Unit 6 Vital Signs PDF

VITAL SIGNS Melissa Albright MSN, RN Textbook pp edited and expanded by Melissa October 2021 P&P 10th ed. Ch. 29 & Giddens 3rd ed. Ch. 10 Revised June 2022 using P&P 11th ed. Set up Web Link Slide 15 https://youtu.be/znhbVRZRLfM https://youtu.be/Hxd68qJfzhQ...

VITAL SIGNS Melissa Albright MSN, RN Textbook pp edited and expanded by Melissa October 2021 P&P 10th ed. Ch. 29 & Giddens 3rd ed. Ch. 10 Revised June 2022 using P&P 11th ed. Set up Web Link Slide 15 https://youtu.be/znhbVRZRLfM https://youtu.be/Hxd68qJfzhQ Jeopardy game in class activity 1  When Should Vital Signs be Assessed  On admission  During home care visits  Prior to healthcare exam in a clinic  On a routine schedule during hospital admission  Before during and after administration of blood products and certain medications  When a patient's physical condition has changed  Before during and after interventions that can impact VS  When a patient "feels funny"  Nurses' discretion What are Vital Signs Temperature Pulse Respirations Blood pressure 5th Vital signs = Pain Oxygen saturation Smoking status: important to assess based on its impact on body functions and vital signs Emotional Distress: pay impact overall physiological functioning. Know your baseline for comparison/context for VSs == are they normal for this patient?? Routine schedule or as ordered Beginning of shift for inpatients. At a visit to the healthcare providers office or clinic. Pre- & Post-procedure Before, during, & after blood transfusion Before & after giving certain meds (ex: Meds affecting heart or respirations, meds for ↑ temp) Any change in condition (ex: ↓ LOC, Severe pain) Before & after interventions affecting VS (ex: 1st time OOB) If patient “feels funny” At nurse’s discretion (gut feeling) 2 Before calling the MD 1st question may be “What are the VS?” BOX 29.2, p.500: When to Measure Vital Signs Key Point: Vital sings may remain stable even if there is a moderate change to your patient's condition. Be sure to evaluate vital signs in context with your overall assessment of the client. It is important for the nurse to decide if vital signs need to be monitored more frequently than prescribed by the primary care provider. Always obtain an initial set of vital signs to establish baseline, if vital sings vary from their baseline, you need to assess and document them more frequently to determine a trend in the degree and severity of the variation Changes may be caused by disease state, effect of therapies or changes in physical activity or environment. 2  Guidelines for measuring vital signs  Most frequent and routine measurements used to evaluate health status are temperature, pulse, blood pressure, respiratory rate and oxygen saturation  Pain is also considered a vital sign and is subjective in nature.  Provide a baseline set of data  Can be affected by environmental factors  The nurse should be able to  Understand and interpret values  Document data accurately  Communicate finding accurately This Photo by Unkown uthor is licensed under CC BY-SA-NC. Vital sign measurements must be taken in an organized manner. You must be aware of the surroundings and any extraneous factors that might affect the measurements. Changes, both positive and negative, will provide you with valuable information regarding your client’s status. Review each point: Baseline: provide an initial assessment for comparison for any changes Understand and interpret: Need to know normal so we know when something is not normal Interpret do you need to give a medication? (temp or BP); do you need to call the MD?; or evaluating a particular nursing intervention (relaxation technique, i.e. comfort measure) Delegate measurement: Would you delegate evaluating your patient for orthostatic hypotension? Would you delegate a BP check for evaluating having given a med for elevated BP and is it down now? Would you delegate an initial BP check for a new admit? Would you delegate BP on a discharge patient? Why? As the nurse you are responsible for assessing the changes in Vital signs Communicate finding: 3  You as the RN are the communicator you are responsible for getting appropriate information to the appropriate person. Ex. abnormal finding to MD Ex. pain med given and pain relief now so PT can come for PT session Equipment in working order: What about a machine BP that is reading high or, just doesn’t seem “right”? What do you do? Re-check with manual cuff. Document findings: Again, you are responsible for “timely” documentation of vital signs 3  Infection Control and Prevention Use thermometer probe covers Disinfect equipment after each use. Follow agency procedures when equipment is used in isolation rooms Handwashing before & after each encounter This Photo by Unknown author is licensed under CC BY. Disposable BP cuff left in room If machine goes into room wipe down with disinfectant wipes when brought out 4  Body Temperature Physiology  Body Temperature = Heat Produced – Heat lost  Normal temperature range = 36°C -38°C (96.8°F-100.4°F)  Temperature Sites Body temperature: The degree of heat maintained by the body Difference between heat produced & heat lost by the body Thermoregulation: the process of maintaining a stable internal body temperature, balance is controlled by the hypothalamus. Hypothalamus recognizes and responds to changes in body temperature that are sent by sensory receptors in the skin. Core temperature : Temperature deep with the body, i.e. viscera and liver. Rectum (typically used to represent core temperature, whereas oral and axillary reflect surface temperatures) Pulmonary artery (most accurate but not frequently used to because requires invasive procedure) Urinary bladder Adult’s normal temp ranges from 97 37 is heaven Variations in temperature above or below normal if temporary, usually are not significant. Greater variations indicate a disturbance of function in some system or region of the body, degree of temperature elevation does not always indicate the seriousness of the underlying disease or condition. Key Point: A continuous elevation, even if slight, is cause for concern and indicates a need for further evaluation. If oral temp is ↑ think & ask, when did they last had something to drink? Smoke? Wait and re-check 5 [Shown is Figure 29-1: Ranges of normal temperature values and abnormal temperature alterations.] 