N113 Vital Signs and Nutrition Spring 2024 Student handout.pdf

Vital Signs (VS) Beverly McLawyer, RN, MSN N113 – Medical Surgical Nursing - Spring 2024 [email protected] 1 1 What we will discuss r/t Vital Signs ▪ ▪ ▪ ▪ ▪ Definitions Normal findings Abnormal findings Skills of assessing each VS Rationales for each action 2 2 What are “Vital Signs”? ▪...

Vital Signs (VS) Beverly McLawyer, RN, MSN N113 – Medical Surgical Nursing - Spring 2024 [email protected] 1 1 What we will discuss r/t Vital Signs ▪ ▪ ▪ ▪ ▪ Definitions Normal findings Abnormal findings Skills of assessing each VS Rationales for each action 2 2 What are “Vital Signs”? ▪ ▪ ▪ ▪ ▪ Indicator of physiologic functioning Reflect health status of a person Often vary by Age “Signs that are necessary to life.” As a part of the nursing assessment are an important component of health care 3 3 1 Components of Vital Signs (VS) ▪ Temperature ▪ Pulse ▪ Respirations ▪ Blood pressure ▪ Pain ▪ Oxygen saturation (not a 6th vs. but commonly measured at this time) 4 4 Definition of VS ▪ Temperature – balance between heat produce and lost ▪ Pulse- wave of blood traveling through arteries as a result of each heartbeat ▪ Respirations- act of breathing – taking in O2, its utilization, and giving off CO2 ▪ Blood pressure- force exerted by the blood against a vessel wall 5 5 Definition of VS ▪ Pain – added by the Joint Commission as a 5th VS ▪ No 6th VS but consider  Oxygen saturation  The non-invasive measurement of arterial oxyhemoglobin saturation 6 6 2 VS Measurement Importance ▪ Helps id normal patterns for patient, changes in patient status, and responses to various therapies ▪ Provides a means to id patients who may be at risk for deterioration and adverse events ▪ Best indicators of cardiopulmonary arrest unplanned ICU admission, and unexpected death 7 7 Select the reasons why you think VS have to be taken? (Select all that apply) a. b. c. d. e. To follow hospital protocol It is a nursing responsibility Obtain baseline Client requested for VS check Assess for problems requiring interventions 8 8 When to Assess Vital Signs ▪ On admission to any health care facility/institution ▪ Based on facility/institution policies and procedures ▪ Change in condition ▪ Before and after  Any surgical or invasive diagnostic procedure  Activity that may increase risk, such as ambulation or surgery 9 9 3 When to Assess Vital Signs ▪ Before and after  Administering medications that affect cardiovascular and respiratory function ▪ ▪ ▪ ▪ Emergency situations As often as a patient’s condition requires it Clinics and Health fairs In home 10 10 Nurse’s roles R/T VS ▪ Monitoring ▪ Collaborating ▪ Client teaching 11 11 Guidelines for Obtaining Accurate VS #1 – Ensure Proper Equipment #2 - Know normal VS ranges Temp Pulse Respirations Blood pressure Average normal ranges Client / patient normal range 12 12 4 Guidelines for Obtaining Accurate VS Use appropriate infection control procedures Perform Hand Hygiene Identify Client Use 2 identifiers Explain Position client What Why Appropriate client position for VS to be taken 13 13 Guidelines for Obtaining Accurate VS ▪ Environment ▪ Use organized system to do VS at the same time ▪ Any abnormality, repeat, and report ▪ Affect of other factors on VS 14 14 Temperature 15 15 5 BODY TEMPERATURE Difference between the heat produced by the body and heat lost to the environment Heat Generated by core body tissues Transferred to skin surface by circulating blood Dissipated to the environment Measured in degrees (°C or °F) 16 16 Body Temperature ▪ Core  Intracranial, Intrathoracic, Intra-abdominal, Tympanic, and Rectal  Is higher than surface temp ▪ Surface  All body surfaces especially those where temperature can be taken 17 17 Body Temperature Regulation ▪ Thermoregulatory set point in the hypothalamus ▪ Compares messages received with a set point ▪ Responds by  Producing / conserving heat or  Increasing heat loss 18 18 6 Body Temperature Regulations The Hypothalamus = the thermostat Anterior Posterior Heat loss Heat production & Heat conservation 19 19 Heat Production ▪ Increase