VITAL SIGNS Module C What are Vital Signs

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VITAL SIGNS Module C

VITAL SIGNS Module C

What are Vital Signs? • • • Temperature Pulse Respirations Blood Pressure Pain (considered

What are Vital Signs? • • • Temperature Pulse Respirations Blood Pressure Pain (considered the 5 th vital sign)

When to measure vital signs? • On admission to health care facility • In

When to measure vital signs? • On admission to health care facility • In a hospital on regular hosp schedule or as MD ordered (q 8 hours, q 4 hours, etc) • Before and after procedures (surgery, invasive diagnostic procedures) • Before, during, and after blood transfusions • When patient’s general condition changes (nursing judgment)

GUIDELINES FOR ASSESSMENT • Taken by nurse giving care • Equipment should be in

GUIDELINES FOR ASSESSMENT • Taken by nurse giving care • Equipment should be in good condition • Know baseline VS and normal range for pt and age group • Know pt’s medical history • Minimize environmental factors

GUIDELINES CONTINUED • Be organized in approach • Increase frequency of VS as condition

GUIDELINES CONTINUED • Be organized in approach • Increase frequency of VS as condition worsens • Compare VS readings with the whole picture • Record accurately • Describe any abnormal VS

VS MUST BE ACCURATE • Both measuring and recording • VS vary according to

VS MUST BE ACCURATE • Both measuring and recording • VS vary according to pt’s illness/condition • Compare results with pt’s normal • Results are used to determine treatments, medications, diagnostic work, etc

REPORTING ABNORMAL VS • WHEN—grossly abnormal, return to normal, noted change for that pt

REPORTING ABNORMAL VS • WHEN—grossly abnormal, return to normal, noted change for that pt • WHY—indicates change in metabolism or physiological function within the body • WHO—student reports to instructor, then TL, RN, Dr (follow chain of command) • HOW—orally to appropriate person, then document on chart

Body Temperature • Difference between heat produced by body processes and the heat lost

Body Temperature • Difference between heat produced by body processes and the heat lost to the external environment • Range 96. 8 – 100. 4 F (36 – 38 degree C) • Average for healthy young adults 98. 6 F or 37 degrees C • No single temp is normal for all people

HEAT IS PRODUCED BY: • Metabolism • Increased muscle activity • Vasoconstriction • External

HEAT IS PRODUCED BY: • Metabolism • Increased muscle activity • Vasoconstriction • External sources

HEAT IS LOST BY: • • • Vasodilation Convection Radiation Conduction Evaporization

HEAT IS LOST BY: • • • Vasodilation Convection Radiation Conduction Evaporization

TEMP or FEVER? • TEMPERATURE—the measurement of heat in the body • FEVER—the measurement

TEMP or FEVER? • TEMPERATURE—the measurement of heat in the body • FEVER—the measurement of heat in the body that is above normal for the individual

TYPES OF THERMOMETERS

TYPES OF THERMOMETERS

READING A THERMOMETER

READING A THERMOMETER

Normal Range Throughout Life Cycle • Adults- 96. 8 - 100. 4 degree F

Normal Range Throughout Life Cycle • Adults- 96. 8 - 100. 4 degree F • Adult Avg 98. 6 F Oral • Adult Avg 99. 5 F Rectal • Adult Avg 97. 7 F Ax • Newborn range – 95. 999. 5 F • Infants and children – same as adults • Elderly – Avg 96. 8 F

Frequently used terms: • • • Pyrexia or fever Febrile Hyperthermia Hypothermia Afebrile

Frequently used terms: • • • Pyrexia or fever Febrile Hyperthermia Hypothermia Afebrile

FEVER—A DEFENSE MECHANISM • • • Indicator of disease in body Pathogens release toxins

FEVER—A DEFENSE MECHANISM • • • Indicator of disease in body Pathogens release toxins Toxins affect hypothalamus Temperature is increased Rest decreases metabolism and heat production by the body

PATTERNS OF FEVER • SUSTAINED- remains above normal with little change • RELAPSING –

PATTERNS OF FEVER • SUSTAINED- remains above normal with little change • RELAPSING – periods of febrile episodes interspersed with acceptable temp values • INTERMITTENT—varies from normal to above normal to below normal (may have a fairly predictable pattern) • REMITTENT—fever spikes and falls w/o a return to normal temp values

Factors Affecting Body Temp • Age ( newborn- temp control mechanism immature, elderlysensitive to

Factors Affecting Body Temp • Age ( newborn- temp control mechanism immature, elderlysensitive to temp changes) • Exercise • Hormonal level • Circadian rhythm (temp normally changes 0. 9 to 1. 8 degree F /24 hr Lowest 1 -4 AM Max-6 PM ) • Stress • Environment

