Fall 2024 N222 Class 2 Vital Signs Notes PDF

N222 Applied Assessment & Nursing fundamentals 1: Health and Wellness Class 2: Fall 2024 Dr. Janice Mark, DNP, FNP-BC, RN Heather Bollinger, MSN, RN Acknowledgments to Dr. Kwong, RN, EdD and Dr. Purpura RN, PhD Today’s Topics ▪ Health History/Interview ▪ Vital Signs...

N222 Applied Assessment & Nursing fundamentals 1: Health and Wellness Class 2: Fall 2024 Dr. Janice Mark, DNP, FNP-BC, RN Heather Bollinger, MSN, RN Acknowledgments to Dr. Kwong, RN, EdD and Dr. Purpura RN, PhD Today’s Topics ▪ Health History/Interview ▪ Vital Signs ▪ Define ▪ Equipment ▪ Process ▪ Normal parameters ▪ Documentation Class 2 Student learning outcomes are listed on p.30-31 of the Simple Syllabus Interview & Health History The Interview ▪ Goals: ▪ to obtain information and build rapport ▪ to record a complete health history ▪ Subjective data Three Phases of the Interview ▪ Introductory ▪ Working ▪ Closure Introductory Phase ▪ Purpose: to develop trust and rapport ▪ Introduce self ▪ Explain purpose of interview ▪ Discuss types of questions you’ll ask ▪ Explain reason for note-taking ▪ Confidentiality ▪ Patient comfort ▪ “Mrs. Ono, I’d like to talk with you about your illness that brought you to the hospital.” Working Phase: Health History Subjective data collection ▪ Biographical Data ▪ Family History ▪ Source of history ▪ Review of Systems ▪ Reasons for seeking care/ ▪ Functional Assessment Chief complaint ▪ Perception of Health ▪ History of present illness (use PQRSTU mnemonic to explore symptoms next slide) ▪ Past health Explore Symptoms Using PQRSTU Mnemonic ▪ P: Provocation and/or Palliation ▪ What brings it on? What were you doing when you first noticed it, what makes it better? Worse? ▪ Q: Quality and/or Quantity ▪ How does it look, feel, sound? How intense/severe is it? ▪ R: Region and/or Radiation ▪ Where is it? Does it spread anywhere? ▪ S: Severity Scale ▪ How bad is it (on a scale of 1 to 10)? Is it getting better or worse, staying the same? ▪ T: Timing Onset, Duration, Frequency ▪ Onset - Exactly when did it first occur? Duration – How long did it last? Frequency – How often does it occur? ▪ U: Understand patient’s perception and/or Unable to do ▪ What do you think it means? What are you not able to do as a result? Health History Form ▪ Let’s review your Health History Form (handout) ▪ Complete as part of your CAA #2 during clinical Closure Phase ▪ Summarize concerns ▪ End by asking if he or she has anymore concerns or questions In-class Activity Interview & Health History (10 Minutes) ▪ Interview a partner and find out Reason for Seeking Care/Chief Complaint ▪ What is the symptom your patient is experiencing? (Choose a non-pain related symptom (e.g., nausea, itching, dysuria (burning with urination), fatigue, etc.) ▪ After finding out your partner’s symptoms/health problem, explore History of Present Illness: ▪ Explore the symptom(s) using PQRSTU mnemonic ▪ Be sure to include the question and patient responses on your form ▪ (P) What brings it on? What were you doing when you first noticed it, what makes it better? Worse? ▪ (Q) How does it look, feel, sound? How intense/severe is it? ▪ (R) Where is it? Does it spread anywhere? ▪ (S) How bad is it (on a scale of 1 to 10)? Is it getting better or worse, staying the same? ▪ (T) Onset - Exactly when did it first occur? Duration – How long did it last? Frequency – How often does it occur? ▪ (U) What do you think it means? What are you not able to do as a result? Vital Signs Temperature, Pulse, Respirations, Blood Pressure, O2 Saturation Vital Signs ▪ Blood pressure (BP) (auscultation, palpation) ▪ Temperature (T) ▪ Pulse (P) ▪ Respiration (R) ▪ Oxygen Saturation (SpO2) ▪ **Pain** When to Measure Vital Signs ▪ On admission to a healthcare facility ▪ When assessing a patient during home care visits ▪ In a hospital on a routine schedule ▪ Before, during, after medication and treatments or procedures ▪ Before, during, and after nursing interventions influencing a vital signs (e.g., after a walk or performance of ADL) ▪ When a patient’s general physical condition changes ▪ When a patient reports nonspecific symptoms of physical distress Temperature Temperature The difference between the amount of heat produced by body processes and the amount of heat lost to the external environment Heat Produced – Heat Loss = Body Temperature Factors Affecting Body Temperature Age Exercise Hormonal level Circadian rhythm Environment Temperature alterations Temperature Measurement Sites ▪ Oral ▪ Axillary ▪ Rectal ▪ Tympanic (Ear) ▪ Temporal Temperature Measurement Devices ▪ Thermometers ▪ Electronic thermometer ▪ Digital thermometer ▪ Tympanic membrane thermometer ▪ Temporal Artery Thermometer ▪ Chemical dot thermometers (Single-use) 19  Temperature Average temperature range for the Adult: 36 to 38C (96.8 to 100.4F) Average oral 37C (98.6F) Average rectal/tympanic: 37.5C (99.5F) Average axillary: 36.6C (97.6F) ** Average Range for the Older Adult (oral) 35 - 36.1C (95 - 97F) Video: Temperature RegisteredNurseRN: How to Take a Temperature: Under Arm, Oral, Ear, Rectum, Skin, Temporal Temperature: Documentation ▪ Temperature: numeric value ▪ Unit of measurement: C or F ▪ Site of measurement: ▪ Oral (PO) ▪ Rectal (R) ▪ Axillary (Ax) ▪ Temporal (TA) ▪ Tympanic (TM) ▪ E.g.: ▪ T = 100.3 F orally (PO) ▪ T = 36.2 C Rectal (R) Pulse & Heart Rate Pulse ▪ The palpable bounding of blood flow in a peripheral artery. Blood flows through the body in a continuous circuit. The pulse is an indirect indicator of circulatory status. ▪ Pulse pressure wave caused by stroke volume ▪ Electrical impulses originating from the sinoatrial (SA) node travel through heart muscle to stimulate cardiac contraction ▪ Mechanical, neural, and chemical factors regulate strength of ventricular contraction and stroke volume ▪ Pulse rate ▪ Number of pulsing sensations in 1 minute Factors Influencing Pulse (Heart) Rate Factor Increases (+) Decreases (-) Exercise Short-term Long-term Temperature Fever, Heat Hypothermia Emotions Sympathetic stimulation Parasympathetic stimulation Medications Positive chronotropic Negative chronotropic drugs (e.g. epinephrine) drugs (e.g. CA-channel blockers) Postural Changes Standing or sitting Lying down Pulmonary conditions Diseases causing poor oxygenation Hemorrhage Sympathetic stimulation Increased by loss of blood Pulse (Heart) Rate & Rhythm ▪ Acceptable range for adult (Eucardia): 60 to 100 beats per minute (bpm) - Tachycardia: > 100 bpm - Bradycardia: < 60 bpm ▪ Rhythm (regular or irregular) ▪ When to be *concerned ▪ P > 120 ▪ P < 50 ▪ *pt specific Assessment of Radial Pulse Radial Pulse Assessment Technique: palpation Rate (beats/min) Rhythm (steadiness/pattern) Regular or Irregular Strength/Amplitude (force) ** (3+, 2+, 1+, 0) Equality** (even, same on all peripheries) Documentation ▪ E.g : ▪ P= 78, strong (2+) and regular ▪ P = 88 thready (1+) and irregular Video: Pulse RegisteredNurseRN: How to Check Your Pulse: Finding the Radial Pulse Assessment: Heart rate (apical pulse rate) Technique: Auscultation 5th ICS, MCL Rate (beats/min) Rhythm (steadiness/pattern) 29 Video: Normal Heart Sounds Medzcool: Normal Heart Sounds Respiration Respiration ▪ The mechanism the body uses to exchange gases between the atmosphere and the blood and the blood and the cells. ▪ Respiration involves ventilation, diffusion, and perfusion. Concepts ▪ Ventilation: the movement of gases in and out of the lungs. ▪ Diffusion: the movement of oxygen and carbon dioxide between the alveoli and the red blood cells. ▪ Perfusion: the distribution of red blood cells to and from the pulmonary capillaries. Respiration ▪ Physiological control ▪ Regulated via CO2 levels ▪ Mechanics of breathing ▪ Inspiration is an active process ▪ Expiration is a passive process Respiratory Cycle = one full cycle of inspiration and expiration Copyright © 2021, Elsevier Inc. All Rights Reserved. 34 Factors Affecting Respiration Exercise Acute Pain Anxiety Smoking Body position Medications Neurological Injury Hemoglobin Function Respiration Acceptable range for adult (Eupnea): 12 to 20 breaths per minute - Tachypnea > 20 per minute - Bradypnea < 12 per minute ▪ When to be *concerned ▪ > 24 breaths/minute ▪ < 10 breaths/minute ▪ * pt specific Assessment of Respiration Ventilation is assessed by determining respiratory rate, depth, and rhythm. Technique: Observation and palpation Best to do without patient knowing Rate (numeric value) Depth (deep, normal/even, or shallow) Rhythm (regular or irregular) Effort (easy or hard to breathe) Video: Respirations RegisteredNurseRN: Counting Respirations: Counting Respirations Nursing Skill Assessment In-Class Activity ▪ Practice taking Temperature, Pulse (radial), Respiratory Rate with your partner ▪ One student will play the nurse and the other will play patient ▪ Practice walking into the patient’s room and do your introduction ▪ Complete T, RR, P ▪ Rectal temperatures: verbalize/document the process and state normal ranges ▪ Switch roles and repeat process ▪ Document your findings on your In-Class Activity Form ▪ Be sure to include each assessment element ▪ Interpret (analyze) your findings ▪ Are findings within the normal/healthy parameters? ▪ Explain why or why not ▪ If not, are the findings within your patient’s normal ranges? ▪ If normal, then describe how the patient has good function for that system ▪ E.g., For normal pulse rate range: pt has good circulatory function; for normal RR: pt has good/adequate ventilation, etc. ▪ Allotted Practice Time: 15 minutes Blood Pressure Blood Pressure ▪ The force exerted on the walls of an artery by the pulsing blood under pressure from the heart. ▪ The peak of the maximum pressure when ejection occurs is the systolic pressure. ▪ Diastolic pressure is the minimal pressure exerted against the arterial walls at all times. Blood Pressure Reflects interrelationships of: ▪ Cardiac output ▪ Peripheral resistance ▪ Blood volume ▪ Viscosity ▪ Elasticity * An increase or decrease in any of these factors can affect blood pressure Factors That Influence Blood Pressure Age Stress Ethnicity* Gender Daily variation Medications Activity & weight Smoking “Normal” Blood Pressure Value ▪ Systolic Blood Pressure (SBP) < 120 mmHg AND ▪ Diastolic Blood Pressure (DBP) < 80 mmHg Abnormal Blood Pressure Ranges (AHA) Elevated vs Hypertension: See Table below Hypotension: SBP