Metabolism (Primary source of heat produced by various mechanisms)  Hormones  Epinephrine / norepinephrine  Thyroid hormone  Shivering  Physical exertion 20 20 Heat Conservation ▪ Also, contraction of pilomotor muscles causes piloerection aka goose bumps  Reduces surface area of skin available for heat loss. Reference: Picture obtain August 02, 2018 from: https://www.google.com/search?biw=1536&bih=698&tbm=isch&sa=1&ei=ldZgWXVHpH10wLT8Y3wBw&q=cold+person+with+goosebumps&oq=cold+person+with+goosebumps&gs_l= img.3...135085.140545.0.140795.17.17.0.0.0.0.157.1539.10j7.17.0....0...1c.1.64.img..0.5.681...0j0i7i30 k1j0i8i7i30k1j0i8i30k1j0i24k1.0.vYemQLK9-4A#imgdii=uS6mNj2CMXQTM:&imgrc=Oynbth8xCbj3FM:&spf=1533073186789 21 21 7 Heat Loss ▪ Skin is the primary site of heat loss ▪ In response to core body temperature and environmental temperature, the sympathetic nervous system controls the opening and closing of the Arterio-venous shunts located below the skin surface  Open to allow heat to dissipate  Closed to retain heat 22 22 Heat loss Radiation – diffusion or dissemination of heat by electromagnetic waves Convection – Dissemination of heat by motion between areas of unequal density 23 23 Heat loss Evaporation- Liquid to vapor Conduction – transfer of heat to another object during direct contact 24 24 8 Other Heat Losses ▪ Cooling and humidifying of inspired air ▪ Elimination of urine ▪ Elimination of feces 25 25 Factors That Affect Temperature ▪ ▪ ▪ ▪ ▪ ▪ Time of day (Circadian rhythms) Age Biological sex Physical activity State of health Environmental temperatures 26 26 ▪ Person with a normal temperature is considered to be: AFEBRILE ▪ Note:  Temperature varies among people  A range of 0.3°C – 0.6°C (0.5°F – 1°F ) from the average temp is considered with in normal limits 27 27 9 Increased Body Temperature ▪ Fever  Pyrexia  Hyperpyrexia ▪ Hyperthermia ▪ Neurogenic fever ▪ Fever of unknown origin 28 28 Fever ▪ Fever (Pyrexia)  Response to an upward displacement of the thermoregulatory set point in the hypothalamus  Can be caused by chemicals, bacteria, viruses, chemicals released in response to injury 29 29 Fever ▪ Valuable indicator of health status ▪ Beneficial effects  Destruction of dz causing microorganisms  Increased susceptibility of microorganisms to anti- effectives  Enhanced response by the immune system 30 30 10 Fever  When greater than or equal to 41 °C (106°F) (Aka – Hyperpyrexia) = Emergency  Body must be cooled rapidly to prevent brain damage ▪ Most are self limiting and return to normal after causes are controlled ▪ Also, read page 720 of Taylor, Lynn, & Bartlett, 10th ed., regarding terms and definitions for types of fever. 31 31 Fever ▪ Onset & significance of fever from illness differ according to age  Onset in children faster than in adults  Older adults have lower baseline temps. So fever maybe a late sign  Important to assess a baseline temp in all patient’s  Older adults it’s especially needed to be able to identify unique manifestations of fever 32 32 Hyperthermia ▪ High body temperature  Hypothalamic set point is NOT changed  In situation of extreme heat exposure or production mechanisms that control body temp are ineffective 33 33 11 Neurogenic Fever & FUO ▪ Neurogenic Fever = Result of damage to the hypothalamus from pathologies such as:  Intracranial t______ and or b__________  Increased I_____c________ P__________ ▪ Does not respond to antipyretic medications ▪ Fever of Unknown Origin (FUO)  Fever of 38.3 °C (101 °F)or higher lasting 3 weeks or longer  No identified cause 34 34 Potentially Dangerous Complications of Fever ▪ Fluid & Electrolyte Imbalance ▪ Acid – Base Imbalance 35 35 Effects of Fever & Treatment ▪ Possible Physical Effects:        Loss of appetite Headache, Fatigue Hot, dry skin Flushed face Thirst Muscle aches Increased respirations  Increased pulse ▪ Treatment  Treat the underlying cause  If due to bacteria or other type of microbial anticipate antibiotic administration  Administer antipyretic drugs (Aspirin, Ibuprofen, or acetaminophen) as prescribed 36 36 12 Fever – Treatment Continued ▪ Modifications to