Vital Signs and Laboratory Reference Intervals PDF

CHAPTER 10 Foundations of Care Vital Signs and Laboratory Reference Intervals Linda A. Silvestri, PhD, RN, FAAN Angela E. Silvestri, PhD, APRN, FNP-BC, CNE PRIORITY CONCEPTS Cellular Regulation;...

CHAPTER 10 Foundations of Care Vital Signs and Laboratory Reference Intervals Linda A. Silvestri, PhD, RN, FAAN Angela E. Silvestri, PhD, APRN, FNP-BC, CNE PRIORITY CONCEPTS Cellular Regulation; Perfusion I. Vital Signs 6. Whenever a client’s condition changes or the cli- A. Description: Vital signs include temperature, pulse, ent verbalizes unusual feelings such as nonspe- respirations, blood pressure (BP), oxygen saturation cic symptoms of physical distress (i.e., feeling (pulse oximetry), and pain assessment. funny or different, feeling sick) B. Guidelines for measuring vital signs 7. Whenever an intervention (e.g., ambulation) 1. Initial measurement of vital signs provides base- may affect a client’s condition line data on a client’s health status and is used to 8. When a fever or known infection is present help identify changes in the client’s health status. (check vital signs every 2 to 4 hours) 2. Some vital sign measurements (temperature, 9. See Clinical Judgment: Analyze Cues Box pulse, respirations, BP, pulse oximetry) may be delegated to assistive personnel (AP), but the II. Temperature nurse is responsible for interpreting the ndings. A. Description 3. The nurse collaborates with the primary health 1. In the literature, variations regarding the nor- care provider (PHCP) in determining the fre- mal range of body temperature are noted. Ac- quency of vital sign assessment and also makes cording to 2020 WebMD, the normal body independent decisions regarding their frequency temperature can fall within a wide range, on the basis of the client’s status. from 97.0° F (36.1° C) to 99.0° F (37.2° C). https://www.webmd.com/lung/what-is-a-fever#1 The nurse ensures that vital sign measurements 2. A person is considered to have a fever if they have are documented correctly and reports abnormal, unex- an elevated temperature, feel warm to touch, re- pected ndings to the PHCP. port feeling feverish, have a ushed face, glassy eyes, or chills (https://www.cdc.gov/quarantine C. When vital signs are measured /air/reporting-deaths-illness/denitions-symp- 1. On initial contact with a client (e.g., when a cli- toms-reportable-illnesses.html) ent is admitted to a health care facility; clinic vis- 3. Some health care providers consider a client has its, home care visits) a fever if the temperature is at or above 100.4° F 2. During physical assessment of a client (38° C). It is important to follow agency guide- 3. Before and after an invasive diagnostic proce- lines and provider preferences regarding the nor- dure or surgical procedure mal range of body temperature. 4. During the administration of medication that 4. Common measurement sites are the mouth, affects the cardiac, respiratory, or temperature- rectum (unless contraindicated), axilla, ear, and controlling functions (e.g., in a client who has a fe- across the forehead (temporal artery site). ver; a client taking a antihypertensive medication or 5. Rectal temperatures are usually 1° F (0.5° C) other cardiac medication); may be required before, higher, and tympanic and axillary temperatures during, and after administration of the medication about 1° F (0.5° C) lower than the normal oral  5. Before, during, and after a blood transfusion temperature.  CHAPTER 10 Vital Signs and Laboratory Reference Intervals 117 client to keep the tongue down and the lips closed BOX 10.1 Body Temperature Conversion and to not bite down on the thermometer. Foundations of Care To convert Fahrenheit to Celsius: Degrees Fahrenheit 2. Rectal – 32 × 5/9 = Degrees Celsius a. Place the client in the left side-lying position. Example: 98.2° F – 32 × 5/9 = 36.7° C b. The temperature is taken rectally when an accu- To convert Celsius to Fahrenheit: Degrees Celsius × 9/5 + 32 rate temperature cannot be obtained orally or via = Degrees Fahrenheit other methods, including by an electronic meth- Example: 38.6° C × 9/5 + 32 = 101.5° F od, or when the client has nasal congestion, has undergone nasal or oral surgery or had the jaws wired, has a nasogastric tube in place, is unable to 6. Know how to convert a temperature to a Fahren- keep the mouth closed, or is at risk for seizures. heit or Celsius value (Box 10.1). c. The thermometer is lubricated and inserted B. Nursing considerations into the rectum, toward the umbilicus, about 1. Time of day 1.5 inches (3.8 cm) (no more than 0.5 inch a. Temperature is generally in the low-normal [1.25 cm] in an infant). range at the time of awakening as a result of muscle inactivity. The temperature is not taken rectally in cardiac cli- b. Body temperature peaks in the late afternoon ents; the client who has undergone rectal surgery; or the or evening, sometimes by as much as 1 or 2 de- client with diarrhea, fecal impaction, or rectal bleeding grees, usually as a result of the metabolic pro- or who is at risk for bleeding. cess, activity, and environmental temperature. 2. Environmental temperature: Body temperature 3. Axillary is lower in cold weather and higher in warm a. This method of taking the temperature is weather. used when the oral or other methods of tem- 3. Age: Temperature may uctuate during the rst perature measurement are contraindicated. year of life because the infant’s heat-regulating b. Axillary measurement is less accurate than mechanism is not fully developed. the oral, rectal, tympanic, or temporal artery 4. Physical exercise: Use of the large muscles creates methods but is used when other methods of heat, causing an increase in body temperature. measurement are not possible. 