ORAL TEMPERATURE • • Accessible Dependable Accurate Convenient

ORAL TEMPERATURE • • Accessible Dependable Accurate Convenient

RECTAL TEMPERATURE • Most reliable • MUST hold thermometer in place

RECTAL TEMPERATURE • Most reliable • MUST hold thermometer in place

AXILLARY TEMPERATURE • Safe • Non-invasive • Least accurate

AXILLARY TEMPERATURE • Safe • Non-invasive • Least accurate

TYMPANIC TEMPERATURE • • Non-invasive Safe Accurate Disadvantages – Excessive cerumen – Improper technique

TYMPANIC TEMPERATURE • • Non-invasive Safe Accurate Disadvantages – Excessive cerumen – Improper technique

AXILLARY TEMPERATURE IMPORTANT POINTS • AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF

AXILLARY TEMPERATURE IMPORTANT POINTS • AXILLA MUST HAVE ADEQUATE TISSUE & BE FREE OF PERSPIRATION • Not good method for persons with elevated temp • Used when cannot get oral or tympanic • Leave in place 10 minutes

ORAL TEMPERATURES • Wait 15 -30 minutes after eating, drinking, chewing gum or smoking

ORAL TEMPERATURES • Wait 15 -30 minutes after eating, drinking, chewing gum or smoking • If mouth breather-do not take orally • Leave in place 2 – 4 minutes with glass thermometer

TYMPANIC TEMPERATURES • Oral & tympanic readings will be same/ similar • Must direct

TYMPANIC TEMPERATURES • Oral & tympanic readings will be same/ similar • Must direct probe toward TM (eardrum) • Follow instructions • Keep plugged in and on charger when not in use • Usually preferred method • Adults –pull pinna of ear up & back • Children under 3 y/o-pull pinna of ear down & back

RECTAL TEMPERATURES • MOST accurate • MUST hold thermometer in place • Very high

RECTAL TEMPERATURES • MOST accurate • MUST hold thermometer in place • Very high temp • Unconscious • Do not take rectal temp on clients with heart conditions • Leave in place 2 -3 min with glass thermometer • Lubricate thermometer • DO Not take hand from thermometer while rectal in progress

NURSING DIAGNOSIS Hyperthermia> 100. 4 F Hypothermia <96. 8 F Risk for altered body

NURSING DIAGNOSIS Hyperthermia> 100. 4 F Hypothermia <96. 8 F Risk for altered body temperature Ineffective Thermoregulation

Temperature Conversion • Temperature can be measured in Fahrenheit (F) or centigrade or Celsius

Temperature Conversion • Temperature can be measured in Fahrenheit (F) or centigrade or Celsius (c) • To convert F to c, subtract 32 from F reading and multiply times 5/9. Ex. (104 F – 32) x 5/9 = 40 degree c • To convert c to F, multiply the c reading by 9/5 and add 32 to the product. Example (40 x 9/5) + 32 =104 F

Pulse • Pulse- is the palpable bounding of the blood noted at various points

Pulse • Pulse- is the palpable bounding of the blood noted at various points on the body. It is an indicator of circulatory status.

TERMS RELATED TO PULSE • • • Pulse—Rate, Rhythm, Quality Pulse Deficit Auscultate Palpate

TERMS RELATED TO PULSE • • • Pulse—Rate, Rhythm, Quality Pulse Deficit Auscultate Palpate Tachycardia, Bradycardia

Pulse Sites • • • Temporal Carotid Apical Brachial Dorsalsis Pedis (Pedal) Radial and

Pulse Sites • • • Temporal Carotid Apical Brachial Dorsalsis Pedis (Pedal) Radial and Apical are most common pulse sites used! • • • Radial Ulnar Femoral Popliteal Posterior Tibial

PULSE RANGES AGE RANGE ELDERLY (65+) 60 -100 AVERAGE ADULT 60 -100 (50 or

PULSE RANGES AGE RANGE ELDERLY (65+) 60 -100 AVERAGE ADULT 60 -100 (50 or below if extremely athletic) NEWBORN 0 -24 HOURS INFANT 1 MONTH – 1 YEAR CHILDREN 120 -160 100 -120 (varies with age)

TECHNIQUE • • • Feel over BONY area DO NOT use thumb Use 2

TECHNIQUE • • • Feel over BONY area DO NOT use thumb Use 2 -3 fingers DO NOT squeeze Count 30 seconds if regular x 2 • Note Rate, Rhythm, Quality • If irregular, count for 1 full minute or take apical pulse for 1 minute.

