Fundamentals Vital Signs student version.pptx

VITAL SIGNS  Temperature Pulse Respirations WHAT ARE VI TAL SIG NS? Blood Pressure Oxygen saturation (in some facilities) Pain  Indication of basic...

VITAL SIGNS  Temperature Pulse Respirations WHAT ARE VI TAL SIG NS? Blood Pressure Oxygen saturation (in some facilities) Pain  Indication of basic body functioning WHY DO WE Need baseline with NEED VITAL which to compare SIGNS? all other vital signs Objective data  WHEN TO ASSESS VITAL/SIGNS During admission and discharge Routine schedule as ordered by physician Before and after surgical procedures Before and after invasive diagnostic procedures Before and after administering medications When general condition changes Before and after certain nursing procedures (ambulating, suctioning) When patient reports nonspecific complaints (“I feel funny.”) Routinely as part of a procedure (administering blood)  Take your own patient’s v/s Know normal ranges Know patient’s normals Know patient’s history Know and use equipment properly RULES FOR Use proper techniques TAKING V/S Know implications of changes Use organized, systemic approach Communicate changes to appropriate personnel Know how to control/minimize environmental factors that may influence vital signs CULTURAL CONSIDERATIONS Many cultures believe in natural or herbal products to treat health Privacy for vital signs Routine procedures to some are anxiety producing for others possibly If there is a language barrier, ensure client understands what nurse is doing Use interpreter if needed  TEMPERATURE  Types ◦ Surface ◦ Core  Normal body temperatures ◦ Oral  98.6 ◦ Rectal  99.6 ◦ Axillary  97.6 ◦ Tympanic/Temporal  98.6 ◦ Range  97-99.6  FACTORS INFLUENCING TEMPS Age Exercise Hormonal Diurnal Stress Environment Smoking  SITES Oral Rectal Axillary Tympanic Temporal  MEASURING DEVICES Electronic Tympanic Temporal Strips  HYPERTHERMIA Known as febrile or pyrexia May be first sign of illness Body defense Will destroy invading bacteria But if gets too high, normal cells can be damaged Classifications Signs and symptoms  If abnormal, repeat Remove or reduce outer coverings Keep clothing and bed linen dry Check q 4 hours Administer antipyretics NUR SI NG Limit physical activity/rest INTE RVE NTI ON Increase/encourage fluids S Assess for signs of infection Frequent oral hygiene Assess mucous membranes for dryness (dehydration) If subnormal, apply coverings, eliminate drafts, remove wet clothes, warm liquids  HYPOTHERMIA Abnormally low body temperature Less than 93.2 can result in death Can be therapeutic May be caused by disease process Recheck temperature if it is abnormally low Treatment Hypothermia blanket Warm blankets Warm IV fluids  O B TA I N I N G A N O RA L T E M P Nothing to eat or drink within 20 minutes Shake thermometer down to below 96 (if using a glass thermometer) Place under the tongue and have patient close mouth around it Leave in 5 minutes (for glass thermometers) or until beeps Read result and record Contraindications  OBTAINING A RECTAL TEMPERATURE Obtain correct glass thermometer or electronic probe Turn patient to the side Shake down to less than 96 Wear gloves Lubricate Insert Hold in place for 2 minutes or until beeps Read result and document Contraindications  OBTAINING AN AXILL ARY TEMP Considered the least accurate Used most often on children and infants Shake glass thermometer down to less than 96 degrees Make sure axilla is clean and DRY Place thermometer into center of axilla, close arm over axilla and place arm across chest Leave in 5-10 minutes or until beeps Read and document thermometer reading and method used  OBTAINING A TYMPANIC TEMP Make sure that you put a plastic disposable probe on tip Children Pinna down and back Adults Pinna up and back Probe should fit snugly into canal Depress scan button (takes about 10 seconds to read) Read and document reading and method  INTERVENTIONS FOR ABNORMAL TEMPERATURE For elevation Check for and administer antipyretics as ordered Tepid sponge bath Cooling blanket For subnormal Warm blankets Warming blanket, warmed IV fluids (for hypothermic patients) STETHOSCOPE  PULSE Pulsation felt over an artery with each contraction of the heart Normal—60-100 Variations Bradycardia--100  Age Medications Exercise Metabolism Acute pain, anxiety FACTOR