5. Menstrual cycle: Temperature decreases slightly c. The thermometer is placed in the client’s dry just before ovulation but may increase to 1° F axilla, and the client is asked to hold the arm above normal during ovulation. tightly against the chest, resting the arm on the 6. Pregnancy: Body temperature may consistently chest. Follow the instructions accompanying the stay at high-normal because of an increase in the measurement device for the amount of time the woman’s metabolic rate. thermometer should remain in the axillary area. 7. Stress: Emotions increase hormonal secretion, 4. Tympanic leading to increased heat production and a high- a. The auditory canal is checked for the pres- er temperature. ence of redness, swelling, discharge, or a for- 8. Illness: Infective agents and the inammatory eign body before the probe is inserted; the response may cause an increase in temperature. probe should not be inserted if the client has 9. The inability to obtain a temperature should not an inammatory condition of the auditory be ignored, because it could represent a condi- canal or if there is discharge from the ear. tion of hypothermia, a life-threatening condi- b. The reading may be affected by an ear infec- tion in very young and older clients. tion or excessive wax blocking the ear canal. C. Methods of measurement 5. Temporal artery a. Ensure that the client’s forehead is dry. b. The thermometer probe is placed ush against Various types of electronic measuring devices are com- the skin and slid across the forehead or placed in monly used to measure temperature; it is important to fol- the area of the temporal artery and held in place. low the manufacturer’s instructions on the use of the device. c. If the client is diaphoretic, the temporal ar- tery thermometer probe may be placed on 1. Oral the neck, just behind the earlobe. a. If the client has recently consumed hot or cold foods or liquids or has smoked or III. Pulse chewed gum, the nurse must wait 15 to 30 A. Description minutes before taking the temperature orally. 1. Pulse is a palpable bounding of blood ow in b. The thermometer is placed under the tongue in a peripheral artery; it is an indirect indicator of one of the posterior sublingual pockets; ask the circulatory status. 118 UNIT III Foundations of Care 2. The average adult pulse (heart) rate is 60 to 100 BOX 10.2 Grading Scale for Pulses beats per minute. 3. Changes in pulse rate are used to evaluate the Foundations of Care 4 + = Strong and bounding client’s tolerance of interventions such as ambu- 3 + = Full pulse, increased lation, bathing, dressing, and exercise. 2 + = Normal, easily palpable 4. Pedal pulses are checked to determine whether 1 + = Weak, barely palpable the circulation is blocked in the artery up to that 0 = Absent, not palpable pulse point. 5. When the pedal pulse is difcult to locate, a Dop- 10. The dorsalis pedis pulse is located on the top pler ultrasound stethoscope (ultrasonic stetho- of the foot, in line with the groove between the scope) may be needed to amplify the sounds of extensor tendons of the great and rst toes. pulse waves. B. Nursing considerations The apical pulse is counted for 1 full minute and 1. The heart rate slows with age. is assessed in clients with an irregular radial pulse or 2. Exercise increases the heart rate. a heart condition, before the administration of cardiac 3. Emotions stimulate the sympathetic nervous sys- medications such as digoxin and beta blockers, and in tem, increasing the heart rate. children younger than 2 years. 4. Pain increases the heart rate. 5. Increased body temperature causes the heart rate E. Pulse decit to increase. 1. In this condition, the peripheral pulse rate (radi- 6. Stimulant medications increase the heart rate; al pulse) is less than the ventricular contraction depressants and medications affecting the car- rate (apical pulse). diac system slow it. 2. A pulse decit indicates a lack of peripheral perfu- 7. When the BP is low or when the client has de- sion; it can be an indication of cardiac dysrhythmias. creased circulating volume, the heart rate is usu- 3. One-examiner technique: Auscultate and count ally increased. the apical pulse rst and then immediately count 8. Hemorrhage increases the heart rate. the radial pulse. C. Assessing pulse qualities 4. Two-examiner technique: One person counts 1. When the pulse is being counted, note the rate, the apical pulse and the other counts the radial rhythm, strength (force or amplitude), and equality. pulse simultaneously. 2. Once you have checked these parameters, use 5. A pulse decit indicates that cardiac contractions the grading scale for pulses to assess the infor- are ineffective, failing to send pulse waves to the mation you have elicited (Box 10.2). periphery. D. Pulse points and locations 6. If a difference in pulse rate is noted, the PHCP is 1. The temporal artery can be palpated anterior to notied. or in the front of the ear. 2. The carotid artery is located in the groove be- IV. Respirations tween the trachea and the sternocleidomastoid muscle, medial to and alongside the muscle. A. Description 3. The apical pulse may be detected at the left mid- 1. Respiration is a mechanism the body uses to ex- clavicular, fth intercostal space. change gases between the atmosphere and the 4. The brachial pulse is located above the elbow blood and between the blood and the cells. at the antecubital fossa, between the biceps and 2. Respiratory rates may vary with age. triceps muscles. 3. The normal adult respiratory rate is 12 to 20 5. The radial pulse is located in the groove along breaths per minute. the radial or thumb side of the client’s inner B. Nursing considerations wrist. 1. Many of the factors that affect the pulse rate also 6. The ulnar pulse is located on the medial side of affect the respiratory rate. the wrist (little nger side of the forearm at the 2. An increased level of carbon dioxide or a lower wrist). level of oxygen in the blood results in an increase 7. The femoral pulse is located below the inguinal in respiratory rate. ligament, midway between the symphysis pubis 3. Head injury or increased intracranial pressure and the anterosuperior iliac spine. will depress the respiratory center in the brain, 8. The popliteal pulse is located behind the knee. resulting in shallow respirations or slowed 9. The posterior tibial pulse is located on the inner breathing. side of the ankle, behind and below the medial 4. Medications such as opioid analgesics depress malleolus (ankle bone). respirations.  