Chapter29 Vital signs fall 2024 pdf.pdf

Chapter 29 Vital Signs Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Guidelines for Measuring Vital Signs ❖ Measuring vital signs is your responsibility. ❖ Assess equipment is working correctly. ❖ Select the appropriate equipment for the patient. ❖ K...

Chapter 29 Vital Signs Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Guidelines for Measuring Vital Signs ❖ Measuring vital signs is your responsibility. ❖ Assess equipment is working correctly. ❖ Select the appropriate equipment for the patient. ❖ Know the patient's usual range of vital signs. ❖ Know the patient's health history, therapies, and prescribed and over-the-counter medications. ❖ Control environmental factors and be organized. ❖ Verify and communicate significant changes. ❖ Provide patient teaching about your findings. Copyright © 2019 Wolters Kluwer All Rights Reserved 2 Vital Signs ❖ Temperature (T) ❖ Pulse (P) ❖ Respiration (R) ❖ Blood pressure (BP) ❖ Pain (often included as fifth sign) ❖ Oxygen Saturation Copyright © 2019 Wolters Kluwer All Rights Reserved Normal Ranges for Vital Signs for Healthy Adults ❖ Oral temperature—37.0°C, 98.6°F (Range 96.6-100.5) ❖ Pulse rate—60 to 100 (80 average) ❖ Respirations—12 to 20 breaths/min ❖ Blood pressure— 92% o Lung disease 88%-92% Copyright © 2019 Wolters Kluwer All Rights Reserved When to Assess Vital Signs ❖ On admission to any health care facility or institution ❖ Based on facility or institutional policy and procedures ❖ Any time there is a change in the patient's condition ❖ Any time there is a loss of consciousness ❖ Before and after any surgical or invasive diagnostic procedure ❖ Before and after activity that may increase risk, such as ambulation after surgery ❖ Before administering medications that affect cardiovascular and respiratory function Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Affecting Frequency of Vital Signs Assessment ❖ Patient’s medical diagnosis ❖ Co-morbidities ❖ Types of treatments received ❖ Patient’s level of acuity Copyright © 2019 Wolters Kluwer All Rights Reserved Types of Thermometers Used to Assess Body Temperature Copyright © 2019 Wolters Kluwer All Rights Reserved Equipment for Assessing Temperature ❖ Electronic and digital thermometers ❖ Tympanic membrane thermometers ❖ Disposable single-use thermometers ❖ Temporal artery thermometers ❖ Automated monitoring devices Copyright © 2019 Wolters Kluwer All Rights Reserved Body Temperature: Physiology ❖Body temperature regulation o Neural and vascular control o Heat production o Heat loss o Skin in temperature regulation o Behavioral control Copyright © 2019 Wolters Kluwer All Rights Reserved Factors Affecting Body Temperature ❖Age & Gender ❖Physical Activity ❖Hormone level ❖Circadian rhythm ❖Stress ❖Environment ❖General State of Health ❖Temperature alterations o Fever, hyperthermia, heatstroke, heat exhaustion, hypothermia Copyright © 2019 Wolters Kluwer All Rights Reserved Temperature Alterations ❖ Fever ❖ Hyperthermia ❖ Heatstroke ❖ Heat exhaustion ❖ Hypothermia Copyright © 2019 Wolters Kluwer All Rights Reserved  Types of Fever ❖ Fever (pyrexia) o Heat-loss mechanisms are unable to keep pace with excessive heat production o Febrile/Afebrile ❖ Intermittent: temperature returns to normal at least once every 24 hours ❖ Remittent: temperature does not return to normal and fluctuates a few degrees up and down ❖ Sustained or continuous: temperature remains above normal with minimal variations ❖ Relapsing or recurrent: temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days Copyright © 2019 Wolters Kluwer All Rights Reserved Sources of Heat Loss ❖ Skin (primary source) ❖ Evaporation of sweat ❖ Warming and humidifying inspired air ❖ Eliminating urine and feces Copyright © 2019 Wolters Kluwer All Rights Reserved Transfer of Body Heat to External Environment ❖ Radiation ❖ Convection ❖ Evaporation ❖ Conduction Copyright © 2019 Wolters Kluwer All Rights Reserved Pulse Physiology ❖ Regulated by the autonomic nervous system through cardiac sinoatrial node ❖ Parasympathetic stimulation—decreases heart rate ❖ Sympathetic stimulation—increases heart rate ❖ Pulse rate = number of