5  Body Temperature Regulation Neural and Vascular control Heat Production Heat Loss Skin in Temperature Regulation Behavioral Control The body temperature is regulated by physiological mechanisms & behavioral mechanisms, these 2 mechanisms help adjust the body’s heat loss & heat production Body’s response to Variations in Temperature Neuro-feedback mechanism in the hypothalamus senses internal temperature changes and initiates compensatory mechanisms to maintain a stable environment Our body’s metabolism produces heat is a series of chemical reactions that take place in the body, Food is the primary source of the body’s metabolic process. Decreasing in Body temperature: When heat sensors in the hypothalamus are stimulated, they send the message to reduce the body temperature Activating compensatory mechanisms such as peripheral vasodilation (increase in the diameter of the blood vessels, diverting core-warmed blood to the body surface for transfer to the surround environment), sweating, and inhibition of heat production. Increasing the Body Temperature: When sensors I the hypothalamus detect cold, they send out the message to increase heat production and reduce heat loss. To produce heat the body responds with shivering and release of epinephrine which increases metabolism. To reduce heat loss, the blood vessels constrict(vasoconstriction, narrowing of blood vessels conserves heat by shunting blood away from the periphery where heat is lost to the core of the body where the blood is warmed) Piloerection (hairs standing on end ) also occurs but is not an important heat-conserving mechanism. Behavioral control; 6  Depends upon a person’s ability to control body temperature Ability to sense comfort or discomfort and respond to it The person's mobility or ability to add or remove clothing How is heat produced in the body? The body produces heat through the interaction of three factors, metabolism, movement of skeletal muscles and non-shivering thermogenesis Metabolism: Uses energy and generate heat Basal metabolic rate: (BMR), is the heat produced by the body at absolute rest, body size, lean muscle mass, and hormones influence BMR Skeletal Muscle Movement Skeletal muscles are used in all body movements. Muscles need fuel to function. Catabolism (the breakdown of fats and carbohydrates in muscle that produces energy and heat. Takes very little muscle activity to sit and watch t.v. or read. In contract going for a run requires a lot of muscle activity therefore body temperature will go up. If you go outside without a coat when the temperature is below freezing your hypothalamus will sense a drop in body temperature causing your body to shiver to produce heat. Non-shivering Thermogenesis: The metabolism of brown fat to produce heat, used by infants because they cannot produce heat through shivering like adults, disappears in the first few months after birth. How is Heat Exchanged between the Body and The Environment? Heat moves from an area of higher to and area of lower temperature (i.e. cooler air and objects ”pick up” heat from warmer ones. Radiation: Accounts for 50% of body heat loss. Loss of heat from surfaces that are warmer than the surrounding air. If uncovered skin is warmer than the air, body loses heat through the skin. (why a cool room with a lot of people will eventually become warm) Influenced by vasodilation/constriction, blood flow from internal organs to the skin Conduction: Heat is transfer from a warm to a cool surface by direct contact. Pt who changes into a thin, hospital gown and lies on a cool metal radiology table (temp may drop by as much as a degree) Ice pack, cool clothes Convection: Transfer of heat through currents of air or water Immersion in a warm bath may raise body temperature for a hypothermic client Current of cool air produced by a fan can reduce a fever Together the process of convection and conduction account for approximately 15%-20% of all heat loss to the environment Evaporation: Occurs when water is converted to vapor and lost from the skin (perspiration) or mucous membranes (breathing) Causes cooling Water loss by evaporation is called insensible loss. Evaporation is affected by relative humidity. If the air is already humid less moisture evaporates from the skin and less cooling occurs. 6  Factors Affecting Body Temperature  Age  Exercise  Hormone Level  Circadian Rhythm  Stress  Environment  Temperature Alterations Factors influencing Body Temperature Developmental Level/Age: Infants and older adults are most susceptible to the effects of environmental temperature extremes Infants lose approximately 30% of their body heat through the head, which is proportional greater than adults, placing them at a greater risk for decreased body temperature. Body temperature stabilizes during early childhood and remains stable until older adulthood Older adults have difficulty maintain body heat because of slower metabolism, decreased vasomotor control and loss of subcutaneous tissue. Normal body temperature is usually between 95 Exercise: Increase in metabolism d/t hard work or strenuous exercise can increase core boy temperature to 101 Gender A woman's body temperature varies with her menstrual cycle and pregnancy. Women experience greater fluctuations in body temperature than men Emotions and Stress: Emotional stress, excitement, anxiety, and nervousness stimulate the sympathetic nervous system, triggering and increase in metabolic rate, which in turn increases body temperature. Environment Warm room temperature, high humidity , or hot baths can increase body temperature Very high external temperatures can significantly increase internal temperatures, causing heat 7  stroke Cold environments, especially with strong air currents, can lower body temperatures, and in sever cases, lead to hypothermia Circadian Rhythm Body temperature normally changes 0.5° to 1° C (0.9° to 1.8° F) during a 24-hour period. Usually lowest in the early morning hours and highest in the late afternoon or early evening. The circadian rhythm does not change with age but will change for those who work the night shift; usually takes 1 to 3 weeks. Shown is Figure 29.2: Temperature cycle for 24 hours. 