CHAPTER 10 Vital Signs and Laboratory Reference Intervals 119 5. Additional factors that can affect the respiratory BOX 10.3 Hypertension Categories and rate include exercise, pain, anxiety, smoking, and Guidelines Foundations of Care body position. C. Assessing respiratory rate Categories 1. Count the client’s respirations after measuring Normal: Less than 120/80 mm Hg the radial pulse. (Continue to hold the client’s Elevated: Systolic between 120-129 mm Hg and diastolic less wrist while counting the respirations, or position than 80 mm Hg the hand on the client’s chest.) Stage 1: Systolic between 130-139 mm Hg or diastolic be- 2. One respiration includes both inspiration and tween 80-89 mm Hg expiration. Stage 2: Systolic at least 140 mm Hg or diastolic at least 90 3. The rate, depth, pattern, and sounds are assessed. mm Hg Hypertensive crisis: Systolic over 180 mm Hg and/or diastolic over 120 mm Hg, with clients needing prompt changes in The respiratory rate may be counted for 30 seconds medication if there are no other indications of problems, and multiplied by 2, except in a client who is known to or immediate hospitalization if there are signs of organ be very ill or is exhibiting irregular respirations, in which damage. case respirations are counted for 1 full minute. Guidelines V. Blood Pressure Using proper technique to measure blood pressure. Teaching the use of home blood pressure monitoring us- A. Description ing validated devices. 1. Blood pressure (BP) is the force on the walls of Appropriate training for health care providers to reveal an artery exerted by the pulsating blood under white-coat hypertension. pressure from the heart. Prescribing medication for stage I hypertension if a client 2. The heart’s contraction forces blood under has already had a cardiovascular event such as a heart at- high pressure into the aorta; the peak of maxi- tack or stroke or is at high risk for heart attack or stroke mum pressure when ejection occurs is the systol- based on age, the presence of diabetes mellitus, chronic kid- ic pressure; the blood remaining in the arteries ney disease, or calculation of atherosclerotic risk (using the when the ventricles relax exerts a force known as same risk calculator used in evaluating high cholesterol). the diastolic pressure. Recognizing that many people will need two or more types 3. The difference between the systolic and diastolic of medications to control their blood pressure and that people may take their pills more consistently if multiple pressures is called the pulse pressure. medications are combined into a single pill. 4. For an adult (age 18 years and older), a normal Identifying socioeconomic status and psychosocial stress BP is a systolic pressure below 120 mm Hg and a as risk factors for high blood pressure that should be con- diastolic pressure below 80 mm Hg. sidered in a client’s plan of care. 5. A diagnosis of hypertension may be made when there are two or more readings on at least From American College of Cardiology, 2017, New ACC/AHA High Blood Pressure Guidelines Lower Denition of Hypertension. http://www.acc.org/latest-in-cardiolo two subsequent health care visits greater than gy/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017 120/80 mm Hg. 6. Categories of hypertension from the American c. The incidence of high BP is more common College of Cardiology (Box 10.3) among Black and East Asian populations 7. For the International Society of Hypertension than in other populations. guidelines refer to: Hypertension Clinical Prac- d. Antihypertensive medications and opioid an- tice Guidelines (ISH, 2020), Medscape, May 29, algesics can decrease BP. 2020. https://reference.medscape.com/viewartic e. BP is typically lowest in the early morning, le/931364 gradually increases during the day, and peaks 8. In postural (orthostatic) hypotension, a normo- in the late afternoon and evening. tensive client exhibits symptoms and low BP on f. Additional factors affecting the BP include rising to an upright position. smoking, activity, and body weight. 9. To obtain orthostatic vital sign measurements, 2. Guidelines for measuring BP check the BP and pulse with the client supine, a. Determine the best site for assessment. sitting, and standing; readings are obtained 1 to b. Avoid applying a cuff to an extremity into 3 minutes after the client changes position. which intravenous (IV) uids are infusing, B. Nursing considerations where an arteriovenous shunt or stula is pre- 1. Factors affecting BP sent, on the side on which breast or axillary a. BP tends to increase as the aging process pro- surgery has been performed, or on an extrem- gresses. ity that has been traumatized or is diseased. b. Stress results in sympathetic stimulation that c. The leg may be used if the brachial artery is increases the BP. inaccessible; the cuff is wrapped around the 120 UNIT III Foundations of Care thigh and the stethoscope is placed over the hypotension, anemia, or peripheral vascular dis- popliteal artery. orders. Ensure that the client has not smoked or exer- C. Procedure Foundations of Care d. cised in the 30 minutes before measurement, 1. A sensor is placed on the client’s nger, toe, nose, because both activities can yield falsely high earlobe, or forehead to measure oxygen satura- readings. tion, which then is displayed on a monitor. e. Have the client assume a sitting (with feet at 2. Do not select an extremity with an impediment on oor) or lying position and then rest for to blood ow or that is cold in temperature (cold 5 minutes before the measurement; ask the ngers). client not to speak during the measurement. f. Ensure that the cuff is fully deated, and then A usual pulse oximetry reading is between 95% and wrap it evenly and snugly around the extremity. 