environment to increase heat transfer may be implemented  Cool sponge baths (NOT Ice baths)  Cool packs  Cooling blankets ▪ Increase oral fluids to prevent dehydration ▪ Include simple carbohydrates to prevent tissue breakdown d/t a hypermetabolic state. See page 721 of Taylor, Lynn, & Bartlett, 10th ed. for additional information 37 37 Nursing Care for Febrile Clients ▪ Monitor parameters ▪ Measures to lower temp ▪ Provision of comfort ▪ Prevent complications 38 38 Hypothermia ▪ Two types  Intentional (induced)  Unintentional (accidental)  Nursing care focus 39 39 13 Hypothermia ▪ Body temperature below the lower limit of normal ▪ Occurs when compensatory physiologic responses meant to produce and retain heat are overwhelmed by unprotected exposure ▪ Results in accidental exposure (unintentional) or impaired perception 40 40 Hypothermia ▪ Increase risk with  Chronic conditions (ie, alcoholism, malnutrition, hypothyroidism)  Newborns  Perioperative period ▪ When body temp falls below 35 °C death may occur but there have been some to survive. 41 41 Therapeutic Hypothermia ▪ Purposeful lowering of core body temp. ▪ Used to improve outcomes after cardiac arrest ▪ Works by reducing the body’s metabolic rate and oxygen demand to improve survival and neurologic outcomes 42 42 14 Hypothermia ▪ Possible Physical Effects:         Poor coordination Slurred speech Poor judgment Amnesia, hallucinations Stupor Decreased respirations Weak & irregular pulse Decreased BP ▪ Treatment:  Rewarming by:  Covering with blankets  Put on additional clothes  Use of heating blankets  Radiant warmers  Warm fluids orally or intravenously 43 43 44 44 Types of Thermometers Used Tympanic (uses infrared sensor) Electronic Disposable with dots Temporal artery 45 45 15 Types of Thermometers Used ▪ Electronic & Digital  Measure oral, rectal and axillary over a few seconds to 30 seconds  Are battery operated ▪ Tympanic membrane  Use infrared sensors to detect heat given of by the tympanic membrane.  Probe is covered and inserted into the ear canal  Reading takes 1 – 3 seconds 46 46 Types of Thermometers Used ▪ Temporal Artery  Measure body temp by capturing heat emitted by the skin over the temporal artery  Technique and cleanliness of the device can affect the readings ▪ Disposable single-use  Non-breakable & measure temp within seconds  Temp sensitive patch or tape applied to forehead or abdomen  Tempa – Dot can be used oral or axillary and is a thermometer with temp sensitive dots that change color. 47 47 Sites to Assess Temperature ▪ Nurses choose the appropriate and site based on  Patient condition  Facility policy  And medical orders ▪ Factors affecting site  Patient’s age and/or Patient’s state of consciousness  Amount of pain  Disease process ( For example, no oral temp on a patient with a broken jaw that is wired closed)  And other care treatments 48 48 16 Sites and Methods of Assessing Temperature ▪ Oral  Client must be able to close mouth around temperature probe.  If a client has been taking hot or cold foods or liquids or smoking or chewing gum, the nurse should then wait 15 -30 mins.  Normal oral range is from 35.9 – 37.5 °C  Probe must remain in the sublingual pocket for the full period of measurement (usually 1 min.) 49 49 Sites and Methods of Assessing Temperature ▪ Tympanic Membrane  Frequent route for estimating core body temp.  Uses infrared sensors to detect heat given off by the tympanic membrane.  Accurate reading are possible when proper technique for obtaining temperature is used.  Do not use with ear drainage, pain, infection, or scarring on the tympanic membrane.  Normal tympanic range is 36.8 – 38.3 °C 50 50 Sites and Methods of Assessing Temperature ▪ Temporal artery  Captures the heat emitted by the skin over the temporal artery. Measure on the right or left side of the forehead. Remove anything covering the temporal area Do Not use the side patient is lying on Do Not measure over scar tissue, open lesions or abrasions  Move across forehead slowly maintaining contact with skin  Normal range 36.3 – 38.1°C  More accurate than axillary     51 51 17 Sites and Methods of Assessing Temperature ▪ Axillary  Safe and noninvasive preferred site for newborns.  