Fundamentals Notes 1 PDF

What do we use vital signs for? -​ To create a baseline in order to compare and know if they changed -​ Monitor patients condition -​ Identify problems (figure out why the patient has high blood pressure (hypertension)) -​ Evaluate response to intervention Vital signs: Temperature, pu...

What do we use vital signs for? -​ To create a baseline in order to compare and know if they changed -​ Monitor patients condition -​ Identify problems (figure out why the patient has high blood pressure (hypertension)) -​ Evaluate response to intervention Vital signs: Temperature, pulse, respiratory rate, blood pressure, oxygen saturation Guidelines for measuring vital signs: -Always check the vital signs to know if they were abnormal and in the correct range -Know the patient's usual range (baseline) of vital signs -Clean device between patients -Make sure equipment is working correctly (manual vs machine) -Know the patients health history (if they have a certain condition their vitals can be impacted), therapies, and prescribed and over-the-counter medications -Before you check your vital signs on your patient, know the health history -Control environmental factors (stress, noisy area, temperature of room) -Use an organized, systematic approach -Collaborate on assessment frequency (often times it is every 4 hours, in peds or sicker patients it is shorter) it varies per patient, as often as you need to but at least the minimum frequency ordered by the provider -How do you know what the frequency is for your patients? Follow the orders given by the care provider -Use vital signs to determine indications for medication administration -Verify and communicate significant changes (as soon as you get vital information, document it) -If there is an abnormal finding, what do you do? Document and tell the nurse in charge -Vital signs are not interpreted in isolation. You need to also know related physical signs or symptoms and must be aware of the patients ongoing health T.S Case study -​ Younger: vital signs may not be affected -​ Smoking may impact vital signs -​ If her BP is high it could result in headaches -​ Someone who frequently feels tired: low oxygen level -​ Overweight: Higher BP Body Temperature Physiology Acceptable temperature range (for adult): -​ 98.6 F to 100.4 F or 36 C to 38 C -Thermometers- electronic or disposable (anyone who has an infection) -Temperature sites: oral, rectal, axillary, tympanic membrane(outer ear), temporal artery, esophageal, pulmonary artery -How do you know where to check the temperature? Think about the patient's state (if they have a tube down their throat) if they just had oral surgery dont use oral, don't use over broken skin -Rectal temperatures are closest to body core temperature (most accurate) and are typically higher than temps at other sites -Temps taken at body surface (further from body core) are less accurate Thermoregulation Homeostasis! Things the body does to get back to normal (thermoregulation is an example) Heat loss: transfer of heat between objects through direct contact, air movement or change from liquid to gas Heat production: through basal metabolic rate and shivering Neural and vascular control: hypothalamus establishes a body “set point” Skin regulation: skin, subcutaneous tissue, and fat keep heat inside the body Behavioral standpoint: ability to control body temperature through emotions, sensing comfort or discomfort mobility, ability to add and remove clothing T.S case study 2 Her temp is 98 F: OK Check all vital signs always! Factors impacts temperature Age: Newborns’ temp are immature Adults tend to have lower Exercise: Increases temp Hormones: Women experience greater fluctuations in body temperature than men Circadian rhythm: Changes the body temperature over 24-hour period -Lowest body temperature occurs 1am-4am -Highest body temperature 4pm Environmental Stress Temperature alterations Pyrexia (fever): important defense mechanism -​ Usually not harmful if it stays below 39 C in adults or below 30 C in children -During a fever cellular metabolism increases, and oxygen consumption rises. Body metabolism increases -Heart and RR increase to meet the metabolic needs of the body for nutrients -Increased metabolic requires additional oxygen-may need oxygen