Chapter 29 Vital Signs Fall 2024 PDF

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UnparalleledTundra3258

Uploaded by UnparalleledTundra3258

Morehead State University

2024

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vital signs medical procedures human anatomy healthcare

Summary

This document details information on vital signs including temperature, pulse, respiration, blood pressure, pain, and oxygen saturation. It also outlines normal ranges, when to assess vital signs, factors affecting frequency, types of thermometers, and equipment used for assessment. This is likely part of a healthcare curriculum or training material.

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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

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