Podcast
Questions and Answers
Excessive heat loss can lead to ______________
Excessive heat loss can lead to ______________
hypothermia
Nursing interventions for clients with fever include monitoring ______________
Nursing interventions for clients with fever include monitoring ______________
Vital Signs
Severe shivering is an ________ sign of hypothermia
Severe shivering is an ________ sign of hypothermia
initial
The most common site for measuring body temperature that is safe and non-invasive is ______________
The most common site for measuring body temperature that is safe and non-invasive is ______________
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A tympanic membrane thermometer reflects the ______________ temperature
A tympanic membrane thermometer reflects the ______________ temperature
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To increase heat loss through conduction, provide a ______________
To increase heat loss through conduction, provide a ______________
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______ Pressure is measured in millimeters of mercury (mmHg)
______ Pressure is measured in millimeters of mercury (mmHg)
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Systolic Pressure is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave
Systolic Pressure is the pressure of the blood as a result of contraction of the ventricles, that is, the pressure of the height of the blood wave
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Diastolic Pressure is the pressure when the Systolic and Diastolic ______ Pressure Measured in mm Hg Recorded as a fraction e.g. 120/80mmHg Systolic = 120 and Diastolic = 80
Diastolic Pressure is the pressure when the Systolic and Diastolic ______ Pressure Measured in mm Hg Recorded as a fraction e.g. 120/80mmHg Systolic = 120 and Diastolic = 80
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Pulse Pressure is the difference between the Systolic pressure and the Diastolic Pressure - normal PP is 40mmHg (at rest) - 100mmHg (exercise)
Pulse Pressure is the difference between the Systolic pressure and the Diastolic Pressure - normal PP is 40mmHg (at rest) - 100mmHg (exercise)
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Determinants of Blood Pressure include A.Pumping Action of the Heart B.Peripheral Vascular Resistance C. ________
Determinants of Blood Pressure include A.Pumping Action of the Heart B.Peripheral Vascular Resistance C. ________
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The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an ______________.
The apical rate would confirm the rate and determine the actual cardiac rhythm for a client with an abnormal rhythm; a radial pulse would only reveal the heart rate and suggest an ______________.
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The radial pulse is appropriate for routine postoperative vital sign checks for clients with ______________ pulses.
The radial pulse is appropriate for routine postoperative vital sign checks for clients with ______________ pulses.
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It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A patient being prepared for elective ______________ surgery with a history of stable hypertension.
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A patient being prepared for elective ______________ surgery with a history of stable hypertension.
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It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A patient receiving a blood transfusion with a history of transfusion ______________.
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A patient receiving a blood transfusion with a history of transfusion ______________.
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It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A client recently started on a new ______________ agent.
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A client recently started on a new ______________ agent.
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It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A patient who is admitted frequently with ______________ attacks.
It would be appropriate to delegate the taking of vital signs of which of the following clients to a UAP? A patient who is admitted frequently with ______________ attacks.
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The ______ barked
The ______ barked
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The ______ meowed
The ______ meowed
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Common Errors in Assessing BP A.Haste B.Subconcsious basis Pulse Oximetry Copyright 2008 by Pearson Pulse Oximetry Noninvasive Estimates arterial blood oxygen saturation (SpO2) Sites – ______ (common) Normal SpO2 85-100%; < 70% life threatening Detects hypoxemia before clinical signs and symptoms Copyright 2008 by Pearson Pulse Oximetry Factors that affect accuracy include: – Hemoglobin level – Circulation – Activity – Carbon monoxide poisoning Copyright 2008 by Pearson Pulse Oximetry Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy Copyright 2008 by Pearson Delegation of Measurement of Vital Signs General considerations prior to DELEGATION – Nurse assesses to determine stability of client – Measurement is considered to be routine – Interpretation rests with the nurse Copyright 2008 by Pearson Delegating to UAP BODY TEMPERATURE – Routine measurement may be delegated to UAP – UAP reports abnormal temperatures – Nurse interprets abnormal temperature and determines response Copyright 2008 by Pearson Delegating to UAP PULSE – Radial or brachial pulse may be delegated to UAP – Nurse interprets abnormal rates or rhythms and determines response – UAP are generally not responsible for assessing apical or one person 2008 by Pearson apical-radialCopyright pulses Delegating to UAP RESPIRATIONS – Counting and observing respirations may be delegated to UAP – Nurse interprets abnormal respirations and determines response Copyright 2008 by Pearson Delegating to UAP BLOOD PRESSURE – May be delegated to UAP – Nurse interprets abnormal readings and determines response OXYGEN SATURATION – Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP – Nurse interprets oxygen saturation value and determines response Copyright 2008 by Pearson Post Test Use your clickers to complete the following post test.