contractions over a peripheral artery in 1 minute Copyright © 2019 Wolters Kluwer All Rights Reserved Pulse ❖Assessment of pulse o Fingers (palpation) ▪ Radial o Use of a stethoscope (auscultation) ▪ Apical Copyright © 2019 Wolters Kluwer All Rights Reserved Characteristics of the Pulse ❖ Rate: Normal, tachycardia, bradycardia ❖ Rhythm ❖ Amplitude and quality (strong or weak) o Grade Description 0 Absent, Unable to palpate +1 Diminished, weaker than expected +2 Brisk, expected (normal) +3 Bounding ❖ Volume of blood ejected with each heartbeat (stroke volume) Copyright © 2019 Wolters Kluwer All Rights Reserved Sites for Detecting Pulse by Light Palpation Copyright © 2019 Wolters Kluwer All Rights Reserved Respirations ❖ Ventilation: movement of air in and out of lungs o Inhalation: breathing in o Exhalation: breathing out ❖ Diffusion o Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood ❖ Perfusion o Exchange of oxygen and carbon dioxide between circulating blood and tissue cells Copyright © 2019 Wolters Kluwer All Rights Reserved  Assessment of Diffusion and Perfusion ❖Measure oxygen saturation of the blood ❖Measurement of arterial oxygen saturation Copyright © 2019 Wolters Kluwer All Rights Reserved Assessment of Ventilation ❖ Easy to assess o Respiratory rate: breaths/minute o Ventilatory depth: deep, normal, shallow o Ventilatory rhythm: regular/irregular Copyright © 2019 Wolters Kluwer All Rights Reserved Rate and Depth of Breathing ❖ Changes in response to tissue demands ❖ Controlled by respiratory centers in the medulla and pons ❖ Activated by impulses from chemoreceptors ❖ Increase in carbon dioxide is the most powerful respiratory stimulant Copyright © 2019 Wolters Kluwer All Rights Reserved Respiratory Rates ❖ Eupnea: normal, unlabored respiration; one respiration to four heartbeats ❖ Tachypnea: increased respiratory rate; may occur in response to an increased metabolic rate ❖ Bradypnea: decreased respiratory rate; occurs in some pathologic conditions ❖ Apnea: periods when no breathing occurs ❖ Dyspnea: difficult or labored breathing ❖ Orthopnea: changes in breathing when sitting or standing Copyright © 2019 Wolters Kluwer All Rights Reserved Knowledge Check 2. Which action would the nurse take when noting a postoperative patient is breathing rapidly? A. call the physician B. count the respirations C. assess the oxygen saturation D. ask the patient if he feels uncomfortable Copyright © 2019 Wolters Kluwer All Rights Reserved 24 ANS Answer: C. assess the oxygen saturation. Copyright © 2019 Wolters Kluwer All Rights Reserved 25 Factors Affecting Blood Pressure ❖ Age, gender, race ❖ Circadian rhythm ❖ Food intake ❖ Exercise ❖ Weight ❖ Emotional state ❖ Body position ❖ Drugs/medications Copyright © 2019 Wolters Kluwer All Rights Reserved Physiology of Arterial Blood Pressure Factors Affecting Arterial Blood Pressure Cardiac output Peripheral resistance Blood volume Viscosity Elasticity Copyright © 2019 Wolters Kluwer All Rights Reserved Equipment for Assessing Blood Pressure ❖ Stethoscope and sphygmomanometer ❖ Doppler ultrasound ❖ Electronic or automated devices Copyright © 2019 Wolters Kluwer All Rights Reserved Assessing Blood Pressure ❖ Listening for Korotkoff sounds with stethoscope ex BP 120/80 o First sound =systolic pressure ( top BP reading “120”) o When Korotkoff sounds STOP =diastolic pressure (bottom reading “ 80” ) ❖ The brachial artery and popliteal artery are commonly used. Copyright © 2019 Wolters Kluwer All Rights Reserved Parts of a Sphygmomanometer—3 Sizes of Cuffs Copyright © 2019 Wolters Kluwer All Rights Reserved Hypertension ❖ More common than hypotension ❖ Thickening of walls ❖ Loss of elasticity ❖ Family history ❖ Risk factors Copyright © 2019 Wolters Kluwer All Rights Reserved Copyright © 2019 Wolters Kluwer All Rights Reserved Major Classifications of Hypertension ❖ Primary (essential) o Characterized by an increase above normal in both systolic and diastolic pressures o No known cause ❖ Secondary o Caused by another disease conditions o Common causes include kidney disease, adrenal cortex disorders, and aorta disorders Copyright © 2019 Wolters Kluwer All Rights Reserved Hypotension ❖ Systolic