7   Normothermic: Normal body temperature (36.5°C- 37.2°C)  Hypothermia: Body temperature below 36.2° C  Hyperthermia: Body Temperature above 37.6°C  Hyperexia: Extremely high temperature above Important 41.5° C  Fever or Pyrexia: heat-loss mechanisms are unable Terms to keep up with excessive heat production  Afebrile: without fever  Heatstroke Fever or pyrexia An oral temperature higher than 100 Three phases of a fever 1. Initial phase (febrile episode or onset): The period during which body temperature is increasing but 8  has not yet reached the new set point. May be sudden or gradual depending on the condition causing it. Person usually feels chilly and generally uncomfortable and may shiver 2. Second phase (course): The period during which body temperature reaches its maximum (set point) and remains fairly constant at the new higher level. Person is flushed and feels warm and dry. May last a few days to a few weeks. 3. Third phase (defervescence or crisis): The period during which the temperature returns to normal. Person feels warm and appears flushed in response to vasodilation. Diaphoresis occurs, which assist with heat loss by evaporation. Commonly referred to as the fever “Breaking” Ways to describe a fever: 1. Intermittent fever: temperature alternates regularly between periods of fever and periods of normal or below-normal temperature without pharmacological intervention. Temperature returns to normal at least once during a 24-hour period. 2. Remittent Fever: Fluctuations in temperature all above normal during a 24-hour period. 3. Constant (sustained) fever: Temperature may fluctuate slightly (less than 1 Antipyretic: medications that reduce a fever Nursing Process & Nursing Care Will revolve around either raising or lowering the client’s body temperature. Acute care: treat the fever, interventions for client a with a fever (provide fluids either IV or PO, reassess vital more frequently i.e. every 2 hours)/ Point out paragraph Box 29.5 pg. 508 8 Shown is Figure 29.3: Effect of changing set point of hypothalamic temperature control during a fever. 9  Medical Management of Hyperthermia Remove excess clothing and blankets Provide external cool packs or cooling Hydrate with cool fluids (oral or intravenous) Lavage with cool fluids Administer antipyretic drug therapy This Photo by Unknown author is licensed under CC BY. Hyperthermia Like hyperpyrexia in that the body temperature is above normal, however in hyperthermia the elevated body temperature is higher than the set point. The hypothalamic regulation of body temperature is overwhelmed and does not reset the setpoint as it does in a fever. Occurs when the body cannot promote heat loss fast enough to balance heat production or high environmental temperatures. Heat exhaustion and heat stroke can occur Objective of treatment is to increase heat loss, reduce heat production, and prevent complications Intervention depends on the cause, adverse effects; and the strength, intensity and duration of elevated temp Heat exhaustion S&S: warning signs vary but pay include; diaphoresis, weakness, n/v syncope, tachycardia, tachypnea, muscle aches, headache flushed skin Heatstroke Occurs from prolonged exposure to the sun or high environmental temperatures, athletes and construction workers are at risk, Body lose its ability to seat and is unable to cool down S&S: inability to sweat; rapid breathing, rapid, strong pulse, throbbing headache, delierum, confusion, slurred speech, impaired judgment, lethargy; red, hot dry skin Dizziness, Seizures, coma EMERGENCY Interventions 10  Objective of treatment is to increase heat loss, reduce heat production, and prevent complications Intervention depends on the cause, adverse effects; and the strength, intensity and duration of elevated temp Heat exhaustion Have patient rest in col dry place, encourage fluids, loosen and remove excess clothing, provide cloth-covered ice packs or cool washcloths to the head, groin, neck or axillae, provide cool water mist; fan the skin while it is moist. Heat stroke Obtain cultures of body fluids such as urine sputum or blood to determine cause of the fever.(make sure this is done prior to admin of antibiotics) Establish IV access; administer cool IV fluids or oral intake to replace fluid loss, lower body temperature, and to prevent dehydration or hypovolemia Provide cooling blankets that circulate water; cool at a controlled rate. Maximize heat loss by removing external covering (make sure to keep pt's clothing and bedding dry if they begin to sweat) Provide appealing nutritional food Encourage good mouth care with water soluble lubricant to treat or prevent cracked lips, swollen tongue Monitor temperature and vital signs at least every 2 hours Monitor urinary output Provide cooling measures (cool bathtub, cool shower, or sponge with cool water. Control environmental temp (if outdoors move person to a shady area) Pt teaching: Drink plenty of fluids, avoid alcohol, caffeine and sugar Wear loose fitting, lightweight, light-colored clothing Avoid long periods of sun exposure in hot weather Limit the amount of time working or exercising in hot weather Teach signs of heat exhaustion and to notify provider if signs develop Older Adults: stay in air-conditioned buildings when the outside temperature is extremely high, encourage family and friends to check on elderly neighbors and family members at least twice a day and make sure they have an electric fan. 10  Medical Management of Hypothermia ◦ Remove the person from cold ◦ Provide external warming measures ◦ Provide internal warming measures ◦ Safety Tip: Rewarming must be done slowly to minimize risk for dysrhythmias. Cardiac monitoring as well as close monitoring of vital signs is required. Hypothermia Occurs with exposure to cold. The core body temperature drops, and the body is unable to compensate. Initial s/s: cool skin, shivering, fatigue, confusion, loss of coordination, cyanosis of lips and fingers, decreased heart rate and respirations. Followed by: pain in the extremities, confusions, further slowing of heart rate and respirations Late symptoms: loss of ability to shiver, blue skin; dilated pupils; amnesia; hypotension; slow, impaired respirations; cardiac arrythmias Death occurs when the body temperature falls below 70-75. Interventions Monitor vital signs Monitor rewarming, A severely hypothermic client should be rewarmed gradually Monitor skin color and temperature Position patient in supine position minimizing orthostatic changes Institute warming measures: Move to warm environment Remove cold, wet clothing Provide a warm bath or shower Apply head coverings, blanket, hot