APICAL-RADIAL PULSE • Requires 2 nurses • 1 nurse counts apical heart rate •

APICAL-RADIAL PULSE • Requires 2 nurses • 1 nurse counts apical heart rate • 1 nurse counts radial pulse • BOTH count during the same 60 seconds • 1 nurse acts as timekeeper for both nurses

PULSE DEFICIT • Count apical-radial pulse • The difference is the PULSE DEFICIT •

PULSE DEFICIT • Count apical-radial pulse • The difference is the PULSE DEFICIT • Apical pulse will always be the same or higher than the radial pulse if both are counted correctly • If the radial pulse is higher, one or both nurses counted incorrectly

Factors Affecting Pulse Rates • • Exercise Temperature Emotions Drugs Hemorrhage Postural Changes Pulmonary

Factors Affecting Pulse Rates • • Exercise Temperature Emotions Drugs Hemorrhage Postural Changes Pulmonary Conditions

Variations of Pulse Rates • Tachycardia – Abnormally elevated pulse rate. (above 100 beats/

Variations of Pulse Rates • Tachycardia – Abnormally elevated pulse rate. (above 100 beats/ min) • Bradycardia – Abnormally slow pulse rate (less than 60 beats / min)

Pulse Rhythm • Regular – A regular interval of time occurs between each heartbeat

Pulse Rhythm • Regular – A regular interval of time occurs between each heartbeat or pulse felt. • Irregular – Interval interrupted by early, late, or missed beat.

Strength and Quality of Pulse • Pulse strength may be described as weak, strong,

Strength and Quality of Pulse • Pulse strength may be described as weak, strong, bounding, or thready. • PULSE GRADING (0 -4 rating scale) • 0 – absent, not palpable • 1+ - diminished, barely palpable • 2+- easily palpable, normal pulse • 3+ - full, increased strength • 4+ - bounding, cannot be obliterated

Respirations • Mechanism the body uses to exchange gases between the atmosphere, blood, and

Respirations • Mechanism the body uses to exchange gases between the atmosphere, blood, and the cells. Involves three processes: • Ventilation • Diffusion • Perfusion

PROCESS OF RESPIRATION • EXTERNAL RESPIRATION – Inhaled air enters lungs, at alveoli O

PROCESS OF RESPIRATION • EXTERNAL RESPIRATION – Inhaled air enters lungs, at alveoli O 2 crosses over to bloodstream – CO 2 and other wastes cross over from bloodstream to alveoli and are exhaled • INTERNAL RESPIRATION – O 2 carried in bloodstream crosses over to body cells – CO 2 and other wastes from body cells cross over to the bloodstream

RESPIRATION • Chest Cavity—airtight vacuum with negative pressure • INSPIRATION—diaphragm contracts and pulls down,

RESPIRATION • Chest Cavity—airtight vacuum with negative pressure • INSPIRATION—diaphragm contracts and pulls down, ribs move up, lungs fill with air • EXPIRATION—diaphragm relaxes and moves up, ribs move down, lungs expel air

NORMAL RESPIRATION RANGE AGE RANGE ELDERLY (65+) 12 -20 AVERAGE ADULT 12 -20 NEWBORN

NORMAL RESPIRATION RANGE AGE RANGE ELDERLY (65+) 12 -20 AVERAGE ADULT 12 -20 NEWBORN 0 -24 HOURS INFANT 1 MONTH – 6 Months CHILDREN 30 -60 30 -50 (varies with age)

COUNTING RESPIRATIONS • Count pulse first, then count respirations while holding wrist • Note

COUNTING RESPIRATIONS • Count pulse first, then count respirations while holding wrist • Note rate, rhythm, quality, and character • Observe a full inspiration and expiration • Respiratory rates below 12 or greater than 20 require further assessment.

Counting Respirations cont. • If respirations regular, count respirations for 30 seconds and multiply

Counting Respirations cont. • If respirations regular, count respirations for 30 seconds and multiply times 2. • If irregular, less than 12 or greater than 20, count for 1 full minute. • Quality of respirations- assess movement of chest or abdominal wall- deep, normal, shallow • Deep- full expansion of lungs • Normal- normal • Shallow- limited expansion of lungs

Factors Influencing Characteristics of Respirations • • • Exercise Acute Pain Anxiety Smoking Body

Factors Influencing Characteristics of Respirations • • • Exercise Acute Pain Anxiety Smoking Body position • • • Medications Neurological injury Age Environmental Temp Hemoglobin Function

Blood Pressure • Force exerted on the walls of the artery. Created by the

Blood Pressure • Force exerted on the walls of the artery. Created by the pulsing blood under pressure of the heart. • Systolic- Peak and maximum pressure of ejection of blood from the heart into the aorta. This is the top number. • Diastolic- The minimal pressure remaining the heart when the heart relaxes. This is the bottom number. • Recorded as a ratio Ex. 120/80 • Pulse pressure- Difference between the systolic and diastolic. ( 120/80 – Pulse pressure 40)