Common Errors in Assessing BP A.Haste B.Subconcsious basis Pulse Oximetry Copyright 2008 by Pearson Pulse Oximetry Noninvasive Estimates arterial blood oxygen saturation (SpO2) Sites – ______ (common) Normal SpO2 85-100%; < 70% life threatening Detects hypoxemia before clinical signs and symptoms Copyright 2008 by Pearson Pulse Oximetry Factors that affect accuracy include: – Hemoglobin level – Circulation – Activity – Carbon monoxide poisoning Copyright 2008 by Pearson Pulse Oximetry Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy Copyright 2008 by Pearson Delegation of Measurement of Vital Signs General considerations prior to DELEGATION – Nurse assesses to determine stability of client – Measurement is considered to be routine – Interpretation rests with the nurse Copyright 2008 by Pearson Delegating to UAP BODY TEMPERATURE – Routine measurement may be delegated to UAP – UAP reports abnormal temperatures – Nurse interprets abnormal temperature and determines response Copyright 2008 by Pearson Delegating to UAP PULSE – Radial or brachial pulse may be delegated to UAP – Nurse interprets abnormal rates or rhythms and determines response – UAP are generally not responsible for assessing apical or one person 2008 by Pearson apical-radialCopyright pulses Delegating to UAP RESPIRATIONS – Counting and observing respirations may be delegated to UAP – Nurse interprets abnormal respirations and determines response Copyright 2008 by Pearson Delegating to UAP BLOOD PRESSURE – May be delegated to UAP – Nurse interprets abnormal readings and determines response OXYGEN SATURATION – Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP – Nurse interprets oxygen saturation value and determines response Copyright 2008 by Pearson Post Test Use your clickers to complete the following post test.
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General considerations prior to DELEGATION – Nurse assesses to determine stability of client – Measurement is considered to be ______ – Interpretation rests with the nurse Copyright 2008 by Pearson Delegating to UAP BODY TEMPERATURE
General considerations prior to DELEGATION – Nurse assesses to determine stability of client – Measurement is considered to be ______ – Interpretation rests with the nurse Copyright 2008 by Pearson Delegating to UAP BODY TEMPERATURE
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Delegating to UAP RESPIRATIONS – Counting and observing respirations may be delegated to UAP – Nurse interprets abnormal respirations and determines ______ Copyright 2008 by Pearson Delegating to UAP BLOOD PRESSURE
Delegating to UAP RESPIRATIONS – Counting and observing respirations may be delegated to UAP – Nurse interprets abnormal respirations and determines ______ Copyright 2008 by Pearson Delegating to UAP BLOOD PRESSURE
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OXYGEN SATURATION – Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP – Nurse interprets oxygen saturation value and determines ______ Copyright 2008 by Pearson Post Test Use your clickers to complete the following post test.
OXYGEN SATURATION – Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP – Nurse interprets oxygen saturation value and determines ______ Copyright 2008 by Pearson Post Test Use your clickers to complete the following post test.
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Common Errors in Assessing BP A.Haste B.Subconcsious basis Pulse Oximetry Copyright 2008 by Pearson Pulse Oximetry Noninvasive Estimates arterial blood oxygen saturation (SpO2) Sites – finger (common) Normal SpO2 85-100%; < 70% life threatening Detects hypoxemia before clinical signs and symptoms Copyright 2008 by Pearson Pulse Oximetry Factors that affect accuracy include: – Hemoglobin level – Circulation – Activity – Carbon monoxide poisoning Copyright 2008 by Pearson Pulse Oximetry Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy Copyright 2008 by Pearson Delegation of Measurement of Vital Signs General considerations prior to DELEGATION – Nurse assesses to determine stability of client – Measurement is considered to be routine – Interpretation rests with the nurse Copyright 2008 by Pearson Delegating to UAP BODY TEMPERATURE – Routine measurement may be delegated to UAP – UAP reports abnormal temperatures – Nurse interprets abnormal temperature and determines ______ Copyright 2008 by Pearson Delegating to UAP PULSE – Radial or brachial pulse may be delegated to UAP – Nurse interprets abnormal rates or rhythms and determines ______ – UAP are generally not responsible for assessing apical or one person 2008 by Pearson apical-radialCopyright pulses Delegating to UAP RESPIRATIONS – Counting and observing respirations may be delegated to UAP – Nurse interprets abnormal respirations and determines response Copyright 2008 by Pearson Delegating to UAP BLOOD PRESSURE – May be delegated to UAP – Nurse interprets abnormal readings and determines response OXYGEN SATURATION – Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP – Nurse interprets oxygen saturation value and determines response Copyright 2008 by Pearson Post Test Use your clickers to complete the ______