water bottle, warm the chest, neck, head, and groin areas first with external warming blankets or heating pads. Do not use electric blankets Provide warm, high carbohydrate beverages; avoid alcohol or caffeinated drinks 11  Pulse Physiology and Regulation  The pulse is an indirect indicator of circulatory status  Electrical impulses originate in the SA node and travel through the heart stimulating cardiac contraction  Important Terms  Stroke Volume (SV)  Cardiac Output (CO)  Heart Rate (HR)  Mechanical, neural, and chemical factors regulate the strength of ventricular contraction and the SV. This Photo by Unknown author is licensed under CC BY-SA. Perfusion: refers to the continous supply of oxygenated blood through the blood vessels to the vital organs. Pulse: The rhythmic expansion of an artery produced when oxygenated blood is forced into it by contraction of the heart. The palpable bounding of the blood flow in the body The indicator of the circulatory status for the area being checked Normal Pulse Rate: 60-100 beats/min If there is concern you will use a cardiac monitor to determine rate, rhythm and intensity of pulse How is pulse rate regulated? Pulse wave begins when the left heart ventricle contracts and ends when it relaxes. Each contraction forces blood into the already filled aorta, increasing pressure Intermittent pressure and expansion of arteries causes blood to move in a wavelike motion. You can palpate a light tap at the peak of the wave. This corresponds to systole (the contraction of the heart) The trough or low point of a pulse wave occurs when the artery contract to push blood along its way. This corresponds to diastole the resting phase of the heart. Stroke volume: is the amount of blood pumped from the ventricles with each beat of the heart. (usually will not know the actual stroke volume, average is 70 mL in most healthy adults) Cardiac output : is the amount of blood pumped by the heart in one minute; expressed in liters per minute Cardiac Output = heart rate X stroke volume. If there is an ↑ or ↓ in the heart rate and the blood pressure cannot respond you will have a health 12  problem Autonomic nervous system regulates the heart rate. Sympathetic stimulation increases the heart rate = increase in cardiac output. Parasympathetic stimulation decreases cardiac output. Factors that influence pulse rate: In healthy adults the peripheral pulse rate is the same as the heart rate, therefore it is a quick and simple way to assess the condition of the heart, blood vessels, and circulation. Pulse will vary in response to Changes in volume of blood pumped through the heart Variations in heart rate Changes in the elasticity of the arterial walls Any condition that interferes with heart function Impaired functioning of the nervous system. Other factors Developmental level: newborns have a rapid pulse that stabilizes in childhood and gradually slows through old age. Gender: women have a slightly more rapid pulse rate than men Exercise: muscle activity normally increases the pulse rate. After exercise, well conditioned heart will return to normal fairly quickly. People who are well condition have lower heart rates both before and during exercise. Food intake: ingestion of a meal causes a slight increase in pulse rate for several hours Stress: triggers the fight-or-flight sympathetic nervous system response, which increase both pulse rate and strength of heart contractility Fever will increase the pulse rate about 10 beats/min for each degree Fahrenheit of temperature elevation. (1. metabolic rate increases, 2. peripheral vasodilation occurs, causing a decrease in blood pressure. The body then responds by increase the heart rate to faster compensate for the decrease in blood pressure) Disease: hyperthyroidism, respiratory disease and infections are generally associated with increased pulse. Blood loss: small amount are generally well tolerated and produce only a temporary increase in pulse rate. A large amount of blood loss will cause the heart rate to increase in order to compensate of the decrease in volume Position changes: standing and sitting positions generally cause a temporary increase in pulse rate and decrease in blood pressure as a result of blood pooling in the feet and legs. This causes decreased blood return to the heart, decreasing blood pressure and subsequently increasing the heart rate. Medications: stimulate drugs increase pulse rate, Cardiotonic, opioids and sedative drugs will decrease pulse rate. 12  Assessment of Pulse  Select appropriate pulse site  Table 29.3 Pulse Sites, P. 478  Note Pulse character  Rate  Rhythm  Strength  Equality Select the most appropriate and age-specific site to measure the pulse. Sites include temporal, carotid, apical, brachial, radial, ulnar, femoral, popliteal, posterior tibial, or dorsalis pedis. Carotid pulse must be assessed carefully, must palpate only one side at a time, should be light avoid massaging the area as this can cause Valsalva response = decrease in heart rate and BP. Radial is most commonly assessed site because it is easy to find and readily accessible. Use radial when teaching people to monitor their own pulse, If radial pulse is irregular apical pulse should be assessed for 1 minute. Apical the most accurate pulse, should be about the same as peripheral pulses in healthy people. Is measured using a stethoscope over the 4th to 5th ICS at the left MCL, assessed when radial pulse is week or irregular or if pulse is less than 60 or greater than 100, patient is taking cardiac medications, pt is below the age of 3 (peripheral pulses may be difficult to palpate) Brachial pulse is used when performing CPR on infants Carotid/Femoral used for unresponsive, not breathing, CPR Dorsalis pedi (Pedal pulse) and posterior tibial arteries are used to assess peripheral circulation to the legs and feet. Table 29.3, p.478 = Pulse Sites, presents pro’s and con’s for each site; location & assessment criteria important to establish a baseline for future comparison. Be careful when delegating the assessment of vital signs to nursing assistive personnel they may not know how to assess the pulses that are important for your patient’s health assessment needs 13 When auscultating an apical pulse assess rate and rhythm only 13  Pulse Characteristics ◦ Rate: 60-100 bpm ◦ Rhythm: Regular or Irregular ◦ Strength: (Graded as) 4+= Bounding 3+= Full 2+=Normal 