100%. A pulse oximetry reading lower than 90% necessi- g. Ensure that the stethoscope being used ts tates PHCP notication; values below 90% are acceptable the examiner and does not impair hearing. only in certain chronic conditions. Agency procedures h. Document the rst Korotkoff sound at phase 1 and PHCP prescriptions are followed regarding actions (heard as the blood pulsates through the ves- to take for specic readings. sel when air is released from the BP cuff and pressure on the artery is reduced) as the systolic pressure, and the beginning of the fth Korot- koff sound at phase 5 as the diastolic pressure. CLINICAL JUDGMENT: i. BP readings obtained electronically with a ANALYZE CUES vital sign monitoring machine should be A client arrives from the postanesthesia care unit (PACU) at checked with a manual cuff if there is any 1300, and the nurse is monitoring vital signs. concern about the accuracy of the reading.   Temperature 37.2° C (98.9° Temperature to be 36.8° C When taking a BP, select the appropriate cu size; a F) orally (98.2° F) orally cu that is too small will yield a falsely high reading, and a cu that is too large will yield a falsely low one. Heart rate 98 beats per minute Heart rate 118 beats per minute Respiratory rate 14 breaths Respiratory rate 18 breaths per minute per minute VI. Pulse Oximetry BP 142/78 mm Hg BP 95/54 mm Hg A. Description Oxygen saturation 95% on Oxygen saturation 92% on 1. Pulse oximetry is a noninvasive test that registers 3 L of oxygen via nasal 3 L of oxygen via nasal the oxygen saturation of the client’s hemoglobin. cannula cannula 2. The capillary oxygen saturation (Sao2) is record- On analysis of the data, the client’s vital signs are showing a ed as a percentage. signicant change, particularly the blood pressure, heart rate, 3. The normal value is 95% to 100%. and oxygen saturation levels. Given the signicant change 4. After a hypoxic client uses up the readily availa- and considering the client had surgery, the nurse analyzes ble oxygen (measured as the arterial oxygen pres- these cues as an indication of postoperative bleeding. sure, Pao2, on arterial blood gas [ABG] testing), the reserve oxygen—that is, oxygen attached to the hemoglobin (Sao2)—is drawn on to provide VII. Pain oxygen to the tissues. A. Types of pain 5. A pulse oximeter reading can alert the nurse to 1. Acute/transient pain: Usually associated with an hypoxemia before clinical signs occur. injury, medical condition, or surgical procedure; 6. If pulse oximetry readings are below normal, in- lasts hours to a few days struct the client in deep-breathing technique and 2. Chronic/persistent noncancer pain: Usually as- recheck the pulse oximetry. sociated with long-term or chronic illnesses or B. Nursing Considerations disorders; may continue for months or even 1. A vascular, pulsatile area, such as the ngertip or years earlobe, is needed to detect the degree of change 3. Chronic/episodic pain: Occurs sporadically over in the transmitted light that measures the oxy- an extended period of time. Pain episodes last genated and deoxygenated hemoglobin. for hours, days, or weeks. Examples are migraine 2. Factors that affect light transmission also affect headaches and pain related to sickle cell crisis. the measurement of SpO2 4. Cancer pain: Not all individuals with cancer have 3. Some factors that affect light transmission can pain. Some have acute and/or chronic pain. Can- include sensor movement, ngernail polish, cer pain is usually caused by tumor progression  CHAPTER 10 Vital Signs and Laboratory Reference Intervals 121 and related pathological processes, invasive pro- BOX 10.4 Nonverbal Indicators of Pain cedures, treatment toxicities, infection, and physi- Foundations of Care cal limitations. Moaning 5. Idiopathic pain: This is a chronic pain in the ab- Crying sence of an identiable physical or psychologi- Irritability cal cause or pain perceived as excessive for the Restlessness extent of an organic pathological condition. Grimacing or frowning B. Assessment Inability to sleep Rigid posture 1. Pain is a highly individual experience. Increased blood pressure, heart rate, or respiratory rate 2. Ask the client to describe pain in terms of tim- Nausea ing, location, severity, quality, aggravating and Diaphoresis precipitating factors, and relief measures. Use of the FLACC® (face, legs, activity, cry, consolability) 3. Ask the client about the use of complementary scale or FACES® pain scale is appropriate for children or and alternative therapies to alleviate pain. clients who cannot communicate their pain verbally. The 4. Pain experienced by the older client may be scales are scored in a range of 0–10, with 0 representing manifested differently from pain experienced by no pain. members of other age-groups (e.g., sleep distur- bances, changes in gait and mobility, decreased socialization, depression). 5. Clients with cognitive disorders (e.g., a client with dementia, a comatose client) may not be Numerical able to describe their pain experiences. 0 1 2 3 4 5 6 7 8 9 10 6. The nurse should be alert to nonverbal indica- No pain Severe pain tors of pain (Box 10.4). 7. Ask the client to use a number-based pain scale Descriptive (a picture-based scale may be used in children or clients who cannot verbally describe their pain) No pain Mild pain Moderate Severe Unbearable pain pain pain to rate the degree of pain (Fig. 10.1). 