Use when oral or rectal sites unavailable  Should not be use where accurate temp measurement is required  Most common site in neonates  Place probe in center of axilla and hold patient’s arm down  Normal axillary range 35.4 – 36.9 °C 52 52 Sites and Methods of Assessing Temperature ▪ Rectal  A core temperature. One of the most accurate sites  Most clients are embarrassed to have rectal temps taken  Contraindicated for clients who are have undergone rectal surgery, have diarrhea or dz of the rectum , are immunosuppressed, clotting disorders, low platelet count, hemorrhoids, neutropenia, or neurological disorders. 53 53 Sites and Methods of Assessing Temperature ▪ Rectal  Use caution during insertion because can stimulate the vagus nerve and cause HR slowing.  Should not be used in newborns or children with diarrhea  Normal rectal range is 36.3 – 38.1 °C 54 54 18 Pulse Physiology ▪ Regulated by autonomic nervous system (ANS) through the sinoatrial (SA) node 55 55 Pulse Physiology ▪ Parasympathetic Nervous system  Via the vagus nerve  Decreases heart rate ▪ Sympathetic Nervous System  Via the SA node  Increases heart rate & force of contraction 56 56 Results from a wave of blood being pumped into the arterial circulation by the contraction of the left ventricle Pic: Obtained August 08, 2018 from https://meded.ucsd.edu/clinicalmed/vital.htm 57 57 19 Pulse is the number of pulsations felt over a peripheral artery or heard over the apex in 1 minute. The pulse rate normally corresponds to the beating heart rate 58 58 Normal Pulse Rate ▪ Adults  60 – 100 bpm ▪ Athletes have may have pulse rate ▪ Gradually diminishes across the life span. This Photo by Unknown Author is licensed under CC BY-SA 59 59 Factors Affecting Pulse ▪ Age– HR with age ▪ Gender- Females HR slightly ▪ Exercise- w/ exercise HR Fever- HR ▪ Stress- HR ▪ Medications- can or ▪ Acute and chronic health conditions (presence of disease or health conditions) 60 60 20 Increased Pulse Rate ▪ A rapid HR  Decreases ventricular filling time which in turn = decreased stroke volume ▪ Tachycardia is a HR 100 - 180 bpm 61 61 Decreased Pulse Rate ▪ Bradycardia is a HR < 60 bpm. ▪ HR normally slower during sleep in men and those who are thin ▪ HR slows during hypothermia as metabolic processes slow down ▪ There are medications designed to HR and force of contraction 62 62 Decreased Pulse Rate ▪ Can also be caused by vagal stimulation, severe pain, with ICP, or during and after a myocardial infarction (MI) ▪ Should immediately report to the provider bradycardia accompanied by difficulty breathing, change in level of consciousness, decreased blood pressure, change in ECG and angina. 63 63 21 Pulse Amplitude & Quality ▪ Pulse amplitude     Describes the quality in terms of fullness Reflects strength of LV contraction Assessed by the feel of the bld flow thru the vessel Graded 0 - +3 ▪ Pulse grading (amplitude) scale: O= Absent, unable to palpate 1+= diminished, weaker than expected 2+= Normal, brisk, expected 3+= Bounding  See Taylor, Lynn, & Bartlett, 10th ed., p. 727 - 728 64 64 Pulse Amplitude & Quality ▪ Pulse quality description  Full & bounding when forceful  Weak and thready when feeble 65 65 Pulse Rhythm ▪ Pattern of the beats and pauses between them ▪ Normally is regular ▪ Irregular = beats and pauses occur at unequal intervals  Called a dysrhythmia  Must be reported immediately 66 66 22 Pulse Assessment ▪ Equipment  Nurses use their fingers to assess peripheral pulses  Stethoscope used for apical pulse  Doppler Ultrasound - used when peripheral pulses are difficult to palpate or auscultate This Photo by Unknown Author is licensed under CC BY-SA 67 67 Identify the Sites Where Pulses are Assessed 68 68 Apical Pulse ▪ Assess when  Problem with peripheral pulse  Giving medications that can alter HR & rhythm ▪ Preferred methods for infants and children < 2 yrs. ▪ What you will do:  Use stethoscope to listen for 1 min. over the apex of the heart  Left chest  Heard between 5th & 6th rib = (5th intercostal space)  Midclavicular line Note: while you are in clinical you will be expected to check apical pulse with your initial vital signs each morning. 