood Pressure Mosby items and derived items © 2009, 2005 by Mosby,

Measurement of Blood Pressure Mosby items and derived items © 2009, 2005 by Mosby,

Vital Signs Blood pressure Systolic pressure Ø Diastolic pressure Ø Pulse pressure Ø Mean arterial pressure Ø Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. Slide 9 -29 29

Measurement of Blood Pressure Equipment Auscultation Children Ultrasonic stethoscope Palpation Lower extremity Electronic blood pressure Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 30

Nursing Process and Blood Pressure Determination Assessment of blood pressure and pulse evaluates the general state of cardiovascular health. Hypertension, hypotension, orthostatic hypotension, or narrow/wide pulse pressures define nursing diagnoses. Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 31

Knowledge check! Significant elevation in blood pressure measurements from one day to the next could be attributed to: A. A decrease in cuff size B. An increase in cuff size C. New onset of pain or anxiety D. A and C Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 32

Measurement of Arterial Oxygen Saturation Pulse oximeter Allows indirect measurement of oxygen saturation Sp. O 2 is a reliable estimate of Sa. O 2 Measurement is affected if extremity is cold, edematous or if nail polish is present (interference with light transmission) Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 33

Health Promotion and Vital Signs Monitor vital signs. Include age-related factors. Include environmental and activity factors. Mosby items and derived items © 2009, 2005 by Mosby, Inc. , an affiliate of Elsevier Inc. 36