8. Evaluate client response to nonpharmacological Visual analog interventions. No pain Unbearable pain Consider the client’s culture and spiritual and reli- Clients designate a point on the scale corresponding to gious beliefs in assessing pain; some cultures frown on their perception of the pain’s severity at the time of assessment. the outward expression of pain. A C. Conventional nonpharmacological interventions 1. Cutaneous stimulation a. Techniques include heat, cold, and pressure and vibration. Therapeutic touch and mas- sage are also cutaneous stimulation and may B be considered complementary and alterna- FIG. 10.1 Pain assessment scales. A, Numerical, descriptive, and visual tive techniques. analog scales. B, Wong-Baker FACES® Pain Rating Scale. (B, Copyright b. Such treatments may require a PHCP’s pre- 1983, Wong-Baker FACES® Foundation, www.WongBakerFACES.org. scription. Used with permission. Originally published in Whaley & Wong’s Nursing Care of Infants and Children. ©Elsevier Inc.) 2. Transcutaneous electrical nerve stimulation (TENS) a. TENS is also referred to as percutaneous elec- trical nerve stimulation (PENS). b. Some devices may require a PHCP’s prescrip- b. This technique, which may require a PHCP’s tion. prescription, involves the application of a c. Elevation of the affected body part is another battery-operated device that delivers a low intervention that can reduce swelling; sup- electrical current to the skin and underlying porting an extremity on a pillow may lessen tissues to block pain (some similar units can discomfort. be purchased without a prescription). 4. Heat and cold 3. Binders, slings, and other supportive devices a. The application of heat and cold or alternat- a. Cloths or other materials or devices, wrapped ing application of the two can soothe pain around a limb or body part, can ease the pain resulting from muscle strain; cold reduces of strains, sprains, and surgical incisions. swelling. 122 UNIT III Foundations of Care b. In some conditions, such treatment may re- BOX 10.5 Complementary and Alternative quire a PHCP’s prescription. Therapies Foundations of Care c. Heat applications may include warm-water compresses, warm blankets, thermal pads, Acupuncture and acupressure and tub and whirlpool baths. Biofeedback d. The temperature of the application must be Chiropractic manipulation monitored carefully to prevent burns; the Distraction techniques skin of very young and older clients is extra Guided imagery and meditation techniques sensitive to heat. Herbal therapies Hypnosis e. The client should be advised to remove the Laughter and humor source of heat or cold if changes in sensation Art therapy, music therapy or discomfort occur. If the change in sensa- Massage tion or discomfort is not relieved after re- Relaxation, breathing and repositioning techniques moval of the application, the PHCP should Spiritual measures (e.g., prayer, use of a rosary or prayer be notied. beads, reading of scripture) Therapeutic touch Ice or heat should be applied with a towel or other barrier between the pack and the skin but should not be left in place for more than 15 to 30 minutes. BOX 10.6 Side and Adverse Effects of NSAIDs and Acetylsalicylic Acid D. Complementary and alternative therapies NSAIDs 1. Description: Therapies are used in addition to conventional treatment to provide healing re- Gastric irritation Sodium and water retention sources and focus on the mind-body connection Blood dyscrasias (Box 10.5). Tinnitus 2. Nursing considerations Pruritus a. Some complementary and alternative thera- pies require a PHCP’s prescription. Acetylsalicylic Acid b. Herbal remedies are considered pharma- Gastric irritation cological therapy by some PHCPs; because Flushing Tinnitus of the risk for interaction with prescription medications, it is important that the nurse ask the client about the use of such therapies. 2. Acetaminophen c. If cultural or spiritual measures are to be em- a. Acetaminophen, commonly known as Tylenol, ployed, the nurse must elicit from the client is contraindicated in clients with hepatic or re- the preferred forms of spiritual expression nal disease, alcoholism, or hypersensitivity. and learn when they are practiced so that b. Assess the client for a history of liver dysfunc- they may be integrated into the plan of care. tion. c. Monitor the client for signs of hepatic dam- VIII. Pharmacological Interventions age (e.g., nausea and vomiting, diarrhea, ab- A. Nonopioid analgesics dominal pain, jaundice). 1. Nonsteroidal antiinammatory drugs (NSAIDs) d. Monitor liver function parameters. and acetylsalicylic acid (aspirin) (Box 10.6) e. Tell the client that self-medication should not a. These medication types are contraindicated if continue longer than 10 days in an adult or 5 the client has gastric irritation or ulcer disease days in a child because of the risk of hepato- or an allergy to the medication. toxicity. b. Bleeding is a concern with the use of these f. The antidote to acetaminophen is acetyl- medication types. cysteine. c. Instruct the client to take oral doses with milk or a snack to reduce gastric irritation. The major concern with acetaminophen is d. NSAIDs can amplify the effects of anticoagu- hepatotoxicity. lants. e. Hypoglycemia may result for the client taking B. Opioid analgesics ibuprofen if the client is concurrently taking 1. Description an oral antidiabetic agent. a. These medications suppress pain impulses but f. A high risk of toxicity exists if the client is can also suppress respiration and coughing by taking ibuprofen concurrently with a calcium acting on the respiratory and cough center, lo- channel blocker. cated in the medulla of the brainstem.  