69 69 23 70 70 Assessing Apical–Radial Pulse ▪ Difference between apical pulse rate and radial pulse rate  Called pulse deficit  Indicates thrust of blood from the heart is too weak to be felt at the peripheral pulse site  Can also indicate peripheral dz is preventing impulses from being transmitted 71 71 Pulse Assessment and Nursing Responsibility Method of assessment Nursing responsibility ▪ Palpation ▪ Rate ▪ Rhythm ▪ Auscultation ▪ Volume ▪ Elasticity ▪ Doppler ▪ Presence ▪ Absence ▪ Pulse volume ▪ Bilateral equality Taylor, Lynn, & Bartlett, 10th ed., pp. 728 - 730 72 72 24 Respirations ▪ Ventilation (breathing)  Act of moving gases in and out of the lungs ▪ Inspiration /Inhalation  Act of breathing in ▪ Expiration/Exhalation  Act of breathing out ▪ One inspiration & one expiration = one respiratory cycle 73 73 Diffusion & Perfusion ▪ Diffusion (Pic on right)  Exchange of O2 and CO2 between alveoli and circulating blood ▪ Perfusion (Pic on left)  Exchange of O2 and CO2 between circulating blood and tissue cells 74 74 Respiration ▪ Controlled by respiratory centers in the brain and chemoreceptors ▪ A vital sign is ventilation ▪ Measuring allows for baseline of respiratory function 75 75 25 Physiology of Respirations ▪ Activation of Respiratory centers  Chemo receptors located in aortic arch and carotid bodies  Stretch and irritant receptors in the lungs  Receptors in muscles and joints ▪ Increase in CO2 is most powerful resp. stimulant 76 76 Physiology of Respirations ▪ Rate and depth of Inhalation and Exhalation  Smooth  Effortless  Without conscious effort ▪ Environmental and pathophysiologic alterations may result in or respirations Picture obtained August 6, 2018 from: http://www.netanimations.net/Heart-beating-lungs-breathingbody-organ-animations.htm 77 77 Factors Affecting Respiration ▪ Exercise ▪ Resp. & CV disease ▪ Fluid, Electrolyte ▪ ▪ ▪ ▪ imbalances Acid – base imbalance Medications Trauma Pain & Emotions 78 78 26 Normal Respirations ▪ Adults 12 – 20 breaths/min ▪ Infants and children breath more rapidly ▪ Teens breath about the same rate as adults Taylor, Lynn, & Bartlett 10th ed., Pg 733 79 79 Increased Respiratory Rate ▪ Tachypnea – increased resp. rate  May occur in response to increase in metabolic rate (for example with a fever)  Cells require more O2 and produce more CO2  This will cause an in rate and depth of respirations known as hyperventilation (Example , pneumonia) 80 80 Decreased Respiratory Rate ▪ Bradypnea – resp. rate ▪ Occurs in some pathologic conditions  Increased ICP depresses the respiratory center results in irregular or shallow breathing or slow breathing or both ▪ Certain drugs including opioids (e.g. morphine, hydromorphone, etc.) 81 81 27 Respiratory Depth and Rhythm ▪ Depth varies from shallow to deep ▪ All people automatically inhale deeply (sighs) periodically ▪ Certain terms describe nature and depth  Apnea – No breaths. If lasts > 4 – 6 mins brain damage and death may occur  Dyspnea – difficulty breathing with shallow rapid respirations  Orthopnea – Dyspnea where breathing is easier in an upright position Also read Taylor, Lynn, & Bartlett, 10th ed., p. 733 82 82 Respiratory Assessment & Nursing Responsibility ▪ ▪ ▪ ▪ ▪ Assessment Rate Rhythm Depth Quality ▪ Nursing ▪ ▪ ▪ ▪ responsibility Breathing pattern Health problem(s) Medications Cardiovascular function 83 83 Alterations in Respiration ▪ ▪ ▪ ▪ ▪ Eupnea – _____________________________ Tachypnea - ___________________________ Bradypnea - ___________________________ Apnea - _______________________________ Dyspnea - _____________________________ 84 84 28 Alterations in Respiration ▪ ▪ ▪ ▪ Orthopnea -___________________________ Hyperventilation - ______________________ Hypoventilation -_______________________ Cheyne-Stokes breathing -_______________ __________________________________ ▪ Biot’s - _________________________________ 85 85 Blood Pressure Obtained July 31, 2018 from: https://www.preeclampsia.org/the-news/53-health-information/614-your-bloodpressure-know-the-basics 86 86 Blood Pressure ▪ Blood pressure  Force of moving blood against the arterial walls when the left ventricle contracts  Pressure rises as the ventricles contract = Systole  Pressure falls as the ventricles relax = Diastole 87 87 29 Determinants of BP ▪ Cardiac output  Heart rate X Stroke volume ▪ CO & Peripheral resistance  Determine systole and diastole ▪ Peripheral resistance  Viscosity of blood (thickness of blood)  Changes in radius of arterioles (constriction & dilation) This Photo by Unknown Author is licensed under CC BY-NC-ND 88 88 Blood Pressure ▪ Recorded in mmHg as a fraction Picture retrieved August 6, 2018 from: https://www.hypnotension.com/high-bloodpressure/ ▪ The pulse pressure  Difference between systole and diastole  120 – 80 = 40 89 89 Blood Pressure - Definitions ▪ Systolic Pressure - ________________ _____________________________________ ▪ Diastolic Pressure -________________ ______________________________________ ▪ Pulse pressure – Difference between_ ______________________________________ 90 90 30 Physiology of B/P ▪ Elasticity of the arterial walls and in addition to the resistance of arterioles help maintain normal B/P ▪ With age arteriole walls become less elastic = rising pressure in the vascular system ▪ Also controlled by various short term and long term mechanisms 91 91 Short-term Regulation of B/P ▪ Occurs over minutes to hours  Neural (nerve)  Humoral (pertaining to body fluids) ▪ Strong ventricular contraction = increase CO which in turn increases B/P ▪ Weak ventricular contraction decreases CO which in turn decreases B/P ▪ Baroreceptors 92 92 Short-term Regulation of B/P ▪ Baroreceptors  Pressure sensitive receptors located in the heart and arterial walls  Stimulated by stretch and send impulses to the cardiovascular center of the brain to initiate changes in HR and vascular smooth muscle 93 93 31 Short-term Regulation of B/P ▪ Humoral  Epinephrine – a sympathetic neural transmitter is released by the adrenal gland to increase HR and contractility thereby increasing CO = increased BP  Vasopressin (antidiuretic hormone) – stimulated by decreased B/P and volume = vasoconstriction to increase B/P 94 94 Short-term Regulation of B/P Humoral Renin-angiotensin-aldosterone system through angiotensin 2 causes vasoconstriction = increased B/P 95 95 Long-term Regulation of B/P ▪ Regulate extracellular volume through the kidneys ▪ Function by regulating B/P for a person’s equilibrium point  Pressure rises when body has too much extracellular fluid. In response sodium and fluid are excreted.  When B/P decrease the opposite occurs  Extracellular fluid volume regulates B/P by increasing CO and renal blood flow 96 96 32 Factors Affecting BP ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Age Circadian rhythm Biological sex Food intake Exercise Weight Emotional state Body position Race Drugs/Medications Cigarette smoking 97 97 Normal Blood Pressure ▪ Varies with age ▪ Due to individual differences it is important to know the B/P range of a particular person ▪ A rise or fall of 20 – 30 mmHg in a person’s B/P is significant ▪ Sustained long term changes are not normal ▪ Measurement taken after the patient rests for 5 mins and has not consumed coffee or smoked for 30 mins before. 98 98 Normal Blood Pressure ▪ Blood Pressure:  Less than 120/80 is considered normal  New from the 2017 Hypertension Clinical Practice Guidelines (Wheaton et al, 2018) & American Heart Association normal blood pressure ranges  Evidenced based and most widely used in hospitals and clinics. 99 99 33 American Heart Association BP Retrieved August 7, 2018 from: https://www.heart.org/en/health-topics/high-blood-pressure 100 100 Increased BP ▪ Hypertension  One of the most common health problems  Elevated B/P for a sustained period  Diagnosis made when systolic B/P > 130 mmHg or diastolic is > 80 mmHg  Changed in 2017 and resulted in almost half of the US population being diagnosed with hypertension, especially in younger people  Elevated B/P progressively increases with age 101 101 Decreased BP ▪ Hypotension  B/P < 90/60 mmHg  Occurs as a result of the inability of the body’s control mechanisms to maintain or return blood pressure back to normal  May occur due to pathology.  