Common Errors in Assessing BP A.Haste B.Subconcsious basis Pulse Oximetry Copyright 2008 by Pearson Pulse Oximetry Noninvasive Estimates arterial blood oxygen saturation (SpO2) Sites – finger (common) Normal SpO2 85-100%; < 70% life threatening Detects hypoxemia before clinical signs and symptoms Copyright 2008 by Pearson Pulse Oximetry Factors that affect accuracy include: – Hemoglobin level – Circulation – Activity – Carbon monoxide poisoning Copyright 2008 by Pearson Pulse Oximetry Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy Copyright 2008 by Pearson Delegation of Measurement of Vital Signs General considerations prior to DELEGATION – Nurse assesses to determine stability of client – Measurement is considered to be routine – Interpretation rests with the nurse Copyright 2008 by Pearson Delegating to UAP BODY TEMPERATURE – Routine measurement may be delegated to UAP – UAP reports abnormal temperatures – Nurse interprets abnormal temperature and determines ______ Copyright 2008 by Pearson Delegating to UAP PULSE – Radial or brachial pulse may be delegated to UAP – Nurse interprets abnormal rates or rhythms and determines ______ – UAP are generally not responsible for assessing apical or one person 2008 by Pearson apical-radialCopyright pulses Delegating to UAP RESPIRATIONS – Counting and observing respirations may be delegated to UAP – Nurse interprets abnormal respirations and determines response Copyright 2008 by Pearson Delegating to UAP BLOOD PRESSURE – May be delegated to UAP – Nurse interprets abnormal readings and determines response OXYGEN SATURATION – Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP – Nurse interprets oxygen saturation value and determines response Copyright 2008 by Pearson Post Test Use your clickers to complete the ______
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Rate. Rhythm. Volume. Arterial wall elasticity. Presence/absence of bilateral equality. Apical-Radial Pulse Locate apical and radial sites Two nurse method: – Decide on starting time – Nurse counting radial says “start” – Both count for 60 seconds – Nurse counting radial says “stop” – Radial can never be greater than apical Copyright 2008 by Pearson Assessing the Pulse. Tachycardia – excessively fast HR. Bradycardia – Slow, less than 60bpm in adult Pulse Rhythm – pattern and interval of the beats. Dysrhythmia/arrhythmia – pulse rate with irregular rhythm. Assessing the Pulse Pulse Volume – the force of blood with each beat; aka pulse strength or amplitude - absent to bounding. Full/Bounding Pulse – obliterated with difficulty. Weak/Feeble/Thready Pulse – easily obliterated Pulse: Lifespan Considerations Infants Newborns may have heart murmurs that are not pathological Children The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old Copyright 2008 by Pearson Education, Inc.
Rate. Rhythm. Volume. Arterial wall elasticity. Presence/absence of bilateral equality. Apical-Radial Pulse Locate apical and radial sites Two nurse method: – Decide on starting time – Nurse counting radial says “start” – Both count for 60 seconds – Nurse counting radial says “stop” – Radial can never be greater than apical Copyright 2008 by Pearson Assessing the Pulse. Tachycardia – excessively fast HR. Bradycardia – Slow, less than 60bpm in adult Pulse Rhythm – pattern and interval of the beats. Dysrhythmia/arrhythmia – pulse rate with irregular rhythm. Assessing the Pulse Pulse Volume – the force of blood with each beat; aka pulse strength or amplitude - absent to bounding. Full/Bounding Pulse – obliterated with difficulty. Weak/Feeble/Thready Pulse – easily obliterated Pulse: Lifespan Considerations Infants Newborns may have heart murmurs that are not pathological Children The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old Copyright 2008 by Pearson Education, Inc.
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Dorsalis Pedis (Pedal) Figure 29-13 Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult. Assessing the Pulse: Palpation or Auscultation. Middle 3 fingers are used with moderate pressure. Nurse should determine: Any medication that could affect the HR. If client has been physically active. Baseline data about normal HR. Whether client need to assume a particular position. Measuring Apical Pulse Copyright 2008 by Pearson Assessing the Pulse Data Collection: (Characteristics of Pulse) Rate.
Dorsalis Pedis (Pedal) Figure 29-13 Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult. Assessing the Pulse: Palpation or Auscultation. Middle 3 fingers are used with moderate pressure. Nurse should determine: Any medication that could affect the HR. If client has been physically active. Baseline data about normal HR. Whether client need to assume a particular position. Measuring Apical Pulse Copyright 2008 by Pearson Assessing the Pulse Data Collection: (Characteristics of Pulse) Rate.
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Dorsalis Pedis (Pedal) Figure 29-13 Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult. Assessing the Pulse: Palpation or Auscultation. Middle 3 fingers are used with moderate pressure. Nurse should determine: Any medication that could affect the HR. If client has been physically active. Baseline data about normal HR. Whether client need to assume a particular position. Measuring Apical Pulse Copyright 2008 by Pearson Assessing the Pulse Data Collection: (Characteristics of Pulse) Rate. Rhythm.