CHAPTER 10 Vital Signs and Laboratory Reference Intervals 123 b. Review the client’s history, and note that cli- C. Adjuvant analgesics ents with impaired renal or liver function 1. Description Foundations of Care may only be able to tolerate low doses of opi- a. These medications are used to complement oid analgesics; also assess for allergy. the effects of opioid analgesics. c. Intravenous route administration produces a b. They are especially helpful for neuropathic faster effect than other routes, but the pain pain. relief effect is shorter. c. The medications that are used as adjuvant d. Opioids, which produce euphoria and seda- analgesics were originally developed to treat tion, can cause physical dependence if used other conditions, such as depression, sei- for long periods of time. zures, or dysrhythmias. e. Administer the medication 30 to 60 minutes be- d. Examples include amitriptyline, venlafaxine, fore painful activities, such as coughing and deep and gabapentin. breathing, ambulation, and dressing changes. e. Nursing interventions depend on the medi- f. Monitor the respiratory rate; if it is slower cation class, side effects, and considerations than 12 breaths per minute in an adult, with- for the adjuvant analgesic prescribed. hold the medication and notify the PHCP. f. Marijuana and other substances such as CBD g. Monitor the pulse; if bradycardia develops, may be considered for use for pain manage- withhold the medication and notify the PHCP. ment, depending on physician preference h. Monitor the BP for hypotension and assess and its legal status for use. before administering pain medications to de- crease the risk of adverse effects. IX. Laboratory Reference Intervals i. Auscultate the lungs for normal breath sounds. A. For reference throughout the chapter, see Fig. 10.2 j. Encourage activities such as turning, deep B. Methods for drawing blood (Table 10.1) breathing, and incentive spirometry to help C. Serum sodium prevent atelectasis and pneumonia. 1. A major cation of extracellular uid k. Monitor the client’s level of consciousness. 2. Maintains osmotic pressure and acid-base bal- l. Initiate safety precautions. ance, and assists in the transmission of nerve m. Monitor intake and output and assess the cli- impulses ent for urine retention; also constipation is 3. Is absorbed from the small intestine and excreted common with opioid use. in the urine in amounts dependent on dietary in- n. Instruct the client to take oral doses with take milk or a snack to reduce gastric irritation. 4. Normal reference interval: 135 to 145 mEq/L o. Instruct the client to avoid activities that re- (135 to 145 mmol/L) quire alertness. 5. Elevated values occur in the following: dehydra- p. Assess the effectiveness of the medication 30 tion, impaired renal function, increased dietary minutes after administration. or IV intake of sodium, primary aldosteronism, q. Have an opioid antagonist (e.g., naloxone), use of corticosteroid therapy oxygen, and resuscitation equipment available. 6. Below-normal values occur in the following: Ad- r. Prescriptions for opioid analgesics can be dison’s disease, decreased dietary intake of so- given in only very specic circumstances. dium, diabetic ketoacidosis, diuretic therapy, ex- Specic forms regarding use of opioid an- cessive loss from the gastrointestinal (GI) tract, algesics, including risk assessment tools excessive perspiration, water intoxication and informed consent forms, need to be re- viewed and signed by the client. Prescription Drawing blood specimens from an extremity in monitoring systems may need to be checked which an IV solution is infusing can produce an inaccu- prior to a client lling a prescription for a rate result, depending on the test being performed and controlled substance, to ensure that multiple the type of solution infusing. Prolonged use of a tour- prescriptions for the same medication are niquet before venous sampling can increase the blood not being lled. Frequent collaboration be- level of potassium, producing an inaccurate result. tween the nurse and the provider on contin- ued need for this type of medication should D. Serum potassium be done. 1. A major intracellular cation, potassium regulates s. A pain management specialist needs to be con- cellular water balance, electrical conduction in sulted for complex pain management cases. muscle cells, and acid-base balance. 2. The body obtains potassium through dietary in- An electronic infusion device is always used for con- gestion and the kidneys preserve or excrete po- tinuous or dose-demand IV infusion of opioid analgesics. tassium, depending on cellular need. 124 UNIT III Foundations of Care TOTAL WHOLE BLOOD PLASMA PROTEINS BODY WEIGHT (percentage (percentage by weight) by volume) Albumins 54% Foundations of Care Blood 8% Proteins 7% Globulins 38% Fibrinogen 4% Prothrombin 1% Water 91% Other OTHER SOLUTES fluids and Gases Regulatory PLASMA Other solutes 2% Ions substances tissues 55% Nutrients Waste products 92% FORMED ELEMENTS Buffy coat Platelets 150,000-400,000 mm3 LEUKOCYTES (150-400 × 109/L) FORMED ELEMENTS White blood 5000-10,000 mm3 45% cells (5.0-10.0 × 109/L) Neutrophils Lymphocytes Monocytes Centrifuged 60-70% 20-25% 3-8% sample of blood Eosinophils Basophils 2-4% 0.5-1% FIG. 10.2 Approximate values for the components of blood in a normal adult. TABLE 10.1 Obtaining a Blood Sample Peripheral Intravenous Line Central Intravenous Line Check PHCP’s prescription. A blood sample may be drawn from a peripheral Check PHCP’s prescription. line on insertion, but typically not thereafter. Check the agency’s policy on this practice. Identify foods, medications, or other factors such as the type of Identify foods, medications, or other factors such as the type of solution infusing that may aect the procedure or results. solution infusing that may aect the procedure or results. Gather needed supplies, including gloves, tourniquet, transparent dressing or other Gather needed supplies, including gloves, transfer/collection type of dressing, tape, 2 x 2-inch gauze, antiseptic agent, extension set (optional), device per agency policy, specimen containers per agency policy, two 5- or 10-mL normal saline ushes, one empty 5- or 10-mL syringe (depending on two 5- or 10-mL normal saline ushes, one empty 5- or 10-mL the amount of blood needed), transfer/collection device per agency policy, specimen syringe (depending on the amount of blood needed), antiseptic containers per agency policy, alcohol-impregnated intravenous (IV) line end caps, swabs, alcohol-impregnated IV line end caps, two masks, tube labels, biohazard bag, requisition form or bar code per agency policy. biohazard bag, requisition