Is present in some adults with no signs or symptoms 102 102 34 Decreased B/P ▪ Hypotension  Must be immediately reported when patient also has any of the following signs and symptoms       Dizziness, tachycardia, pallor, Increased sweating, blurred vision, nausea and/or confusion 103 103 Orthostatic Hypotension ▪ AKA Postural Hypotension  A decrease in SBP of > 20 mmHg or a decrease in DBP of > 10 mmHg within 3 mins of standing from a sitting or supine position. Also, sitting from a supine position.  An inadequate response to postural changes in B/P  Associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations and headache 104 104 Orthostatic Hypotension ▪ Causes include  Dehydration, blood loss, and problems of the neurologic, cardiovascular, or endocrine systems.  Also certain classes of medications and aging. ▪ Nursing interventions  Teaching and helping patient to arise and move slowly  Have patient sit and dangle feet at the bedside before standing  Return patient to bed if dizzy or feeling faint 105 105 35 How to Assess Orthostatic Hypotension ▪ Place pt. in supine position for 3 - 10 mins. Then measure & record BP & pulse ▪ Assist the pt. to sit. After 1- 3 mins. measure & record the BP and Pulse ▪ Assist the pt. to stand. After 30 seconds and after 60 seconds. measure & record the BP and Pulse See Taylor, Lynn, & Bartlett, 10th ed, box 26-5, p. 737 106 106 How to Assess Orthostatic Hypotension ▪ Positive results:  SBP ↓>20mmHg or DBP ↓>10mmHg ▪ Within 3 mins of standing when compared to BP sitting/supine is 107 107 Assessing Blood Pressure Picture retrieved August 7, 2018 from: https://www.nbcnews.com/health/health-news/new-bloodpressure-guidelines-mean-yours-might-be-too-high-n820456 108 108 36 Assessing B/P & Nursing Responsibility ▪ Nurse must know  Appropriate equipment to use  How to describe sounds  Site to choose for accurate assessment of B/P (clients upper arm) ▪ Auscultation is the preferred method to measure B/P in adults ▪ Appropriate cuff size 109 109 Assessing B/P & Nursing Responsibility ▪ Automated B/P monitors  Determine B/P by analyzing the sounds of blood flow or measuring oscillations in blood flow.  Can take and record blood pressures at pre-set intervals when needed.  Note: all of the DHS hospitals are currently using the automated B/P monitors. (Nurses need to know how to manually measure BP for times when unable to obtain by automatic monitor and when there is no automated monitor available) 110 110 Korotkoff Sounds ▪ 5 phases in the series of sounds heard as bp cuff pressure released  Phase 1 = first appearance of faint tapping and is the systolic pressure  Phase 2 = muffled or swishing sound that may disappear for up to 40mmHg long then reappear  Auscultatory gap = the temporary disappearance of sounds in the latter part of Phase 1 and during Phase 2 (Taylor, Lynn, & Bartlett, 10th ed., pg. 741, Table 26-9) 111 111 37 Korotkoff Sounds ▪ 5 phases in the series of sounds heard as bp cuff pressure released  Phase III = loud sounds as the blood flows freely thru the open artery  Phase IV = abrupt muffled sounds with a soft blowing sound. Considered to be the first diastolic pressure  Phase V = Last sound before continuous silence and is used to define diastolic pressure ▪ In some each sound is distinct. In others can only hear the beginning sounds and the ending sounds (Taylor, Lynn, & Bartlett, 10th ed., pg. 741, Table 26-9 112 112 Assessing BP ▪ Brachial and popliteal arteries are most commonly used to assess BP ▪ Brachial - At first assessment should check B/P on both arms ▪ Most people have differences in B/P readings between arms  Use arm with the higher pressure when not contraindicated 113 113 Contraindications for Obtaining BP on a Specific arm ▪ Axillary node dissections or Mastectomy side ▪ ▪ ▪ ▪ of the arm On-going IV infusion or blood transfusion Arteriovenous fistula or shunt Injuries, cast Specific doctor’s order  Pre and post op  No BP or blood draw in left arm 114 114 38 Assessing BP ▪ Radial Arterial  Place BP cuff on the forearm  Place stethoscope over the radial artery  Ensure the wrist is elevated to the level of the heart 115 115 Assessing B/P at the Radial Artery ▪ Becoming more commonly used ▪ The forearm measurement is higher than upper arm ▪ Readings are affected by the position of the wrist relative to the heart ▪ Suggested as an alternative for obtaining readings in an obese patient.  