1+=Weak 0=Absent oEquality Table 29.5, P. 480 Factors influencing Heart Rate Rate: For healthy adults can determine rate by palpating or listening for 30 seconds and multiplying by 2 If rate is irregular or slow always best to count for 1 minute Bradycardia 100 your nursing interventions will relate to disturbances to the general state of the client’s cardiovascular health. The nursing care plan will include interventions designed to help the client alleviate the problem Rhythm: Interval between heartbeats establishes a pattern Abnormal rhythm is called a dysrhythmia Regular or irregular Should be regular; however, both normal and abnormal variations will occur Regularly irregular: an irregular rhythm that forms a pattern Irregularly irregular: unpredictable rhythm If irregular count out for 1 minute at Pulse site and verify auscultating the apical pulse for one minute Pulse Quality/Strength: Pulse volume refers to the amount of force produced by the blood pulsing through the arteries Normally the pulse volume for each beat is the same 0 = absent, not palpable 1+ = pulse diminished, barely, palpable2+ = expanded/normal 3+ = full pulse, increased 4+ = bounding pulse (actually visible) 14  You also will hear: strong, weak, thready, or bounding Equality: Symmetrical pulses equal in strength from one side to the other (ex. comparing right to left), or is one absent? (make sure to assess for cyanosis [bluish or grayish discoloration] or pallor [ paleness of skin in one are compared with another part of the body]) Assess symmetrical pulses at the same time EXCEPT carotid pulse Provides valuable information Ex. Post op surgery on an extremity indicator of proper circulation 14  Practice Counting Pulses Apical Pulse Radial Pulse PMI (point of maximum impulse) also called apical impulse Find angle of Louis Find 2nd ICS Locate 5th ICS Go to MCL Count as lub-dub = 1 (S1, S2) If time = go to web link and let students practice https://youtu.be/znhbVRZRLfM https://youtu.be/Hxd68qJfzhQ Adult = 63 Infant = 121 15  Nursing Process/Interventions Activity Anxiety Acute Pain intolerance Ineffective Decreased Deficient/excess peripheral tissue Cardiac Output fluid volume perfusion Pulse assessment general state of cardiovascular health and the response of the body to other system imbalances. What Nursing interventions can be done for these areas of concern? Obtain and ECG/EKG Monitor the client’s VS Monitor the client’s activity tolerance Collect and assess Lab data (electrolyte balance, serum levels for various cardiac meds) Identify possible causes of the dysrhythmia Administer antidysrhythmic medications Provide emotional support 16  Respiration Ventilation Diffusion Perfusion Physiological Control Mechanics of Breathing This Photo by Unknown author is licensed under CC BY-SA-NC. Respiration: The exchange of oxygen and carbon dioxide in the body. Consists of Mechanical: the active movement of air into and out of the respiratory system, known as pulmonary ventilation (AKA breathing) Chemical: includes external respiration (exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply, gas transport (transport of the gases throughout the body) and internal respiration (exchange of gases between the capillaries and the body tissue. Normal respiratory rate : 12-20 breaths per minute Regulation of Respiration: Respiratory centers in the medulla oblongata and pons of the brain, along with nerve fibers of the autonomic nervous system regulate breathing in response to changes in the concentration of oxygen and carbon dioxide Primary stimulus for breathing is the level of CO2 in the blood. Central chemoreceptors: located in the respiratory center are sensitive to CO2 and hydrogen ion concentration and increases of these stimulate respirations Peripheral chemoreceptors: located in the carotid and aortic bodies respond to changes in partial pressure of oxygen (between 80-100) if it fall below normal these stimulate respirations Mechanics of breathing: Inspiration: response to impulses sent from the respiratory center that stimulate the thoracic muscles and diaphragm to contract, ribs move upward, diaphragm moves downward and out and the abdominal organs move downward allowing the thorax to expand in all directions. This movement causes airway pressure to decrease below atmospheric pressure and air moves int the lungs. Lasts 1-1.5 seconds 17  Expiration: diaphragm and thoracic muscles relax, the chest cavity decreases in size and the lungs recoil, forcing air from the lungs until the lungs reach atmospheric pressure. Expiration is a passive process and normally takes 2-3 seconds Respiration includes three processes: Ventilation movement of gases in and out of the lung. Diffusion movement of oxygen and carbon monoxide between the alveoli and RBCs Perfusion distribution of red blood cells to and from the pulmonary capillaries. Factors that affect Respiration: Developmental level: newborns respiratory rate is generally 40-60, rate gradually decreases until it reaches the normal adult rate of 12-20. Respiratory rate decreases slightly in older adults. Exercise: muscular activity causes a temporary increase in respiratory rate and depth, to increase oxygen availability to the tissues and rid the body of excess carbon dioxide Pain: acute pain can increase respiratory rate, but decrease depth Stress: psychological stress such as anxiety or fear my influence respirations as a result of sympathetic stimulation, most common change is increase in rate. Smoking: Chronic smoking increases respiratory rate as a result of changes in airway compliance Fever: When heart rate increase because of fever respiratory rate also increase. For every 1 degree the temperature rises, the respiratory rate may increase up to 4 breaths/min Hemoglobin: Respiratory rate and depth increases as a result of anemia. Disease: rate may be increased or decreased d/t various diseases. Medications: Central nervous system depressants such as morphine or general anesthetics cause slower deeper respirations. Caffeine and atropine can cause shallow, fast breathing. Position: Standing up maximizes respiratory depth, where lyng glat reduces respiratory depth. Slumping prevents chest expansion. Breathing is a passive process: The brain stem regulates the involuntary control. The body regulates ventilation through CO2 and O2 and hydrogen ion concentration in arterial blood. If oxygen