form or bar code per agency policy. Perform hand hygiene. Identify the client with at least two accepted Perform hand hygiene. Identify the client with at least two identiers. accepted identiers. Explain the purpose of the test and procedure to the client. Explain the purpose of the test and procedure to the client. Prepare extension set if being used by priming with normal saline. Place mask on self (if one is not already being worn) and Attach syringe to extension set. Place extension set within reach client, or ask client to turn the head away. Stop any running while maintaining aseptic technique and keeping it in the package. infusions for at least 1 minute. Apply tourniquet 10 to 15 cm above intravenous site. Clamp all ports. Scrub port to be used with antiseptic swab. Apply gloves. Scrub tubing insertion port with antiseptic solution Attach 5- or 10-mL normal saline ush and unclamp line. or per agency policy. Flush line with appropriate amount per agency policy and with- draw 5-10 mL of blood to discard (per agency policy). Clamp line and detach ush syringe. Attach 5- or 10-mL normal saline ush and unclamp line. Flush Scrub port with antiseptic swab. Attach 5- or 10-mL syringe or line with appropriate amount per agency policy and withdraw transfer/collection device to port (depending on available equip- 5-10 mL of blood to discard (per agency policy). Clamp line and ment), unclamp line, and withdraw needed sample, or attach detach ush syringe. specimen container to withdraw using vacuum system. Clamp line and detach syringe or transfer/collection device. Scrub tubing insertion port. Attach 5- or 10-mL syringe, extension set, Scrub port with antiseptic swab. Attach a 5- or 10-mL normal or transfer/collection device to port (depending on available saline ush. Unclamp line and ush with amount per agency equipment), unclamp line, and withdraw needed sample, or attach policy. Clamp line, remove ush syringe, and place endcap on specimen container to withdraw using vacuum system. Clamp line IV line. Remove masks if appropriate and acceptable to do so. and detach syringe or transfer/collection device. Remove tourniquet and ush with normal saline to ensure patency. Transfer specimen to collection device per agency policy and proce- dure. Send specimen to the laboratory in biohazard bag with associated Send specimen to the laboratory in biohazard bag with associ- requisition forms or bar codes per agency policy. ated requisition forms or bar codes per agency policy.  CHAPTER 10 Vital Signs and Laboratory Reference Intervals 125 3. Potassium levels are used to evaluate cardiac F. Prothrombin time (PT) and international normal- function, renal function, gastrointestinal func- ized ratio (INR) tion, and the need for IV replacement therapy. Foundations of Care 1. Prothrombin is a vitamin K–dependent glyco- 4. If the client is receiving a potassium supplementa- protein produced by the liver that is necessary tion, this needs to be noted on the laboratory form. for brin clot formation. 5. Normal reference interval: 3.5 to 5.0 mEq/L (3.5 2. Each laboratory establishes a normal or control to 5.0 mmol/L) value based on the method used to perform the 6. Elevated values occur in the following: acute kid- PT test. ney injury or chronic kidney disease, Addison’s 3. The PT measures the amount of time it takes in disease, dehydration, diabetic ketoacidosis, ex- seconds for clot formation and is used to moni- cessive dietary or IV intake of potassium, mas- tor response to warfarin sodium therapy or to sive tissue destruction, metabolic acidosis screen for dysfunction of the extrinsic clotting 7. Below-normal values occur in the following: system resulting from liver disease, vitamin K burns, Cushing’s syndrome, decient dietary deciency, or disseminated intravascular coagu- intake of potassium, diarrhea (severe), diuretic lation. therapy, GI stula, insulin administration, py- 4. A PT value within 2 seconds (plus or minus) of loric obstruction, starvation, vomiting the control is considered normal. 8. Clients with elevated white blood cell (WBC) 5. The INR is a frequently used test to measure the counts and platelet counts may have falsely el- effects of some anticoagulants. evated potassium levels. 6. The INR standardizes the PT ratio and is calcu- E. Activated partial thromboplastin time (aPTT) lated in the laboratory setting by raising the ob- 1. The aPTT evaluates how well the coagulation served PT ratio to the power of the international sequence (intrinsic clotting system) is func- sensitivity index specic to the thromboplastin tioning by measuring the amount of time it reagent used. takes in seconds for recalcied citrated plasma 7. If a PT is prescribed, a baseline specimen should to clot after partial thromboplastin is added be drawn before anticoagulation therapy is to it. started; note the time of collection on the labo- 2. The test screens for deciencies and inhibitors ratory form. of all factors, except factors VII and XIII. 8. Provide direct pressure to the venipuncture site 3. Usually, the aPTT is used to monitor the effec- for 3 to 5 minutes. tiveness of heparin therapy and screen for co- 9. Concurrent warfarin therapy with heparin ther- agulation disorders. apy can lengthen the PT for up to 5 hours after 4. Normal reference interval: 30 to 40 seconds dosing. (conventional and SI units [International Sys- 10. Diets high in green leafy vegetables can increase the tem of Units]), depending on the type of activa- absorption of vitamin K, which shortens the PT. tor used. 11. Orally administered anticoagulation therapy 5. If the client is receiving intermittent heparin usually maintains the PT at 1.5 to 2 times the therapy, draw the blood sample 1 hour before laboratory control value. the next scheduled dose. 12. Normal reference intervals 6. Do not draw samples from an arm into which a. PT: 11 to 12.5 seconds (conventional and SI heparin is infusing. units) 7. Transport specimen to the laboratory immedi- b. INR: 0.81 to 1.20 (conventional and SI units) ately. 