S Fever INFLUENCI NG Hemorrhage THE PULSE Pulmonary problems Postural changes Dehydration Fluid volume excess  PULSE Common Pulse Pulse Pulse deficit sites Carotid descriptions Rate—how fast/slow Difference between apical Apical Rhythm—regular/irregular and radial—requires two nurses Brachial Volume—grades Radial 0—absent Femoral 1+--thready—difficult to feel; not palpable with Popliteal light pressure Pedal 2+--weak—somewhat stronger than thready 3+--normal—easily felt;but not palpable with moderate pressure 4+--bounding—full and spring-like with moderate  INTERVENTIONS FOR ABNORMALITIES Always take an apical rate for one full minute with any abnormality Always take blood pressure—may rise or fall in relationship to heart rate Monitor for chest pain, dyspnea, dizziness, syncope Observe skin color Place on bedrest if symptomatic Ask about medications Report new onset of abnormalities  RESPIRATIONS Breathing Inspiration + expiration = 1 respiratory cycle Normal—12-20respiration/minute Count for one full minute Count inspiration and expiration as one respiration Dyspnea  RESPIRATIONS Factors influencing respirations Disease/illness Stress, fever, exercise Acute pain Medications Age/sex Smoking Brainstem injury Hemoglobin levels Body position  RESPIRATIONS  Descriptions of respirations Rate Rhythm Depth  Deviations Bradypnea Tachypnea Cheyne stokes https://www.youtube.com/watch?v=VkuxP7iChYY Kussmauls https://www.youtube.com/watch?v=TG0vpKae3Js Apnea  INTERVENTIONS FOR ABNORMALITIES Always check oxygen saturation (O2 Sat)— report if less than 94% Auscultate breath sounds Monitor for dyspnea Monitor pulse rate (heart rate usually goes up if there is a respiratory problem)  BLOOD PRESSURE  Measuring force of blood against arterial walls  Measured in mm Hg (millimeters of mercury)  Two parts Systolic Diastolic  Pulse pressure  Normal  Kortokoff  https://www.youtube.com/watch?v=VJrLHePNDQ4  BLOOD PRESSURE Factors that influence Age Anxiety/pain, fear, stress Medications Diurnal Race Gender Obesity Diet  BLOOD PRESSURE— ABNORMAL VARIATIONS Hypotension < 90/60** Causes  Dehydration  Blood loss  Postural changes  Medications Signs/Symptoms  Tachycardia  Dizziness, syncope  Dyspnea  Pallor  BLOOD PRESSURE— ABNORMAL VARIATIONS Hypertension Greater than or equal to 140/90 Risk factors Classes Symptoms  INTERVENTIONS FOR ABNORMALITIES Hypotension Hypertension Recheck and report Recheck and report abnormalities abnormalities Monitor heart rate, respirations, Monitor heart rate and oxygen saturation Patient education Increase fluid intake for Medicate as ordered dehydration Replace blood loss Bedrest with feet elevated  BLOOD PRESSURE Equipment Manual Stethoscope Sphygmomanometer Electronic Electronic device  OBTAINING A BLOOD PRESSURE Correct sized cuff Contraindications Position center of cuff over brachial artery 1-2 inches above antecubital space Close the valve air pump prior to inflation  OBTAINING BLOOD PRESSURE, CONT. Position and support patient’s arm at level of heart Palpate brachial artery Take blood pressure—inflate to ~160 mmHg.  OBTAINING BLOOD PRESSURE, CONT.  Deflate cuff at increments of 2 mmHg per second while auscultating for Korotkoff sounds  Read blood pressure in increments of 2—there can be NO odd readings unless using an automatic measuring device  Document reading and report any deviations from normal  For new patients, take initial readings in both arms  If in doubt about your reading, ask another nurse to recheck  Only systolic readings can be obtained if palpating a B/P  HEIGHT AND WEIGHT On admission Height especially in children because they are still growing Heights important in adults to compare the ratio of weight to height Weights on some patients may be done daily Same scale, same type clothing, same time All scales should be balanced before weighing Ideal time to weigh is before breakfast, after voiding (around 6 am) Document all readings and report any changes  PULSE OXIMETRY Measures oxygen saturation in percentage form Not used in all facilities Normal range in health individual 95-100% May be lower in chronic lung clients (COPD) Keep in mind nail polish, thick nails, artificial nails, cold hands, poor circulation can cause abnormal reading Can be done on ears and toes, if needed. Document all readings and report any changes