Vital Signs & Pain Assessment PDF

NS-HAT 201 TOPIC 2 VITAL SIGNS & PAIN ASSESSMENT Ms. Thushara Sekhar September 20, 2024 www.gmu.ac.ae LEARNING OBJECTIVES: On completion of this unit, the student will be able to: Define vital signs and various factors influencing the vital signs Discuss no...

NS-HAT 201 TOPIC 2 VITAL SIGNS & PAIN ASSESSMENT Ms. Thushara Sekhar September 20, 2024 www.gmu.ac.ae LEARNING OBJECTIVES: On completion of this unit, the student will be able to: Define vital signs and various factors influencing the vital signs Discuss normal values and common alterations in vital signs Identify the sites for assessing temperature, pulse, blood pressure and oxygen saturation Demonstrate the equipment, Technique and Procedure of assessing vital signs Enumerate nurse’s responsibility in assessing and documenting vital signs VITAL SIGNS SIGNS OF BASIC PHYSIOLOGY OF THE BODY Vital signs allow the nurse to know how well the patient is doing or responding to treatment. 1. Body temperature. 2. Pulse / heart rate. 3. Respiration. 4. Blood Pressure 5. Oxygen saturation EQUIPMENT NEEDED Before you Collect Vital Signs Perform hand hygiene Don PPE (if needed) Perform patient identification checks Explain to the patient about the procedure for collecting vitals TEMPERATURE EQUIPMENT USED – THERMOMETER UNIT OF MEASUREMENT - Celsius or Fahrenheit 2 TYPES OF BODY TEMPERATURE – CORE &SURFACE NORMAL BODY TEMPERATURE - 36.7 Cº( 98 Fº) and 37 Cº( 98.6Fº). Taking a Temperature This can be done in various locations, such as: Mouth (oral) Armpit (axillary) Forehead (temporal) Rectum (rectal) Ear (tympanic) MEASUREMENTS TEMPERATURE can be done by HEAT SENSITIVE PATCHES NON-CONTACT INFRARED THERMOMETER TYMPANIC THERMOMETER  HYPERTHERMIA HYPOTHERMIA When the temperature is Drop in body above normal temperature below 95° F. Greater than 38-38.5 C or 101-101.5 F. Pyrexia, Febrile FACTORS INFLUENCING TEMPERATURE Age Diurnal variations Exercise Hormones Stress Environment Assessing Oxygen Saturation (O2 Sat) This is performed with an oxygen saturation monitor This device is placed on the nail bed of a finger A normal oxygen saturation is 95% to 100% Must report if the SPO2 is less than or equal to 92% RESPIRATION NORMAL RESPIRATIONS RESPIRATORY RATE Effortless Normal 12 – 20 / min Regular Bradypnea ↓ 10 / min Smooth Tachypnea 25 / min Apnea AVERAGE RESPIRATIONS Infant to 2 years 24–34/min To puberty 20-26/min Adults 12-18/min RESPIRATORY RHYTHM  Pulse rate The normal pulse for healthy adults ranges from 60 to 100 beats per minute. PULSE Tachycardia The pulse is faster than 100 beats per minute. Result from shock, hemorrhage, exercise, fever, acute pain, and drugs. Bradycardia The pulse is slower than 60 beats per minute. Result from unrelieved severe pain, drugs, resting, and heart block. How to Count a Pulse Rate 1. Use the first three fingers of your hand. 2. Note the rate, strength, and rhythm. 3. Grade the strength of the pulse with the following scale: 0: pulse not palpable or absent 1: weak, thready pulse; difficult to palpate; obliterated with pressure 2: diminished pulse; cannot be obliterated 3: easy to palpate, full pulse; cannot be obliterated 4: strong, bounding pulse; may be abnormal. 4. Count the heart rate (if regular) for 30 seconds and multiply by 2. 5. If the heart rate is irregular count for 1 full minute. 16 FACTORS AFFECTING PULSE RATE Age. As age increases, the pulse rate gradually decreases overall. Gender. Males lower than females Exercise. The pulse rate normally increases with activity. Fever - Elevated Medications. Some medications decrease the pulse rate, and others increase it. Hypovolemia/dehydration.. Stress. Position. Pathology. Types of Pulses Absent pulse: Having difficulty feeling a person’s pulse. Cannot detect a pulse at all. Weak pulse: Abnormally slow heart rate that is less than 60 beats per minute. Thready pulse: Irregularities in strength or rhythm. Bounding pulse: Strong throbbing felt over one of the arteries in the body. Pulse Assessment Techniques PULSE POINTS  BLOOD PRESSURE (BP) The pressure of blood in the arterial wall Assessment: - Normal 120-140/60-80 mmHg - Hypertension 150/90 mmHg - Hypotension ↓100 mmHg Measurements stated in terms of millimeters of mercury (mmHg)  BLOOD PRESSURE (BP) BP reading: Systolic pressure (ventricle contraction) Diastolic pressure (ventricle at rest) Pulse Pressure - Difference between the systolic and diastolic Normal BP readings record: BP 120/80 Equipment: - Sphygmomanometer - Stethoscope  In order to measure the BP Systolic blood pressure - first heard sound. Diastolic blood pressure - last heard sound.  BLOOD PRESSURE (BP) Position for measuring: - upper arm (brachial artery) Sitting position Arm and back are supported. Feet should be resting firmly on the floor and not dangling Measuring techniques: Auscultation (Sphygmomanometer + Stethoscope) Palpation (Sphygmomanometer) Invasive methods (CVP)  Blood Pressure - CUFF SIZE If it is too small, the readings will be artificially elevated. The opposite occurs if the cuff is too large.  