therapy - If the body cannot meet demand for additional oxygen, cellular hypoxia (not enough oxygen occurs) -Myocardial hypoxia produces angina (chest pain) -Cerebral hypoxia produces confusion - When someone has a sustained fever they tend to have a fever to make up for the water loss - diaphoresis (extreme fever) -If they have a fever vital signs are going to be higher -Heatstroke(104 F or higher)- occurs from prolonged exposure to the sun or high environmental temps - S and S : hot, dry skin -Treatment, move patient to cooler environment, remove clothing, place cool wet towels over the skin, and use fan Heat exhaustion: when profuse diaphoresis results in water and electrolyte loss Hypothermia: Core body temperature drops and body is unable to compensate -​ Frostbite: ice crystals from inside cell, and permanent circulation and tissue damage occurs -​ Treatment of frostbite: Heated blanket, remove wet clothes , replace with dry ones Pulse Physiology and regulation -​ Pulse: palpable bounding of blood flow in peripheral artery -​ The indicator of circulatory status -​ Blood flows through body in a circuit Sites: temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, and dorsalis pedis Character of pulse: rate, rhythm Pulse rate: radial rate-number of pulsing sensations in 1 minute -​ Acceptable pulse rates: 60-100 BPM -​ Postural changes affect the pulse rate -​ Apical rate: S1 (lub) and S2 (dub) = lub + dub is 1 heartbeat -​ If patient is stable and regular than it is okay to count to 30 and multiply by 2 -​ If patient has a irregular heartbeat count for 60 seconds -​ Bradycardia: slow rate - below 60 beat/per min in adult  -​ Tachycardia: fast rate - above 100 beats/per min in adult -​ Pulse deficit: difference between radial and apical (heart) pulse rates Rhythm: -​ Dysrhythmia: regularly or irregularly irregular -​ Threatens the ability of a heart to provide adequate cardiac output Strength: -​ Amplitude of pulse = volume of blood ejected against the arterial wall with each heart contraction -​ The pulse strength: - Bounding (4+) - Full or strong (3+) - Normal or expected (2+) - Diminished or barely palpable (1+) - Absent (0) If there is no palpable pulse what do you check with? Doppler Equality - pulse in one extremity is sometimes unequal in strength or absent in many disease states -​ Stroke -​ What are some other reasons? Respiration -​ Ventilation: movement of gases in and out of the lungs (in oxygen out carbon dioxide) -​ Diffusion: movement of oxygen and carbon dioxide between alveoli and red blood cells -​ Perfusion: distribution of red blood cells to and from the pulmonary capillaries -​ Physiological control- breathing is a passive process. Brain stem regulates involuntary control. Hypoxemia: low blood level of oxygen Eupnea: ventilation of a normal rate and depth Respiratory rate: breaths/minute: acceptable respiratory rate 12-20 breaths per minute in adults -​ Influenced by activity, age, illness Ventilatory depth: deep, normal, shallow, labored Ventilatory rhythm: regular/irregular Diffusion and perfusion- evaluate respiratory processes of diffusion and perfusion by measuring the oxygen saturation of blood Factors influencing character of respirations Exercise Acute pain Anxiety Smoking Body position Medication Neurological injury Hemoglobin function Alterations in breathing pattern -​ Bradypnea: rate of breathing is abnormally slow (less than 12 breaths per minute) -​ Tachypnea: rate of breathing is abnormally rapid (greater than -​ Hyperventilation: -​ Hypoventilation: -​ Apnea: sleep apnea, respirations cease for several seconds Assessment of diffusion and perfusion -​ Measurement of arterial oxygen saturation, the percent of hemoglobin that is bound with oxygen in arteries -​ Usually 95% to 100% -​ Pulse oximeter -​ What are some things to look for when oxygen saturation is low? Coldness of patient, make sure oxygen machine is working if they are on it, have them take slow breaths, raise head of breath, make sure no nail polish -​ If Oxygen saturation is low and you have tried everything, what do you do? Turn oxygen on Case study 3 RR: 14 breaths per minute: OK Pulse: 86 beats per minute: OK Blood pressure: 120/80 systolic : maximum peak pressure during ventricular contraction Diastolic : minimal pressure