Vital Signs.pdf

Vital Signs WHAT are Vital Signs? Vital Signs Temperature Pulse Respirations, O2 saturation Blood Pressure How do these health and illness concepts (Giddens, 2017) relate to the assessment vital signs? Homeostasis and Regulation ◦ Thermoregulation ◦ Gas exchange ◦ Perfu...

Vital Signs WHAT are Vital Signs? Vital Signs Temperature Pulse Respirations, O2 saturation Blood Pressure How do these health and illness concepts (Giddens, 2017) relate to the assessment vital signs? Homeostasis and Regulation ◦ Thermoregulation ◦ Gas exchange ◦ Perfusion WHEN do we take vital signs? During a health visit Upon admission Before/after an invasive/surgical procedure Before/during/after a medication administration for which it’s indicated (i.e.: cardiac medications) Critical thinking Physician/NP/routine orders http://what-when-how.com/wp-content/uploads/2012/08/tmp7ff010_thumb222.png WHY do we take vital signs? Screening Baseline data Response to treatment Change in health status Monitoring for complications http://image.nhregister.com/storyimage/NH/20160104/NEWS/160109882/AR/0/AR-160109882.jpg&maxh=400&maxw=667 Now the HOW to take vital signs! http://cliparting.com/free-question-clipart-36765/ First: ALWAYS Check the patient GENERAL SURVEY HEALTH HISTORY Associated signs and symptoms? Double check YOUR technique Double check result (if not sure, take another reading) Temperature Hypothalamus regulates temperature Diurnal pattern (varies.5 to 1 degree over the day lowest in morning highest in evening) Expected: 36.5-37.5 ˚C (oral reading) Fever: > 38.0 ˚C (oral) Adding and subtracting for expected values: ◦ Axillary about 0.5 ˚C lower, ◦ tympanic & rectal about 0.5 ˚C higher ◦ (text is different; this rule is easier to remember). Know the equipment, many types, read the instructions! Wait 15 minutes if exposed to cold weather. More on Fever! https://www.wsj.com/articles/SB10001424052748704615504576172311079669134  Oral – sublingual placement https://manuals.plus/thermometer/flexible-fast-read-digital-clinical-thermometer-kd-181-instruction-manual Wait 15 minutes after smoking, eating or drinking! Make sure mouth closes over device, tongue pressed down on thermometer and wait recommended amount of time (i.e. TempaDOT 1 minute) Oral Temperature Pros & cons Pros Cons Accessible Oral intake may alter reading (i.e. ice chips) Smoking alters reading Easy Body fluid precautions Comfortable Assess LOC!!! Accurate – GOLD STANDARD Axillary recommended for newborns. Axillary – axillary fold placement Against torso, parallel, & completely covered Correct length of time (TempaDOT 3 minutes & retake if over 5 minutes) Pros & cons Pros Cons Accessible Slow (1-2 minutes) (takes longer to obtain reading; must stay with patient until reading completed) Easy Reflects skin temperature, not core temperature (lower reading by 0.5 C) Safe Accuracy (same as above) Rectal – rectal placement Adults 2-3 cm TempaDOT 3 minutes, make sure all dots are covered! Pros & cons Pros Cons Accurate Invasive (best core temperature measurement) Ongoing monitoring possible Body fluid precautions (ICU settings, probe used) Best for: Not in newborns Infants Not in GI patients with GI issues Unconscious patients (pediatric & adult) Privacy Other Sites Text p. 101-120 Inguinal folds Temporal Artery Tympanic Membrane Esophageal Nasopharyngeal Bladder http://clinicalgate.com/wp- content/uploads/2015/03/B9781416003168500168_gr6.jpg Vaginal http://www.thermometerguide.com/wp- content/uploads/2015/02/exergen-thermometer.jpg Radial Pulse Technique 1. Rate ◦ HR = pulsations of heart/minute Finger pads ◦ Normal: 60-100 bpm (adult) ◦ Watch Pressure ◦ Tachycardia: > 100 bpm, Bradycardia: < 60 bpm, Asystole: ◦ Location: radial artery no pulse ◦ For 30 seconds (multiply x 2) 2. Rhythm ◦ Regular vs irregular (if irregular take rate for 1 minute) 3. Strength (amplitude) ◦ Non-palpable – bounding ◦ Absent, weak, strong, full, bounding ◦ O to 4+ *Note also elasticity of the vessel (changes with age) ◦ Smooth and resilient https://medlineplus.gov/ency/images/ency/fullsize/19395.jpg Apical Heart Rate Auscultation of the heart apex gives heart rate (the pulse estimates) Pulse Deficit = Apical beat – Peripheral Pulse 5th intercostal space, midclavicular line 1 minute Diaphragm of stethoscope Expected Findings Normal: 60-100 bpm (adult); regular; 2+; no deficit, artery feels smooth and resilient https://aos.iacpublishinglabs.com/question/8791ae850c163580cc52cfd860ccd793/aq/1400px-788px/normal-pulse-rate- adult_a59cee1fcb346e2f.jpg?domain=cx.aos.ask.com Other Pulses Anywhere an artery can be compressed against an adjacent structure you may feel a pulse. https://web.duke.edu/anatomy/Lab03/images/Grays%203.102.jpg http://www.wesnorman.com/Images/livingneck.jpg Respiration 2 part: ◦ Inspiration ◦ Diaphragm & intercostals contract, active ◦ Expiration ◦ Diaphragm & intercostals relax, passive Technique ◦ Observe breaths (chest rise) ◦ For 30 seconds (multiply x 2) Rate, rhythm, depth, quality https://matterandenergytransformation.wikispaces.com/file/view/Cellular_Respiration.jpg/199429324/560x348/Cellular_Respiration.jpg