Foundations Lab VSS Lecture Revised Version 1.pdf

VITAL SIGNS Foundations of Nursing Practice Kathryn Kushto-Reece, MSN, RN Nicole Johnson MSN, RN Shari Lynn-Slavitt, MSN, RN  Vital Signs What are...

VITAL SIGNS Foundations of Nursing Practice Kathryn Kushto-Reece, MSN, RN Nicole Johnson MSN, RN Shari Lynn-Slavitt, MSN, RN  Vital Signs What are vital signs? Measurements of the body’s most basic functions. Why are vital signs important? Gives us a glimpse of the patient’s overall well-being. https://www.hopkinsmedicine.org/health/conditions-and-diseases/vital-signs-body-temperature-pulse-rate-respiration-rate-blood-pressure https://infiniummedical.com/vital-signs-monitoring/#:~:text=Vital%20signs%20monitoring%20is%20crucial,us%20to%20make%20better%20choices. Vital Signs Read the following scenario. A 35 year old patient is admitted with pneumonia. They have a temperature of 101.8 F, their respiratory rate is 28 bpm and heart rate 90 bpm. They are complaining that they “cannot catch their breath” and are rating their pain at a 5/10. The pulse ox reading is 93% on RA. What are examples of objective data for vital signs? Temperature of 101.8 F, respiratory rate is 28 bpm, heart rate 90 bpm. Pulse ox 93%. What are examples of subjective data for vital signs? Patient states, “I cannot catch my breath” and “I rate my pain at a 5/10.” Vital Signs What are text book norms ? Text book norms provide a gauge or clue. What are baseline vital signs? Baseline vital signs tell us patient specifics and variation from norms. Vital Signs 1st signs of impending distress involve which vital sign/system? Respiratory system What are the signs? Increased RR Decreased O2 saturations Anxiety Difficulty breathing Vital Signs What is SBAR? When do we use SBAR? SBAR is an interdisciplinary We use SBAR to report changes in communication tool. Situation, patient status to provider, update pt. background, assessment, and condition recommendations. Vital Signs What is HERO When do we use HERO? We use HERO to Report an adverse event, like medical error or fall. Hopkins Event Reporting Online What is a Sentinel Event? A Sentinel Event is an event that is life changing or life threatening. An adverse event can become a sentinel event Vital Signs A patient is not feeling well, is anxious and has an increased respiratory rate, with a decreasing pulse oximetry reading. Is this. an SBAR event? Why or why not? Yes because it is a change in or worsening condition of patient Temperature How does circadian rhythm relate to body temperature? With circadian rhythm, when is body temperature lowest? Circadian rhythms fluctuate within 2 degrees throughout 24 hours 3am, sleeping, decreased metabolism, minimal activity When is temperature highest? 4-6pm, active, moving, eating, increased metabolism. Temperature What are core body temperature methods ? Rectal, one degree higher that oral. Tympanic core body temp b/c shares blood supply with hypothalamus. Temporal artery b/c shares same blood supply as pulmonary artery. (Follow lab manual for taking temporal artery temperature) Temperature What is most common method of taking What is best method for taking temperature? an infant's temperature? Oral, but not for infant! Temporal artery b/c core body temp, tympanic and rectal but temporal artery best! More accurate, non -invasive. Pulses What are the characteristics of a pulse? Rate/frequency, rhythm, regularity, quality, and strength. What is average adult pulse? 60-100bpm What would a newborn’s pulse rate be? Infants have increased BMR, so increased pulse. Newborn 130-160bpm. Pulses What is tachycardia? Increased HR, >100bpm What is Bradycardia? 60 = increased risk of CV disease). Blood pressure Where and how do we measure manual BP? How do we find proper cuff size? Upper arm/at brachial artery. Measure, width 40% circumferences upper arm, length 80% length upper arm. Blood pressure What are Korotkoff sounds? Sounds heard when taking a manual blood pressure (bp). Blood Pressure What part of a blood pressure is the 1st Korotkoff sound in adults and children? What part of a blood pressure is the 5th Korotkoff sound in adults? Both is Systolic BP. Diastolic BP Blood pressure What is the 4th Korotkoff sound in How is it different? children? It is a muffled, blowing or Diastolic bp lower pitch sound. Blood Pressure What is auscultatory gap? Is a period of diminished or absent Korotkoff sounds during the