during ventricular relaxation Pulse pressure: difference between systolic and diastolic pressure 120-80=40 Factors influencing blood pressure Age- BP rises throughout lifespan Stress- Ethnicity- Gender- Daily Variation- Medications- Activity, weight- Smoking- Hypertension: -​ More common than hypotension -​ Thickening of walls (Age, plaque build up) -​ Loss of elasticity -​ Family history -​ Risk factors Hypotension -​ Systolic (less than 90 mm Hg) -​ Dilation of arteries -​ Loss of blood volume -​ Decrease of blood flow to vital organs -​ Orthostatic/postural -​ Watch for dizziness, pale skin, clammy, nausea, eyes lose focus Case study 4 -​ Blood pressure is 164/98 -​ How do you respond? Tell the patient it's a little higher than usual. Document it and tell the provider. Patient conditions not appropriate for electronic blood pressure measurement -​ Irregular heart rate -​ Known hypertension -​ Peripheral vascular obstruction (clots, narrowed vessels) -​ Shivering -​ Seizures  -​ Excessive tremors -​ Inability to cooperate -​ Blood pressure less than 90 mm Hg systolic Patient measurement of BP Benefits -​ Detection of new problems (prehypertension) Disadvantages -​ Improper use risks inaccurate readings -​ Unnecessary alarming of patient -​ Patients may inappropriately adjust meds Pain -​ Use appropriate pain scale -​ Numerical pain scale (0-10) -​ Visual scales (faces, pictures) non verbal -​ Behavioral indicators -​ Access characteristics of the pain (location, description) -​ Nonpharmacological interventions (positioning, heat/cold, massage, meditation/prayer, distraction) -​ Reassess pain following intervention Recording Vital signs -​ Record values exactly -​ Document in real time -​ Follow up on vital signs -​ Document investigations -​ If a vital sign is outside anticipated outcomes, notify provider Safety guidelines for skills -​ Infection prevention -​ Rotating sites during repeated measurement of BP  Hygiene *prevents infection, makes patient feel more comfortable* What are some things you assess during hygiene? -​ Skin (intact, wounds, pressure sores) -​ Hands (assesses their ability of their hand hygiene) -​ Feet (clean, dry, we use them for walking and support) -​ Nails (different diseases can cause changes in nails, we do not trim nails!) -​ Oral cavity (mouth, teeth, gums, bacteria easily forms in mouth) -​ Hair (make sure its brushed, out of eyes) -​ Eyes -​ Ears -​ Nos -​ Cognition (what's their mental status? Develop a relationship, get to know them) Nursing knowledge base -​ Many factors influence a patient's personal hygiene preferences Factors influencing hygiene -​ Social patterns (ethnic, social, and family influences on hygiene patterns) -​ Personal preferences (dictate hygiene practices) -​ Body image (removal of a limb, permanent scarring, loss of hair, some type of a tube that can be seen outside their body, if someone doesn't have great body image they might be less motivated to do something for their body) -​ Socioeconomic status (personal hygiene products can be costly) -​ Health benefits and motivation (motivation is the key factor in hygiene) -​ Development stage (affects the patient's ability to perform hygiene care) -​ Cultural variables (people from diverse cultures practice different hygiene rituals) -​ Physical condition (may lack physical energy and dexterity to perform self-care) Developmental stage: -​ Skin: any break in the skin can result in an infection (neonates have sensitive skin, active glands in puberty, thinning and drying with age) -​ Feet and nails: -​ Mouth: chronic disease such as diabetes Bathing -​ Consider normal grooming routines, and individualize care -​ Therapeutic - Sitz: sitz bath cleans and reduces pain and inflammation of perineal and anal areas - Medicated: relieve skin irritation and create an antibacterial and drying effect - Chlorhexidine (CHG): added to bath water to reduce the risk of HAI’s - Partial bed bath: for patients who have trouble getting all the way to the bathroom by themselves but you can bring them a water basin and they can do it themselves - Perineal care: cleansing patients’ genital and anal areas Safety guidelines -​ Identify the patient with two identifiers -​ Move from cleanest to less clean areas -​ Wear gloves -​ Test the temperature of water