DOCUMENTATION Vital Sign Documentation Example Heart Rate (HR) # bpm (e.g.) 72 bpm Respiratory Rate (RR) # / min (e.g.) 12/min Blood Pressure (BP) Systolic / Diastolic (mm Hg) 120/80 mm Hg Temperature (temp) °C or °F e.g. 36.80 C or 98.80 F Oxygen Saturation (O2 sat) #% e.g. 96% 5th VITAL SIGN  What is Pain???? WHAT IS PAIN? Classification of Pain Pain is broadly classified by underlying etiology, anatomic location, the temporal nature, and intensity. Underlying etiology refers to the source of the experienced pain. Anatomic location refers to the site of pain within the body and can divided into somatic and visceral. Temporal nature refers to the duration of the pain. Intensity refers to how the pain experience hurts.  Pain Underlying Anatomic Temporal Intensity Etiology Location Nociceptive Inflammatory Acute Mild Somatic Neuropathic Chronic Moderate Visceral Acute on chronic Severe Psychogenic  PAIN DESCRIPTION/ TYPE OF PAIN Achy pain: Achy pain occurs continuously in a localized area, but at mild or moderate levels. The person may describe similar sensations as heavy or sore. Like after doing unused exercise. Dull pain: Like aching pain, dull discomfort occurs at a low level over a long period of time. A dull pain is not very strong but continues for a long time. Dull pain, however, may intensify when pressure is put on the affected body part. Raw pain: Rawness usually affects the skin. If patient complains of raw-feeling pain, the area may seem extremely sore or tender. Sharp pain: When the person feels a sudden, intense spike of pain - it qualifies as “sharp.” Sharp pain may also fit the descriptors cutting and shooting. Sharp pain is sudden and severe. Stabbing pain: Like sharp pain, stabbing pain occurs suddenly and intensely. stabbing pain is a sudden, very strong pain. However, stabbing pain may fade and reoccur many times. Throbbing pain: Throbbing pain consists of recurring achy pains. The person may also experience pounding, beating, or pulsing pain.  TYPES OF PAIN ACUTE PAIN lasts for short time CHRONIC PAIN pain that lasts beyond the healing of an injury September 20, 2024 www.gmu.ac.ae CHARACTERISTICS OF PAIN SOCRATES  PAIN ASSESSMENT Onset Precipitating / alleviating factors : What causes the pain? What aggravates it? P Quality of pain: Ask the patient to describe the pain Q Radiation: R Location or radiates to other areas? S Severity: Use of description, numeric or visual T Timing: When it begin  Pain Assessment Scales Adult Pediatric Special Situations Sedation scales  Verbal Rating Scales(VRS) The pain response is noted as None, mild, moderate or severe. There are no numbers allotted or scores given for the pain. Advantage-short, easy to express and understand especially in adults and elderly. Binary pain Scale Here only two options will be given and the patient has to select in that. E.g. Do you have pain while walking? Yes/no Do you have a 60% reduction in your pain? “Yes/no”  The numerical rating scale(NRS) Most commonly used in adults. Increase or decrease in pain can be monitored closely. For example: A patient verbalized that his pain score is ‘9’ at6pm. You administered an oral pain medication. At 6:30pm the patient say his pain has reduced and it is ‘5’. This indicates that the medication is working but has not completely stopped the pain.  Visual Analog Scale (VAS) 10 cm horizontal line indicates the distance from no pain to the worst possible pain. The patient mark any point in the line. This indicates the severity of pain numerically. Disadvantage- more time consuming than others & some difficulty in understanding especially in elderly. Wong Baker Faces Scale FLACC (Face, Legs, Activity, Cry, Consolability) Scale This is a behavior scale that has been tested with children age 1 year 3 years. Each of the five categories (Faces, Legs, Activity, Cry, Consolability) is scored from 0-2 and the scores are added to get a total from 0-10. Behavioural pain scores need to be considered within the context of the child's psychological status, anxiety and other environment factors. NIPS (Neonatal Infant Pain Scale) NIPS is used from birth up to 1 year of age. Children at this age are not able to tell us if they are in pain. This scale uses body language to help us to understand if a child is in pain. A child is evaluated and either scored a 0 or 1 in each category based on their behaviour. Most of the time a score greater than 3 tells us an infant is likely to be experiencing pain or discomfort.  References Jarvis C, Eckhardt AL. Physical examination and health assessment. 9th ed. Philadelphia, PA: Elsevier - Health Sciences Division; 2023. ISBN-13: 978-0-323-80984-9. Unit 2, Chapter 10, Page no – 141-161 Weber JR, Kelley JH. Health Assessment in Nursing. 7th Edition. Wolters Kluwer; 2021. ISBN: 13: 978-1-9751-6115-6. Unit 2, Chapter 8, Page Nos – 117 - 136 Berman AT, Snyder S, Frandsen G. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice. Global Edition. 11th ed. London, England: Pearson Education; 2022. ISBN-13: 978-1-292-35979-3. Unit 7, Chapter 28, Page Nos – 532 -567