Vital Signs Spring24 Student PDF

Chapter 30 Vital Signs NURS 300  OBJECTIVES 1. Identify when it is appropriate to assess each vital sign. 2. Evaluate a patient’s disease process, cognition, age, and other factors when selecting sights for temperature, pulse, and blood pressure assessment...

Chapter 30 Vital Signs NURS 300  OBJECTIVES 1. Identify when it is appropriate to assess each vital sign. 2. Evaluate a patient’s disease process, cognition, age, and other factors when selecting sights for temperature, pulse, and blood pressure assessments. 3. Select nursing measures that promote heat loss and heat conservation. 4. Summarize physiological changes associated with fever. 5. Analyze a patient’s body temperature. 6. Analyze a patient’s radial and apical pulse. 7. Evaluate the significance of a pulse deficit. 8. Analyze a patient’s respirations. 9. Explain the benefits and precautions involving self- measurement of blood pressure.  OBJECTIVES 10. Analyze a patient’s blood pressure. 11. Explain factors that cause variation in SpO2 values. 12. Analyze a patient’s SpO2, using pulse oximetry. 13. Summarize factors that cause variations in body temperature, pulse, oxygen saturation, capnography, respirations, and blood pressure measurement. 14. Discuss how clinical judgement is essential in identifying when to measure vital signs. 15. Determine when it is appropriate to delegate vital sign measurement to assistive personnel. 16. Evaluate the effectiveness of nursing interventions to promote or maintain normal vital signs. 17. Discuss accurate recording and reporting of vital sign measurement.  VITAL SIGNS Temperature, pulse, respiratory rate, blood pressure, Oxygen Saturation Pain - Often called the fifth vital Measurement of vital signs provides data from which to determine a patient’s usual state of health (baseline data). Vital signs are used to: Monitor patient’s condition Identify problems Evaluate response to intervention  GUIDELINES FOR MEASURING VITAL SIGNS Measuring vital signs is your responsibility. Clean each device between patients. Assess equipment is working correctly. Select the appropriate equipment for the patient. Know the patient's usual range (baseline) of vital signs. Know the patient's health history, therapies, and prescribed and over-the-counter medications. Control environmental factors.  GUIDELINES FOR MEASURING VITAL SIGNS Use an organized, systematic approach. Collaborate on assessment frequency. Use measurements to determine indications for medication administration. Analyze results based on patient condition. Verify and communicate significant changes. Provide patient teaching. Vital signs are not interpreted in isolation. You need to also know related physical signs or symptoms and must be aware of the patient’s ongoing health status.  7 CASE STUDY Ms. TS is a 26-year-old schoolteacher. Her maternal grandparents immigrated to America from Brazil. She smokes one pack of cigarettes a day and has smoked since she was 16. She is 20 lbs overweight. She made an appointment because she started to have headaches and frequently felt tired. Throughout the chapter, think about how Ms. TS’s history will affect her vital signs  BODY TEMPERATURE PHYSIOLOGY Acceptable temperature range: 98.6° F to 100.4° F or 36° C to 38° C Fahrenheit or Celsius scales Thermometers- electronic or disposable Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery Temperature control mechanisms of humans keep body core temperature (temperature of the deep tissues) relatively constant. Rectal temperatures are closest to body core temperature and are typically higher than temperatures at other sites Temps taken at body surface (further from body core) are less accurate  9 THERMOREGULATION Thermoregulation- the physiological and behavioral mechanisms that regulate the balance between heat loss and heat production Heat loss- transfer of heat between objects through direct contact, air movement, or change from liquid to gas (i.e. sweating) 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 control- ability to control body temperature through emotions, sensing comfort or discomfort, mobility, ability to add or remove clothing  10 CASE STUDY (CONT.) Miguel is a 42-year-old Hispanic nurse who works at the clinic Ms. TS is visiting. He enjoys providing health-related teaching to the patients and has provided Mrs. TS care for 2 years. During the visit, Miguel assesses Ms. TS’s symptoms. He asks her about her headache and fatigue, then takes her vital signs. Her temperature is 98° Fahrenheit. What other vital signs does Miguel need to check? Copyright © 2017, Elsevier Inc. All Rights Reserved.  