Conical shape of the obese arm makes it difficult to properly fit the cuff 116 116 Assessing BP ▪ Popliteal Artery  Used when  brachial artery is not accessible  Contraindicated  Systolic BP is usually 10 – 40 mmHg higher than brachial (Taylor, Lynn, & Bartlett, 10th ed., pg. 744, Guidelines for Nursing Care 26-7 117 117 39 Sources BP Assessment Errors ▪ Falsely low assessments  Wrong size cuff too big or too wide ▪ Falsely high assessments  Wrong cuff size too small or too narrow ▪ Additionally, see page 739 Box 26-6 for Sources of Error in Blood Pressure Measurement 118 118 Pulse Oximetry ▪ A noninvasive technique that measures arterial oxyhemoglobin saturation (SaO2 or SpO2)  SaO2 aka O2 Saturation  Reported as a percentage  Useful for monitoring pts on O2 Therapy, at risk for hypoxia, on a ventilator, post-op  Does not replace arterial blood gas monitoring ▪ Oxygen Saturation – 95% - 100% 119 119 Factors Affecting Oxygen Saturation ▪ Hemoglobin ▪ Circulation ▪ Activity 120 120 40 Can you list all of the times when VS have to be taken? 121 121 Nutrition ▪ Intake of food and how food nourishes our bodies ▪ Nutrients are specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from injury 122 122 What is the Importance of Assessing Height and Weight? ▪ Nutrient needs change throughout the life cycle in response to changes in body size, activity, growth, development and state of health ▪ Height and weight are used to estimate body fat stores and are used as an initial assessment of nutritional status 123 123 41 Weight Gain/Loss - Energy Balance ▪ If a person’s daily energy intake = total daily energy expenditure weight remains stable ▪ Daily energy intake < total daily energy expenditure weight will decrease ▪ Daily energy intake > total daily energy expenditure weight will increase 124 124 Weight Gain/Loss - Basal Metabolism ▪ Basal metabolism is the energy required to carry on involuntary activities when the body is at rest  Maintaining body temperature and muscle tone  Producing and releasing secretions  Propelling food through the GI tract  Inflating the lungs  Contracting the heartbeat 125 125 Basal Metabolism ▪ Factors that may increase BMR:      Growth Infection , fever Emotional tension Environmental temperatures Elevated hormones (e.g. epinephrine, thyroid)  Note: Men have higher BMRs due to larger muscle mass than women. 126 126 42 Basal Metabolism ▪ Factors that may decrease BMR:  Aging  Prolonged fasting  Sleep  Following a very low calorie diet  Note: Prolonged fasting and very low-calorie diet slow BMR and can make it difficult to lose weight. 127 127 Body Weight Standards ▪ Ideal body weight (IBW) is an estimate of optimal body weight for optimal health ▪ Height and weight tables are commonly used in infants and children ▪ Body Mass Index (BMI) is commonly used for adults and children ▪ Waist circumference is used for adults only 128 128 Body Mass Index ▪ Body Mass Index (BMI)  Ratio of weight (in Kg) to height (in meters) Used to indicate body fat stores and whether a person’s weight is appropriate for the height. Used as an initial assessment of nutritional status Provides an estimation of relative risk for heart disease, diabetes, and hypertension BMI is a calculation and is more conveniently used in a table See: Taylor, Lynn, & Bartlett, 10th ed., 1391 - 1392 129 129 43 One Example of BMI Chart Obtained from https://www.ifafitness.com/book/bmi-chart.htm 130 130 Body Mass Index ▪ What the BMI numbers indicate BMI (kg/m2) Underweight 5g:  Ca, Phos, Na, Cl, Sulfates, K, Mg ▪ Microminerals  present in the body in amounts