falls below acceptable parameters, respiratory rate and depth of ven la on will ↑ 17  Assessment of Respiration Rate: Adult = 12-20/minute Depth: deep, normal, or shallow Rhythm: regular or irregular SpO2: 95-100% (arterial diffusion & perfusion) Box 29.6, P.514 Factors influencing Character of Respirations Table 29.7 P.514 Alterations in Breathing Pattern Box 29.7, P.515 Factors Affecting Determination of Pulse Oxygen This Photo by Unknown author is licensed under CC BY-SA. Respirations Are tied to all functions of body systems. Respirations should be assessed without the patient's knowledge. A sudden change in respiration may indicate a problem or can be a normal physiological response Box 29.6, p.514, Factors Influencing character of Respirations Respiratory rate:  is age specific; Ex = infants tend to breathe less regularly (Table 29.6 pg 514 Acceptable Ranges of Respiratory Rate)  can be influenced by activity and age as well as by illness, injury, or disease.  The number of times a person breathes within 1 full minute  Easily counted by placing your hand on the client’s chest (palpation) or observing (inspection the number of times the client’s chest or abdomen rises (inspiration) and falls (expiration)  Can also be counted by placing your stethoscope on the client’s chest (auscultation) and counting the number of inhalation and exhalation cycles.  For a new patient you should count for the full 60 seconds, if you know the patient well can count for 30 seconds and multiply by 2  If respirations vary from normal should count for 1 full minute  Apnea: the cessation of breathing can only be tolerated for a few minutes, if it continues for longer than 4-6 minutes brain damage can occur Depth  Tidal Volume: Normally 300-500 ml of air is inhaled in a breath 18  Ventilatory movements: are described as deep (taking a very large volume of air and fully expanding one’s chest or abdomen) , normal (falling between shallow and deep), or shallow (when the chest barely rises and is difficult to observe.  Table 29.7, p.514: Alterations in Breathing Patterns  Cheyne-Stokes Gradual increase in depth of respirations, followed by gradual decrease and then a period of apnea  Eupnea: Normal respirations with equal rate and depth (12-20)  Bradypnea: slow respiration 24 breaths/min (usually shallow)  Kussmaul’s: respirations that are regular but abnormally deep and increased in rate  Apnea: Absence of breathing Rhythm:  regular or irregular in rhythm:  Infant breathing is more likely to be irregular than adult breathing. Respiratory Effort: Refers to the degree of work required to breathe Normal breathing is effortless Dyspnea is increased effort with breathing or labored breathing Orthopnea is difficulty or inability to breathe when lying flat, observes in clients with respiratory and cardiac conditions (need to ask how many pillows they use) Breath Sounds: Wheezes: high-pitched, continuous musical sounds usually heard on expiation, caused by narrowing of airways Rhonchi: low-pitched, continuous gurgling sound caused by secretions in the large airways, often cleared with coughing. Crackles: caused by fluid in the alveoli. Discontinuous sounds usually heard on inspiration. Pay be high- pitched, popping sounds or low-pitched bubbling sounds. Chest and Abdomen Movement: Chest or abdomen normally rises with inspiration and falls with expiration in a gently and rhythmic pattern. When a person is having difficulty moving are in and out of lungs may see: Intercostal retractions: visible sinking of tissues around and between the ribs that occurs when the person must use additional effort to breathe. Substernal retraction: When tissues are drawn in beneath the sternum Suprasternal retraction: When tissues are drawn in above the clavicle Associated Clinical Signs: Assess for signs of oxygenation Hypoxia (inadequate cellular oxygenation) s/s: Pallor or cyanosis (tongue and oral mucosa are best indicators of hypoxia, cyanosis of nails, lips and skin may be cause by hypoxia, related to cold or a decrease in circulation) Restlessness Apprehension, confusion, dizziness, fatigue, decreased loc, Tachycardia Tachypnea Changes in blood pressure Chronic hypoxia causes clubbing of nails Cough: Forceful expulsion of air during expiration May be symptoms of allergic reactions, lung disease, respiratory infection or heart conditions May be constant or intermittent May be productive (secretions are coughed up) nonproductive or dry (no secretions) Hacking cough (series of dry coughs that occur together Arterial Oxygen Saturation ABG (arterial blood gas) directly measures partial pressure of oxygen and carbon dioxide as well as blood pH 18  and gasses in the arterial blood. Will learn about this in Adult II You will evaluate respiratory processes of diffusion and perfusion by measuring the oxygen saturation of blood. The percentage of hemoglobin that is bound with oxygen in the arteries = SaO2 This should be between 95% and 100%. Arterial oxygen saturation is measured through a pulse oximeter. The Pulse Oxygen Saturation or SpO2 is a reliable estimate of SaO2 when it is higher than 70%. Peripheral vascular disease can reduce pulse volume affects SpO2 (for older adults finding a probe site may be difficult) Box 29.7, p.515 = factors affecting pulse ox sat. O2 Sat especially important patient who has a respiratory infection or diagnosis 18  BREATHING PATTERNS Hyperventilation Occurs when rapid and deep breathing results in excess loss of carbon dioxide. Pt may complain of feeling lightheaded and tingly Causes include anxiety, infection, shock (loss of blood d/t surgery), hypoxia, drugs, diabetes mellitus, or acid-base imbalance Have patient breath into a bag so they are reabsorbing some of their carbon dioxide. Hypoventilation Rate and depth of respirations decrease, and carbon dioxide is retained or alveolar ventilation is compromised Causes include chronic obstructive pulmonary disease (COPD), general anesthesia, impending respiratory failure or other conditions that result in decreased respirations. 