13. For both the PT and INR, elevated values occur 8. Provide direct pressure to the venipuncture site in the following: deciency of one or more of for 3 to 5 minutes. the following: factor I, II, V, VII, or X; liver dis- 9. The aPTT should be between 1.5 and 2.5 times ease; vitamin K deciency; warfarin therapy normal when the client is receiving heparin therapy. If the PT value is longer than 25 seconds and the 10. Elevated values occur in the following: decien- INR is greater than 3.0 in a client receiving standard cy of one or more of the following: factor I, II, warfarin therapy (or per agency policy), initiate bleeding V, or VIII; factors IX and X; factor XI; and factor precautions. XII; hemophilia; heparin therapy; liver disease G. Platelet count If the aPTT value is prolonged (longer than 100 sec- 1. Platelets function in hemostatic plug formation, onds or per agency policy) in a client receiving IV hepa- clot retraction, and coagulation factor activation. rin therapy or in any client at risk for thrombocytopenia, 2. Platelets are produced by the bone marrow to initiate bleeding precautions. function in hemostasis. 126 UNIT III Foundations of Care 3. Normal reference interval: 150,000 to 400,000 TABLE 10.2 Hemoglobin and Hematocrit: Reference mm3 (150 to 400 × 109/L) Intervals Foundations of Care 4. Elevated values occur in the following: acute infections, chronic granulocytic leukemia, Blood Component Reference Interval chronic pancreatitis, cirrhosis, collagen disor- Hemoglobin (altitude dependent) ders, polycythemia, and postsplenectomy; high Male adult 14-18 g/dL (140-180 g/L) altitudes and chronic cold weather can increase Female adult 12-16 g/dL (120-160 g/L) values. 5. Below-normal values occur in the following: Hematocrit (altitude dependent) Male adult 42%-52% (0.42-0.52) acute leukemia, chemotherapy, disseminated in- travascular coagulation, hemorrhage, infection, Female adult 37%-47% (0.37-0.47) systemic lupus erythematosus, thrombocytopenic purpura. 6. Monitor the venipuncture site for bleeding in cli- 5. Triglycerides are synthesized in the liver from ents with known thrombocytopenia. fatty acids, protein, and glucose and are ob- 7. Bleeding precautions should be instituted in tained from the diet. clients when the platelet count falls sufciently 6. Increased cholesterol levels, LDL levels, and tri- below the normal level; the specic value for im- glyceride levels place the client at risk for coro- plementing bleeding precautions usually is de- nary artery disease. termined by agency policy. 7. HDL helps protect against the risk of coronary artery disease. Monitor the platelet count closely in clients receiv- 8. Instruct the client to abstain from food and u- ing chemotherapy because of the risk for thrombocy- id, except for water, for 12 to 14 hours and from topenia. In addition, any client who will be having an alcohol for 24 hours before the test. invasive procedure (such as a liver biopsy or thoracente- 9. Instruct the client to avoid consuming high- sis) should have coagulation studies and platelet counts cholesterol foods with the evening meal before done before the procedure. the test. 10. Normal reference intervals (Table 10.3) H. Hemoglobin and hematocrit 11. Elevated values occur in the following: 1. Hemoglobin is the main component of erythro- a. Cholesterol, LDL: biliary obstruction, cir- cytes and serves as the vehicle for transporting rhosis hyperlipidemia, hypothyroidism, idi- oxygen and carbon dioxide. opathic hypercholesterolemia, renal disease, 2. Hematocrit represents red blood cell (RBC) mass uncontrolled diabetes, oral contraceptive use and is an important measurement in the pres- b. Triglycerides: diabetes mellitus, hyperlipi- ence of anemia or polycythemia (Table 10.2). demia, hypothyroidism, liver disease 3. Fasting is not required for this test. 12. Below-normal values occur in the following: 4. Elevated values occur in the following: a. Cholesterol, LDL: extensive liver disease, hy- a. Hemoglobin: chronic obstructive pulmonary perthyroidism, malnutrition, use of corticos- disease, high altitudes, polycythemia teroid therapy b. Hematocrit: dehydration, high altitudes, b. Triglycerides: hyperthyroidism, malabsorp- polycythemia tion syndrome, malnutrition 5. Below-normal values occur in the following: J. Fasting blood glucose a. Hemoglobin: anemia, hemorrhage 1. Glucose is a monosaccharide found in fruits and b. Hematocrit: anemia, bone marrow failure, is formed from the digestion of carbohydrates hemorrhage, leukemia, overhydration and the conversion of glycogen by the liver. I. Lipids 2. Glucose is the main source of cellular energy for 1. Blood lipids consist primarily of cholesterol, tri- the body and is essential for brain and erythro- glycerides, and phospholipids. cyte function. 2. Lipid assessment includes total cholesterol, 3. Fasting blood glucose levels are used to assist in high-density lipoprotein (HDL), low-density li- diagnosing diabetes mellitus and hypoglycemia. poprotein (LDL), and triglycerides. 4. Instruct the client to fast for 8 to 12 hours before 3. Cholesterol is present in all body tissues and is the test. a major component of LDLs, brain and nerve 5. Instruct a client with diabetes mellitus to with- cells, cell membranes, and some gallbladder hold morning insulin or oral hypoglycemic stones. medication until after the blood is drawn. 4. Low-density lipoprotein (LDL) transports cho- 6. Normal reference interval: glucose (fasting) 70- lesterol from the liver to the tissues of the body. 99 mg/dL (3.9-5.5 mmol/L)  CHAPTER 10 Vital Signs and Laboratory Reference Intervals 127 TABLE 10.3 Lipids: Reference Intervals TABLE 10.4 Glycosylated Hemoglobin (HbAc) and Blood Component Reference Interval Estimated Average Glucose (eAG) Foundations of Care HbAc % eAG mg/dL eAG mmol/L Cholesterol < 200 mg/dL ( 60 mg/dL (>1.55 mmol/L) (HDLs) 6 126 7.0 Low-density lipoproteins < 100 mg/dL (