Respiratory rate in Adults RR = breaths/minute Use of accessory muscles (e.g., abdominal or neck muscles) may indicate respiratory distress. Also note any cyanosis, retractions, or audible sounds such as wheezing or congestion. Accessory muscles include the sternomastoid, rectus abdominis, and Normal: 12-20 breaths/minute internal intercostals. Retractions, or a pulling inward of the soft tissue, are noted in the supraclavicular, intercostal, and costal margin area. Adults 65 and older: 12-24 breaths/minute Tachypnea: > 20 (persistent)/minute Bradypnea: < 12/minute Apnea: no breaths Hyperventilation: deep & rapid Hypoventilation: shallow & slow Rhythm, Depth and Quality Rhythm: Regular or Irregular? Depth: Shallow, Moderate, or Deep? Quality: Easy, no accessory muscles used, no retractions or nasal flaring, tracheal tugging, use of shoulders, intercostal or subcostal retractions! Eupnea = expected rate, regular, moderate depth, and easy Practice! http://40.media.tumblr.com/20529f55fb69403b00111c9441ff3543/tumblr_n1v92ber7f1snhqeto1_1280.png Oxygen saturation Tests percentage of oxygen saturated hemoglobin Lights have to align in order to get an accurate SpO2 Expected: >92-100 % https://www.youtube.com/watch?v=2v3rae-73jc If borderline, reassess!  Conditions that decrease arterial blood flow may also compromise the accuracy of readings, such as peripheral vascular disease, edema, and hypotension. Patients with anemia may have a falsely elevated pulse oximetry reading from circulating hemoglobin containing sufficient oxygen Expected findings but inadequate hemoglobin to carry adequate oxygen. Eupnea: 12-20 breaths per minute, regular, easy, no accessory muscles used, SpO 2 > 92% https://edc2.healthtap.com/ht-staging/user_answer/reference_image/17424/large/97776185.jpeg?1386670345 Auscultation Quick Review For assessment of: ◦ Blood Pressure reading ◦ Lung sounds – depth, adventitia? ◦ Heart sounds – rate, murmur? ◦ Abdomen – Bowel Sounds Relies on stethoscope auditory knowledge – you will further develop these skills in the respiratory/CV/GI assessment laboratories! Tool: Stethoscope 2 sides: ◦ Bell (low pitched sounds) ◦ Diaphragm (high pitched sounds) Both maybe used (i.e.: heart) No amplification, only conduction (unless digital) Read instructions on YOUR stethoscope Blood Pressure Systolic/diastolic pressure ◦ Force exerted on the arterial walls ◦ Pressure of arteries changes as the heart contracts and relaxes ◦ Systolic (highest pressure as the ventricle contracts at the beginning of systole) ◦ Diastolic (lowest pressure as the ventricle relaxes) ◦ Map = mean arterial pressure (Need at least 60mmHg for good perfusion in an adult) ◦ Calculation: [SBP + (2x DBP)] / 3 ◦ CPP=MAP-ICP (normal ICP is 0-15 mmHg or 0-20 cmH2O) ◦ In brain injury usually want CPP= 70-80 mmHg, every loss of 10mmHg increases mortality ◦ Pulse Pressure=Systolic-Diastolic (healthy is 40-60 mmHg) ◦ Multi-limb reading ◦ Assess for cardiac/vascular defects; important in child health assessment  Parts an aneroid system Bladder width 40% arm circumference Bladder length 80-100% arm circumference ◦ Too large = false low reading ◦ Too small = false high reading http://img.tfd.com/mk/S/X2604-S-37.png **Require Calibration – read your manufacturer’s information Technique You will learn a two step method in the laboratory as it is the best place to start: Step 1: Estimate the Systolic Blood Pressure ◦ Support the bare arm (make sure nothing is constricting) at heart level, palm up. ◦ Palpate brachial artery ◦ Position cuff line on it, 2.5 – 3 cm above antecubital fossa ◦ Palpate radial artery, inflate cuff, note when radial pulse disappeared, pump up 30 mmHg more, slowly release valve, and note when the pulse comes back. Release remaining air quickly once you feel the pulse. ◦ This is your estimated systolic pressure Deflate, rest x 30 seconds Step 2: Measure Blood Pressure ◦ Stethoscope diaphragm placement on brachial artery in the antecubital fossa ◦ Inflate cuff 30 mmHg above estimated systolic BP, slowly release valve (deflation rate of 2mm/Hg per heart beat); listen! ◦ Note 1st Korotkoff sound (SBP) – Clear Tapping Sound ◦ Note disappearance of 4th Korotkoff sound to silence (5th Korotkoff sound) (DBP) – When the muffling sounds start if no silence heard. Continue to listen for another 10-10mmHg and then release remaining air quickly. ◦ Allow at least one minute between readings Korotkoff Sounds http://image.slidesharecdn.com/basics-of-taking-a-blood-pressure4190-160121113622/95/basics-of-taking-a-blood-pressure-22-638.jpg?cb=1453984459 Good Video for Practice Korotkoff Sounds and Correlating with your Analogue Dial https://www.youtube.com/watch?v=bHXvhOQ0hYc (1.5 million people have learned from this video!) Interpretation Desired in healthy adult: 80 mmHg SBP /< 80 mmHg mmHg DBP Healthy Pulse Pressure is around 40 – 60mmHg High expected: 130-139 SBP &/or 85-89 DBP High: >140 SBP or >90 DBP (See CHEP Guidelines for Hypertension for detailed guidelines for at home repeated measurements) Diabetes: Keep