FACTORS AFFECTING BODY TEMPERATURE Age - Newborns’ temperature control mechanisms are immature. Until a child Exercise - will increase heat production reaches puberty, temperature regulation is and body temperature unstable. It is not unusual for older adults to reach temperatures no higher than 96.8° F Hormonal level - Women experience greater Circadian rhythm - changes the body fluctuations in body temperature than men. temperature over the 24-hour period. Hormonal variations occur during menstrual The lowest body temperature occurs cycle & menopause. Women may experience between 0100 and 0400 hours. The hot flashes caused by an inability to control body reaches maximum temperature at vasodilation and vasoconstriction. 1600 hours Environment Stress- hormonal and neural stimulation increases metabolism which increases heat production  TEMPERATURE ALTERATIONS Pyrexia (fever): important defense mechanism Fever is usually not harmful if it stays below 39° C (102.2° F) in adults or below 40° C (104° F) in children. Mild temperature elevations as high as 39° C (102.2° F) enhance immune system During a fever cellular metabolism increases, and oxygen consumption rises. Body metabolism increases 10% for every degree Celsius of temperature elevation Heart and respiratory rates increase to meet the metabolic needs of the body for nutrients. The increased metabolism uses energy that produces additional heat. Prolonged fever weakens a patient by exhausting energy stores. Increased metabolism requires additional oxygen- may need oxygen therapy If the body cannot meet demand for additional oxygen, cellular hypoxia (inadequate oxygen) occurs. Myocardial hypoxia produces angina (chest pain). Cerebral hypoxia produces confusion. When water loss through increased respiration & diaphoresis is excessive, the patient is at risk for fluid volume deficit and dehydration- need to maintain optimum fluid volume status  TEMPERATURE ALTERATIONS Heatstroke (104° F or higher) – Occurs from prolonged exposure to the sun or high environmental temperatures. S&S: hot, dry skin; giddiness, confusion, delirium, excessive thirst, nausea, muscle cramps, visual disturbances, elevated body temperature, increased heart rate, and lower blood pressure. Heatstroke Treatment – Move patient to cooler environment, remove clothing, place cool wet towels over the skin, & use fans to increase convective heat loss, providing IV fluids, irrigating stomach & lower bowel with cool solutions, hypothermia blankets Heat exhaustion - When profuse diaphoresis results in water and electrolyte loss. Hypothermia – Core body temperature drops, & body is unable to compensate Frostbite - Ice crystals form inside cell, & permanent circulatory and tissue damage occurs Hypothermia Treatment– Priority goal is to prevent further decrease in body temperature. Remove wet clothes, replace with dry ones, & wrap pt. in blankets, protect any injured tissue.  PULSE PHYSIOLOGY AND REGULATION Pulse: Palpable bounding of blood flow in peripheral artery that can be noted at various points on the body 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, strength, & equality  PULSE CHARACTER Rate Radial rate- number of pulsing sensations in 1 minute Acceptable pulse Rates: 60 – 100 BPM Postural changes affect the pulse rate, HR temporarily increases when a person changes from a lying to a sitting or standing position. Apical rate: S1 and S2, “lub”+“dub” = 1 heartbeat, Lub-dubs per minute = Rate Bradycardia - slow rate—below 60 beats/min in adults. Tachycardia - abnormally elevated HR—above 100 beats/min in adults Pulse deficit = Difference between radial and apical pulse rates Rhythm Dysrhythmia: regularly or irregularly irregular Threatens the ability of the heart to provide adequate cardiac output  PULSE CHARACTER 