19  Blood Pressure Physiology  The force exerted on the walls of an artery  Systemic/Arterial BP is a good indicator of cardiovascular health  Affected by:  Cardiac Output  Peripheral Resistance  Blood Volume  Viscosity  Vessel Elasticity Blood pressure is: The pressure of the blood as it is forced against arterial walls during cardiac contraction. Systolic blood pressure: the maximum peak pressure against arterial walls s the ventricles contract and eject blood Diastolic blood pressure: a minimal pressure is exerted against the arterial walls, between cardiac contractions when the heat is at rest. Blood pressure is measured in millimeters of mercury (mmHg), recorded as systolic over diastolic pressure. Adequate blood pressure is essential for healthy tissue perfusion and is an important indicator of overall cardiovascular health Pulse Pressure is the difference between the systolic and diastolic pressures, and is an indication of the volume output of the left ventricle Need to understand how systolic and diastolic blood pressure contributes to tissue perfusion 1. Contraction of the heart (systolic pressure) forces oxygenated blood into the arterial circulation to provide a continuous supply of oxygen to all body cells (perfusion) 2. The heart then rests and refills with blood (diastolic pressure) which is pumped out to the tissues 3. Any factor that interferes with this cycle can cause impaired tissue perfusion. Regulation of Blood Pressure Highly complex process influenced by cardiac function, peripheral vascular resistance, and blood volume. Cardiac Function: R Remember cardiac output (CO) is the volume of blood pumped by the heart per minute. A change in stroke volume or heart rate alters cardiac output. 20  An increase in cardiac output causes and increase in BP and a decrease in cardiac output causes a decrease in BP (if all other factors remain the same) Increased Stroke Volume: Conditions that increase stroke volume included increased blood volume (ex. during pregnancy), more forceful contraction of the ventricles (ex during exercise) Decreased Stroke Volume: Conditions that decrease stroke volume include dehydration, active bleeding, damage to the heart (after MI), and a very rapid heart rate (an increase in heart rate will increase cardiac output, but a very rapid heart rate limits the time allotted for ventricles to fill resulting in a decreased stroke volume and ultimately decreased cardiac output) Peripheral resistance. Refers to arterial and capillary resistance to blood flow because of friction between blood and the vessel walls. Increased peripheral resistance causes a temporary increase in BP. The amount of friction or resistance depends on: Blood viscosity: Thickness, determined by hematocrit (percentage of red blood cells in the plasma) High hematocrit = elevated BP (any disorder that increased hematocrit [dehydration] increases blood viscosity and therefore BP. Low hematocrit may lower BP (A low hematocrit [anemia] lowers viscosity and may reduce BP Arterial Size: sympathetic nervous system controls vasoconstriction and vasodilation (the smaller the radius of the blood vessel the more resistance to blood flow). Constricted arteries prevent the free flow of blood = increased BP, Dilated arteries allow unrestricted flow of blood = reducing BP Arterial Compliance (elasticity): arteries with good elasticity can distend and recoil easily and adequately. Disease and age can cause loss of elasticity = possible icnrese in peripheral resistance and BP. Arteriosclerosis is a common contributor to increased BP in middle-aged and older adults. Blood Volume Normal circulating volume is 5000 ml. Kidney failure can lead to an increase in volume which can lead to an increase in BP Decrease in volume which can be caused by hemorrhage or dehydration), causes blood pressure to fall. It is important to remember that each hemodynamic factor significantly affects the others. 20  Parts of the Blood Pressure Cuff ◦ Bladder ◦ Occlusive Cuff ◦ Bulb ◦ Valve ◦ Aneroid Manometer Assessment of BP can be done directly or indirectly Direct Measurement: A catheter is threaded into an artery under sterile conditions attached to tubing that is connected to an electronic monitoring system Measurement is very accurate and is mostly used in critical care areas and surgery. Indirect Measurement: You will measure BP via indirect or noninvasive method. Provides an accurate estimate of arterial BP that can be performed in any setting. You will need a stethoscope, a BP cuff and sphygmomanometer, or an electronic BP monitor Sphygmomanometer: Consists of a vinyl or cloth cuff (contains and inflatable rubber bladder), a pressure bulb with a regulating valve, and a manometer. The release valve on the sphygmomanometer needs to be clean and move feely What Size Cuff Should I use? The width of the bladder of a properly fitting cuff will cover approximately 2/3 of the length of the upper arm (or other extremity). Using a cuff or bladder that is the incorrect size can result in measurement error. If cuff is too narrow reading will be too high, if cuff is too wide, reading will be too low. Cuff length should encircle 80% of the arm Which site should I use? Avoid assess BP in an arm that has an IV access device, renal dialysis fistula, skin graft, extensive trauma or a cast or dressing. Do not use the arm that is paralyzed or on the same side of breast or shoulder surgery 21  You can use the forearm, thigh, or calf. Systolic pressure may be 20-30 mm HG higher in the lower extremities than in the arm. 21  Assessment of Blood Pressure Obtained either directly (invasively) or indirectly (noninvasively) Cuff Size Auscultation Stethoscope Ultrasonic Stethoscope Palpation Lower Extremity Electronic Blood pressure Table 29.12 Common errors in BP assessment, p.487 Skill 29.5 Two-step Method, p.510-511 Blood pressure can be measured indirectly by auscultation or palpation. Preferred method is auscultation; however, palpation is useful in certain situations (When BP is difficult to hear shock or other situations that compromise circulation). Usually, can only palpate the systolic BP A baseline is necessary for comparison. Delegation depends upon the condition of the client. Auscultating Blood Pressure When auscultating BP, place your stethoscope over an artery 1. Inflate the cuff: as you inflate the cuff the artery is occluded at this point blood flow is stopped and no sound can be heard. 2. Deflate the cuff slowly: Blood flow begins to flow rapidly through the partially open artery, producing turbulence that you will hear through the stethoscope as a tapping sound Sounds you hear are called Korotkoff sounds 1st sound = Systolic: this is a tapping sound that corresponds to a palpable pulse 2nd sound = Turbulence: This sound is soft and swishing. When the artery is no longer compressed, blood flows feely, and no sound is heard. 3rd sound = Rhythmic Tapping: Begins midway through the BP and is a sharp, loud rhythmic tapping sound 4th sound = Muffled: Soft fading and muffled 5th sound = Diastolic: corresponds with the absence of sound Auscultatory Gap: If a patient has hypertension, you may note the loss of sounds for as much as 30 mmHg, followed by the return of sound. Failure to recognize auscultatory gap can result in serious misreading of the systolic BP. Using palpation with Auscultation helps ensure accuracy of your reading. 22 Table 29.12, p.519 presents common mistakes in blood pressure assessment. An ultrasonic stethoscope will help you to hear a weak BP. This pick up low-frequency sounds. Lower-extremity BP == may need to be assessed if the upper extremities are not available because of dressings, casts, burns, lines, fistulas, or shunts. The proper size is a must. You will need to practice this to acquire competency. Systolic pressure usually 10-40 mm higher than in the brachial (arm); Diastolic same Electronic blood pressure devices come in many styles. You will learn how to take BPs manually and electronically. When taking BP electronically, make sure the device is fully charged and calibrated. If in doubt take a manual BP and go with that reading Skill 29.5, p.541-546: Two-step Method practicum method will be this 22  Factors That Affect Blood Pressure ◦ Non-modifiable ◦ Modifiable ◦ Age ◦ Stress ◦ Ethnicity ◦ Medications ◦ Gender ◦ Activity and Weigh ◦ Genetics ◦ Smoking ◦ Daily variation ◦ Diet Table 29.8 Average Optimal BP for Age, p.484 Table 29.10 Classification of BP for Adults, p.485 Table 29.9 Antihypertensive medications, p.485 Blood pressure is not a constant Many factors influence blood pressure. Table 29.8, p.517 presents the “normal” blood pressure levels throughout the lifespan. Further categories for adults: normal, prehypertension, Stage 1 Hypertension, and Stage 2 Hypertension. Table 29.10,p.518 Age: Newborns have lower BP that gradually increases throughout childhood. A child or adolescent’s BP depends on body size, therefore a smaller child or adolescent will have a lower BP. Both systolic and diastolic BP continue to increase with age as a result of decreased arterial compliance and changes in the left ventricle wall Ethnicity: The incidence of hypertension is higher in African Americans than in European Americans. And have a higher incidence of complications and hypertension-related deaths. Gender: Average BP for men is slightly higher than that of women of comparable age After menopause women’s BP tends to increase (possibly d/t a decrease in estrogen) Genetic/Family History Family history of hypertension increases the likelihood of an individual’s developing hypertension Diabetes Lifestyle: Increased sodium consumption, smoking, and consumption of 3 or more alcoholic drinks per day have been shown to elevate BP Caffeine may raise BP for a short while after ingestion, but has no long-term affect on BP 23 Exercise: Physical fitness has been shown to reduce BP in many individuals Muscular exertion temporarily increase BP as a result of increased heart rate and cardiac output (wait at least 30 minutes before you assess the BP for someone who has been exercising) Body Position: BP is higher when a person is standing than when she is sitting or lying down. Readings are higher if BP is take when the client’s arm is above their head or if their arm is unsupported at their side. Seated readings are higher if the clients feet are dangling rather than resting on the floor or if their legs are crossed. Diurnal Variations: Blood pressure will vary during the day, around sleep intervals and activities. Blood pressure is highest between 1000 and 1800 hours. Blood pressure is lowest between hours of sleep and 0300. As the person wakes up,the blood pressure will rise. Stress: Anxiety, fear, pain, and emotions cause a sympathetic stimulation, which increases heart rate, cardiac output, and vascular resistance. Medications will directly or indirectly alter blood pressure Antihypertensives alter BP directly Antihypertensives often contain parameters of when they can be administered. i.e. hold systolic bp is less than 100 mm Hg. If you have to hold medication make sure to document BP as well as that medication was held. opioid analgesics alter BP indirectly; will lower blood pressure volume and vasoconstrictors: Vasoconstrictors raise BP; Diuretic lowers vol. will lower BP Obesity Obesity increases BP due to the additional vascular supply required to perfuse the large body mass and the resultant increase in peripheral resistance. 23  Variations in Blood Pressure Category Systolic Diastolic Normal 120 or below 80 or below Hypotension 90 or below Orthostatic Hypotension Significant drop in BP when rising Elevated 120 – 129 or 80 or above Stage I Hypertension 130 – 139 or 80 – 89 Stage II Hypertension 140 or above or 90 or above Hypertension A transient elevation BP is a normal response to physiological or psychological stress (after exercise). To confirm diagnosis, use and average based on two or more readings obtained on two or more occasions. Increases stress on the heart and blood vessels. If untreated it increases the risk for stroke, heart attack, damage to kidneys, retinas and peripheral nervous system. Risk Factors: Modifiable: Smoking, secondhand smoke, overweight, obesity, sedentary lifestyle, unhealthy diet, high cholesterol levels, stress, heavy alcohol consumption Nonmodifiable: Family history, increased age, race, CKD Physiologically hypertension is related to thicken of arterial walls and decreased elasticity of arteries, As BP rises, peripheral resistance increase. Overtime, the heart is unable to compensate, and cardiac output declines. Assessment: note any risk factors, may have no S/S, may have headaches, fatigue and visual changes. Interventions: Will depend on cause of hypertension (quit smoking, cardiac risk management etc.) monitor VS, monitor for activity intolerance, monitor I/O, observe for edema, monitor weight gain, assess client’s attitudes about taking medications and making lifestyle changes, monitor for adherence to treatment regimen Teaching: Lifestyle changes, self management, timing of medications, educate about medications. Hypotension Systolic