manual measurement of BP. How do we find it? Put cuff on and find radial pulse. Pump up cuff until we can no longer feel pulse (obliterate). For instance, if you no longer feel the pulse at 120 mmhg add 30 mmhg to number where pulse disappears. That is auscultatory gap. That number is where we pump the cuff to when we are taking a blood pressure. Why do we find it? Interpretation may lead to overestimation of diastolic bp or underestimations of systolic. Auscultatory gap accounts for this. Blood Pressure What is orthostatic hypotension? A drop in BP with change in position, from flat to vertical, either lying to sitting or lying to standing. When/why might it occur? Could occur when patient gets OOB after bed rest, after surgery, with dehydration, anorexia. Blood Pressure What are parameters for Orthostatic What are interventions for hypotension? orthostatic hypotension? A change of at least 20 mmhg Stay in bed, call for nurse before systolic or at least 10 mmhg getting up, sit/lie or stand slowly, be diastolic. sure someone is there to assist, don’t get out of bed alone. Pain What is the best way to assess pain? Verbal report/self-report best! Vital signs only adjunct. What are some pain scales? Numeric 0-10, Faces, CRIES, etc. Pain What are some pain interventions the nurse can employ? In the hospital who manages patient’s pain? Bathing, position, hygiene, massage, hot/cold, medications, (NSAIDS, Nurses, NP’s pain team, all narcotics, PCA/Epidural), relaxation, disciplines., pharmacist. Pain guided imagery, deep breathing, resource nurse. distraction. What is the NCLEX? The NCLEX-RN, which stands for the National Council Licensure Examination [for] Registered Nurses (RN), is a computer adaptive test that is required for nursing graduates to successfully pass to be licensed as a Registered Nurse in the US and Canada. In other words, anyone who wants to become a Registered Nurse in either the US or Canada, must pass the NCLEX-RN. https://www.princetonreview.com/professional/nclex-rn-exam-overview?ceid=tersh-nav-rn-exam-overview NextGen Case Study Part I Assessing Cues A 59 year-old patient, admitted for dehydration, was lying in bed for a few days and tried to stand up to ambulate to the bathroom and felt lightheaded. The patient’s vital signs are listed below. Which vital signs are normal? Normal Abnormal BP 88/56 X HR 104 X Temp 37.4C X RR 20 X Part II What Could it Mean? Based on your initial assessment, what could be 0800 Nurse’s Note: 59 y.o.pt found on happening with the patient? floor in bathroom. Admitted for (Mark All That Apply) dehydration. Admitting vital signs: VS: BP 88/56, a. Fluid volume deficit HR-104, b. MI Temp 37.4C, c. Fluid volume excess RR 20. d. Orthostatic PMHx: HTN e. Gastric reflux f. Asthma Part III Prioritize Hypothsis 0800 Nurse’s Note: 59 y.o.pt found on floor in bathroom. Admitted for dehydration. Admitting vital signs: VS: BP 88/56, As the nurse, based on all the data, what HR-104, concerns you most? Temp 37.4C, a. Temp RR 20. b. RR PMHx: HTN c. Skin turgor d. BP Part IV Generate Solutions (what can the nurse do) Of all of the nursing actions, please indicate the immediacy of the action Action Immediate Within the Hour 0800 Nurse’s Note: 59 y.o.pt found on floor in bathroom. Obtain VS Admitted for dehydration. Notify the provider Admitting vital signs: VS: BP 88/56, Get patient in bed HR-104, Temp 37.4C, Assess LOC RR 20. Give fluids PMHx: HTN Document status  Part V Take Action 0800 Nurse’s Note: 59 y.o.pt found on floor in bathroom. Admitted for dehydration. Based on the new data, what orders Admitting vital signs: should the nurse obtain? VS: BP 88/56, HR-104, a. Order for new vital signs Temp 37.4C, b. Order for 2 L NC RR 20. c. Order for a fluid bolus PMHx: HTN d. Order for a diet e. Order for nebulizer 0815 Patient sitting in bathroom. Complaint of SOB VS: 78/50, HR 110, Temp 37.6, RR 28. O2 sats 94% Part VI 0800 Nurse’s Note: 59 y.o.pt found on floor in The patient is given 500 ml of NS and is on 2 L nasal bathroom. Admitted for dehydration. cannula. A new set of vital signs were obtained. Admitting vital signs: What data tells you that the patient has improved? VS: BP 88/56, HR-104, Temp 37.4C, Improved Same RR 20. PMHx: HTN BP 110/60 HR 86 0815 Patient sitting in bathroom. RR 18 Complaint of SOB VS: 78/50, HR 110, Temp 37.6, RR 28. O2 sat 98% O2 sats 94% (2 L NC) Temp 37.4 C Thank you for your participation