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 & expected (2+) Diminished or barely palpable (1+) Absent (0) Include assessment of pulse strength in the assessment of the vascular system. No palpable pulse, but found with DopplerDOP Equality - Pulse in one extremity is sometimes unequal in strength or absent in many disease states  RESPIRATION Respiration has three processes: ventilation, diffusion, & perfusion. Assess respiratory rate, depth, & rhythm. Ventilation = Movement of gases into and out of the lung. Diffusion= Movement of oxygen and carbon dioxide between alveoli and red blood cells. Perfusion = Distribution of red blood cells to & from the pulmonary capillaries.  RESPIRATION Physiological control - Breathing is a passive process. Brain stem regulates involuntary control. Body regulates ventilation through CO2 concentrations in arterial blood. If oxygen falls below acceptable parameters, respiratory rate & depth of ventilation will increase. Hypoxemia - Low blood level of oxygen Helps to control ventilation in patients with chronic lung disease. Levels of arterial O2 provide stimulus that allows a Pt to breathe, administration of high oxygen levels is fatal for patients with chronic lung disease. Eupnea – ventilation of a normal rate and depth  ASSESSMENT OF VENTILATION Respiratory rate: breaths/minute: Acceptable respiratory Rate: 12 - 20 breaths/min in adults Influenced by activity, age, illness, injury, position, meds, smoking, or disease Ventilatory depth: deep, normal, shallow, labored Ventilatory rhythm: regular/irregular Infants tend to breathe less regularly. Respiration is regular or irregular in rhythm. Diffusion and perfusion - evaluate respiratory processes of diffusion and perfusion by measuring the oxygen saturation of blood  FACTORS INFLUENCING CHARACTER OF RESPIRATIONS Exercise - increases rate and depth to Acute pain - alters the rate and meet the body’s need for additional rhythm of respirations; breathing oxygen and to rid the body of CO2 becomes shallow. Anxiety - increases respiration rate Smoking - Chronic smoking changes and depth as a result of sympathetic pulmonary airways, resulting in stimulation. increased rate of respirations at rest when not smoking Body position - Straight, erect posture Medications - Opioid analgesics, promotes full chest expansion; general anesthetics, and sedative- Stooped or slumped position impairs hypnotics depress rate and depth, ventilatory movement, Lying flat Amphetamines and cocaine prevents full chest expansion. sometimes increase rate and depth, Bronchodilators slow rate by causing airway dilation. Neurological injury - Injury to Hemoglobin function - Decreased brainstem impairs respiratory center hemoglobin levels (anemia) reduce and inhibits respiratory rate and oxygen-carrying capacity of the rhythm. blood, which increases respiratory rate, Increased altitude lowers amount of saturated hemoglobin, which increases respiratory rate and  ALTERATIONS IN BREATHING PATTERN Bradypnea - Rate of breathing is abnormally slow (less than 12 breaths/min) Tachypnea - Rate of breathing is abnormally rapid (greater than 20 breaths/min Hyperventilation - Rate and depth of respirations increase Hypoventilation - Respiratory rate is abnormally low, and depth of ventilation is depressed Apnea - Respirations cease for several seconds - Persistent cessation results in respiratory arrest  ASSESSMENT OF DIFFUSION AND PERFUSION Measurement of arterial oxygen saturation (SaO2), the percent of hemoglobin that is bound with oxygen in the arteries Usually 95% to 100% Pulse oximeter Indirect measurement of oxygen saturation. Pulse oximeter is a probe with a light-emitting diode (LED) and a photodetector connected by cable to an oximeter. Photodetector detects amount of oxygen bound to hemoglobin molecules, & the oximeter calculates the pulse saturation (SpO2)  23 CASE STUDY (CONT.) Miguel continues to take Ms. TS’s vital signs. Ms. TS’s respiratory rate is 14 breaths per minute, and her pulse is 86 beats per minute. Are these vital signs within normal limits?  ARTERIAL BLOOD PRESSURE Force exerted on the walls of an artery by pulsing blood under pressure from the heart Acceptable Blood pressure Range for adults: