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 assessments. 3. Select nursing measures th...

# 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. 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 judgment 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. - 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. ### 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 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 ### 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) ### 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 Ms. 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? ### Factors Affecting Body Temperature | Factor | Description | |---|---| | Age | Newborns' temperature control mechanisms are immature. Until a child reaches puberty, temperature regulation is unstable. It is not unusual for older adults to reach temperatures no higher than 96.8° F. | | Hormonal level | Women experience greater fluctuations in body temperature than men. Hormonal variations occur during the menstrual cycle & menopause. Women may experience hot flashes caused by an inability to control vasodilation and vasoconstriction. | | Exercise | Will increase heat production and body temperature. | | Circadian rhythm | Changes the body temperature over the 24-hour period. The lowest body temperature occurs between 0100 and 0400 hours. The body reaches maximum temperature at 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 the 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 - 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, & the body is unable to compensate. - Frostbite: Ice crystals form inside cells & 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 the 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 rate: 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 - 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 (cont.) - 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 | Factor | Description | |---|---| | Exercise | Increases rate and depth to meet the body's need for additional oxygen and to rid the body of CO2| | Anxiety | Increases respiration rate and depth as a result of sympathetic stimulation. | | Body position | Straight, erect posture promotes full chest expansion; Stooped or slumped position impairs ventilatory movement, Lying flat prevents full chest expansion. | | Neurological injury | Injury to brainstem impairs the respiratory center and inhibits respiratory rate and rhythm | | Acute pain | Alters the rate and rhythm of respirations; breathing becomes shallow| | Smoking | Chronic smoking changes pulmonary airways, resulting in an increased rate of respirations at rest when not smoking. | | Medications | Opioid analgesics, general anesthetics, and sedative-hypnotics depress rate and depth, Amphetamines and cocaine sometimes increase rate and depth, Bronchodilators slow rate by causing airway dilation. | | Hemoglobin function | Decreased hemoglobin levels (anemia) reduce oxygen-carrying capacity of the blood, which increases respiratory rate. Increased altitude lowers the amount of saturated hemoglobin, which increases respiratory rate and depth. | ### 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 the amount of oxygen bound to hemoglobin molecules, & the oximeter calculates the pulse saturation (SpO2) ### 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: <120/<80 - Blood moves from areas of high pressure to areas of low pressure. - Systolic: Maximum peak pressure during ventricular contraction - Diastolic: Minimal pressure during ventricular relaxation - Pulse pressure: Difference between systolic and diastolic pressures - For a BP of 120/80, the pulse pressure is 40 ### Factors Influencing Blood Pressure | Factor | Description | |---|---| | Age | BP rises throughout the lifespan. | | Ethnicity | Incidence of hypertension is higher in African Americans than in European Americans. | | Stress | Causes sympathetic stimulation, which increases heart rate, cardiac output, and vascular resistance. | | Gender | No clinical differences between boys and girls have been noted. However, after puberty, males tend to have higher blood pressure. After menopause, women tend to have higher blood pressure than men of similar age. | | Daily variation | BP 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. | | Medications | Antihypertensives alter blood pressure directly. Indirectly, opioid analgesics lower blood pressure and volume, and vasoconstrictors raise blood pressure. | | Activity, weight | A period of exercise can reduce blood pressure for several hours. Inadequate exercise contributes to weight gain and perhaps obesity, which can trigger hypertension | | Smoking | Directly affects vessels, producing vasoconstriction, which causes BP to rise. | ### Hypertension Versus Hypotension | Condition | Description | |---|---| | Hypertension | | | | More common than hypotension. | | | Thickening of walls | | | Loss of elasticity | | | Family history | | | Risk factors | | Hypotension | | | | Systolic <90 mm Hg | | | Dilation of arteries | | | Loss of blood volume | | | Decrease of blood flow to vital organs | | | Orthostatic/Postural | ### Case Study (cont.) - Ms. TS's blood pressure is 164/98 mm Hg. Ms. TS asks "I think that's close to where it was the last time I came in. Is that okay?" - How would you respond to Ms. TS's question? ### Case Study (cont.) - Miguel responds, "Ms. TS, your blood pressure is pretty high right now. After you see the nurse practitioner today, I am going to take your blood pressure again. - We are also going to talk about the changes you can begin to make to help you be healthier and feel better." - Is this what you would have said to Ms. TS? What types of things do you think Miguel might recommend to her? ### Patient Conditions Not Appropriate for Electronic Blood Pressure Measurement - Irregular heart rate - Known hypertension - Peripheral vascular obstruction (e.g., 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) - Patients with hypertension can provide to their health care provider info about patterns of BP. - Self-monitoring helps adherence to therapy. - Disadvantages - Improper use risks inaccurate readings - Unnecessary alarming of patient - Patients may inappropriately adjust medications ### Pain - Use appropriate pain scale to measure severity - Numerical rating scale (0-10) - Visual scales (faces, pictures) - Behavioral indicators (vocalizations, facial expressions, body movement, social interaction) - Assess characteristics of the pain (location, description) - Nonpharmacological interventions - Positioning (turning, pillows, elevation of extremity) - Heat/Cold compresses - Massage - Meditation/Prayer - Distraction - Pharmacological pain therapy - Reassess pain following intervention ### Recording Vital Signs - Record values exactly - Document in real time - Follow up on vital signs taken by someone else. - Document interventions initiated on the basis of vital sign measurement - If a vital sign is outside anticipated outcomes, notify the provider, and write a note to explain along with any accompanying or precipitating symptoms and interventions ### Safety Guidelines for Skills - Cleaning devices between patients decreases the risk for infection. - Rotating sites during repeated measurements of BP and pulse oximetry decreases the risk for skin breakdown. - Analyze trends for vital signs, and report abnormal findings. - Determine the appropriate frequency of measuring vital signs based on the patient's condition.