Dorsalis Pedis (Pedal) Figure 29-13 Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult. Assessing the Pulse: Palpation or Auscultation. Middle 3 fingers are used with moderate pressure. Nurse should determine: Any medication that could affect the HR. If client has been physically active. Baseline data about normal HR. Whether client need to assume a particular position. Measuring Apical Pulse Copyright 2008 by Pearson Assessing the Pulse Data Collection: (Characteristics of Pulse) Rate. Rhythm.
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Dorsalis Pedis (Pedal) Figure 29-13 Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult. Assessing the Pulse: Palpation or Auscultation. Middle 3 fingers are used with moderate pressure. Nurse should determine: Any medication that could affect the HR. If client has been physically active. Baseline data about normal HR. Whether client need to assume a particular position. Measuring Apical Pulse Copyright 2008 by Pearson Assessing the Pulse Data Collection: (Characteristics of Pulse) Rate. Rhythm. Volume.
Dorsalis Pedis (Pedal) Figure 29-13 Location of the apical pulse for a child under 4 years, a child 4 to 6 years, and an adult. Assessing the Pulse: Palpation or Auscultation. Middle 3 fingers are used with moderate pressure. Nurse should determine: Any medication that could affect the HR. If client has been physically active. Baseline data about normal HR. Whether client need to assume a particular position. Measuring Apical Pulse Copyright 2008 by Pearson Assessing the Pulse Data Collection: (Characteristics of Pulse) Rate. Rhythm. Volume.
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Study Notes
Temperature and Heat Loss
- Excessive heat loss can lead to hypothermia.
- Monitor vital signs and temperature in patients with fever to assess progression and response to treatment.
- Severe shivering is an early sign of hypothermia.
- The tympanic membrane is a safe and non-invasive site for measuring body temperature.
- Tympanic thermometers reflect core body temperature.
Heat Loss Methods
- To increase heat loss through conduction, provide a conductive surface or wrap.
Blood Pressure Measurements
- Blood pressure is measured in millimeters of mercury (mmHg).
- Systolic pressure results from ventricular contraction, representing the peak pressure in arteries.
- Diastolic pressure occurs when the heart is relaxed; recorded as a fraction e.g., 120/80 mmHg (systolic/diastolic).
- Pulse pressure, the difference between systolic and diastolic pressure, averages around 40 mmHg at rest and can reach up to 100 mmHg during exercise.
- Determinants of blood pressure include the pumping action of the heart, peripheral vascular resistance, and blood volume.
Pulse Assessment
- The apical pulse confirms heart rate and rhythm, while the radial pulse indicates heart rate but may not reflect rhythm accurately.
- Radial pulse is sufficient for routine postoperative checks unless specified otherwise.
- Delegation of vital signs assessment should consider each patient's stability and routine status.
Delegation to Unlicensed Assistive Personnel (UAP)
- Routine temperature measurements can be delegated, while abnormal results must be reported for nurse interpretation.
- UAP may take radial or brachial pulses; apical pulse assessment usually requires a nurse.
- Observing and counting respirations, blood pressure readings, and applying pulse oximeters can be delegated to UAP, with nurses interpreting results.
- Common errors in blood pressure assessment include haste and subconscious bias.
Pulse Oximetry
- Pulse oximetry estimates arterial blood oxygen saturation (SpO2); normal range is 85-100%, with values below 70% considered life-threatening.
- Accuracy in pulse oximetry can be affected by hemoglobin levels, circulation, activity, and carbon monoxide exposure.
- Preparing a site for pulse oximetry involves aligning LED and photodetector, connecting alarms, ensuring client safety, and verifying accuracy.
Assessing the Pulse
- Characteristics of pulse assessment include rate, rhythm, and volume; tachycardia is excessively fast (>100 bpm), while bradycardia is slow (<60 bpm).
- Dysrhythmia or arrhythmia indicates irregular pulse rhythm.
- Pulse volume ranges from absent to bounding; full/bounding pulses are difficult to obliterate, while weak/thready pulses can be easily felt.
- Lifespan considerations note that newborns may have transient heart murmurs and children's apex location changes as they grow.
Apical-Radial Pulse Assessment
- To assess apical and radial pulses, a two-nurse method may be employed where one nurse assesses the radial pulse while both agree on timing.
- The radial pulse should never exceed the apical pulse in value.
Final Notes
- Always gather baseline data on a client's normal heart rate and any medications that may affect it.
- Assess responsibility levels and stability before delegating vital sign measurements to ensure quality patient care.
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Description
Learn about blood pressure, a measure of the pressure exerted by the blood as it flows through the arteries. Understand how systolic and diastolic pressures are measured in millimeters of mercury (mmHg) and recorded as a fraction, such as 120/80mmHg.