EQUIPMENT FOR BP

EQUIPMENT FOR BP

“DOPPLER” OR ELECTRONIC BP READINGS

“DOPPLER” OR ELECTRONIC BP READINGS

ALTERNATIVE SITES

ALTERNATIVE SITES

MEASURING BP

MEASURING BP

MEASURING BLOOD PRESSURE • Cuff must be appropriate size • Cuff should be snug,

MEASURING BLOOD PRESSURE • Cuff must be appropriate size • Cuff should be snug, not loose • Do not put stethoscope under cuff ( place cuff 1 -2 inches above elbow) • Make mental note of systolic and diastolic numbers

MEASURING BP CONT’D • If unsure of reading, wait 30 seconds and recheck-if unsure,

MEASURING BP CONT’D • If unsure of reading, wait 30 seconds and recheck-if unsure, have someone else check with you • Loosen cuff even if to be checked q 15 minutes • Make sure all air is out cuff before applying

MEASURING BP • False high if cuff too small, false low if cuff is

MEASURING BP • False high if cuff too small, false low if cuff is too loose • Auscultatory gaptemporary disappearance of sound between first sound and next sound. • Don’t take BP on arm with IV, sling, surgery, mastectomy, renal dialysis shunt, etc.

MEASURING BP CONT’D • Pt should be sitting or lying with arm at the

MEASURING BP CONT’D • Pt should be sitting or lying with arm at the level of the heart • Distinguish Korotkoff sounds (sounds heard when taking BP) from artifact

ASSESSMENT OF BP IN BOTH ARMS • Heart disease • 1 st time BP

ASSESSMENT OF BP IN BOTH ARMS • Heart disease • 1 st time BP • 5 -10 mm Hg difference-use reading that is highest • Difference of 10 mm Hg should be reported

HOW and WHY BP TAKEN BY PALPATION • HOW-apply cuff over brachial artery •

HOW and WHY BP TAKEN BY PALPATION • HOW-apply cuff over brachial artery • Pump up to 20 -30 points above last systolic reading • Feel with 2 fingers for systolic pressure; will not feel diastolic pressure • WHY- unable to hear weak BPs

FACTORS AFFECTING BP • Exercise-increases • Arteriosclerosis (loss of vessel elasticity) & Atherosclerosis (build

FACTORS AFFECTING BP • Exercise-increases • Arteriosclerosis (loss of vessel elasticity) & Atherosclerosis (build up of plaque)increases • Transfusionsincreases • Emotions -increases

FACTORS CONT’D • Drugs • Medications • Diurnal variations

FACTORS CONT’D • Drugs • Medications • Diurnal variations

FACTORS CONT’D • • PAIN-increases Hemorrhage –decrease Sex/Gender RACE-Blacks more prone increase • Age

FACTORS CONT’D • • PAIN-increases Hemorrhage –decrease Sex/Gender RACE-Blacks more prone increase • Age • Heredity-increased chance if immediate family history

Alterations in Blood Pressure • Hypertension – most common alteration in BP. Most often

Alterations in Blood Pressure • Hypertension – most common alteration in BP. Most often asymptomatic. Characterized by persistently elevated BP. Noted when diastolic is greater than 90 mm/Hg and systolic is greater than 140 mm/Hg. Optimal BP for 18 y/o and older is less than 120/80 mm/Hg.

Alterations In BP cont • Hypotension- When systolic blood pressure falls to 90 or

Alterations In BP cont • Hypotension- When systolic blood pressure falls to 90 or below. • Orthostatic (Postural) Hypotension- Occurs when a normotensive person develops symptoms and low blood pressure when rising to an upright position.

Common Mistakes in Blood Pressure Assessments • Cuff too wide or too narrow •

Common Mistakes in Blood Pressure Assessments • Cuff too wide or too narrow • Cuff wrapped too loose or unevenly • Inflating cuff too slowly • Deflating cuff too slowly or too quickly • Arm above or below heart level or not supported • Repeating assessment too quickly • Inaccurate inflation level • Poorly fitting stethoscope • Impairment of examiners hearing

Documentation of Vital Signs • • Graphic sheets Flow sheets Nurses notes Computerized

Documentation of Vital Signs • • Graphic sheets Flow sheets Nurses notes Computerized

Pain – Fifth Vital Sign • Process of measuring pain: • Verbal and nonverbal

Pain – Fifth Vital Sign • Process of measuring pain: • Verbal and nonverbal • Characteristic of pain- onset, duration, location, quality, intensity, variations • Factors affecting pain – culture, developmental stage, gender, anxiety, previous experience • Pain scale- numerical (0 -10), verbal (descriptive), visual analog( faces pain rating scale)