Vital Signs & Temperature (NURS 1090) PDF

VITAL SIGNS NURS 1090  UNIT OUTCOMES Discuss nursing responsibility in assessing vital signs, including pain measurement Explain the physiology for the regulation of temperature, pulse, respirations, blood pressure, and oxygen saturation (pulse oximetry). L...

VITAL SIGNS NURS 1090  UNIT OUTCOMES Discuss nursing responsibility in assessing vital signs, including pain measurement Explain the physiology for the regulation of temperature, pulse, respirations, blood pressure, and oxygen saturation (pulse oximetry). List factors that influence vital signs. Identify vital sign changes in the older adult.  UNIT OUTCOMES Demonstrate the ability to correctly obtain the following vital signs: Temperature Radial/Apical pulse Respiration Blood Pressure Pulse oximetry Identify nursing responsibilities of delegation of vital signs to unlicensed personnel  COURSE COMPETENCIES Use the nursing process at a basic level to deliver patient- centered nursing care to diverse adult populations experiencing common health alterations. Identify the rationale used to make clinical judgments that ensure accurate and safe patient care. Identify the rationale used to prioritize patient care when implementing the nursing process. Identify members of the healthcare team. Identify an example of delegation used within the healthcare team  Assessment Metabolism Oxygenation UNIT CONCEPTS Thermoregulation Perfusion Clinical decision making  VITAL SIGNS T= P = Pulse Indication of patient’s Temperature level of health Provides baseline data R= BP = Blood Delegation Respirations Pressure Pulse ox Pain (sPO2) = assessed Pulse during vital oximetry signs  Why are Vital Signs important?  On admission to a health care agency For routine scheduling according to physician order or institution policy WHEN Before and after certain procedures SHOULD Before and after certain medications VITAL SIGNS BE Whenever there is a change in patient TAKEN? condition Nursing judgment Before or after nursing interventions  Must know normal VS ranges Must know patient’s own range INTERPRETATIO Changes in one vital sign parameter N OF VITAL are usually reflected by changes in others SIGNS VS are influenced by many external factors Trends are more important than a single reading—what are trends?  EXAMPLE Mr. M is admitted with a myocardial infarction today. Vital Signs (VS) while resting in bed Time BP Pulse Interpretation____________ 1400 140/80 68 Baseline 1500 126/82 94 Begin to become concerned 1530 106/60 100 Still within normal range? Should the nurse inform the healthcare provider?  WHEN TO NOTIFY THE HEALTHCARE PROVIDER? Abnormal results Changes in patient’s normal vs Change in health status  TEMPERATURE Body temperature is maintained through a balance between heat production and heat loss Heat produced – Heat lost = Body Temperature Regulation occurs via neural and vascular control Hypothalamus: regulatory center in brain for body temp. Maintains stability of body temperature despite changes in environmental temperatures.  PRINCIPLES OF HEAT TRANSFER PEARSON, VOLUME 1 Conduction Convection Radiation Evaporation  TEMPERATURE REGULATION Trigger:  body Temperature Hypothalamic heat promotion center activated Vasoconstriction of blood vessels; Voluntary muscle Blood shunted to vital organs contraction Decreased heat loss to environment Body temperature  to normal range  TEMPERATURE REGULATION Trigger:  Body temperature Hypothalamic heat loss center Activated Activation of sweat glands Dilation of blood vessels Evaporation radiation & convection Body temperature  to normal range  ASSESSMENT OF TEMPERATURE Normal Range: 36°-38° C. (96.8°- 100.4°F) Core Most accurate Temperature of the deep tissues Relatively constant Rectal, Tympanic membrane Surface Skin, oral, axillary Fluctuates depending on blood flow to skin and amount of heat lost to external environment  BODY TEMPERATURE IN OLDER ADULTS Thermoregulatory response altered in aging Lower core body temperature Average body temperature 36 Sensitive to temperature extremes – due to alterations in control mechanisms Decreased peripheral vasoconstriction/vasodilation ability Reduced subcutaneous fat acting as insulation Reduced metabolism Reduced sweat gland ability  ALTERATIONS IN BODY TEMPERATURE Terminology Pyrexia, hyperthermia, fever heat produced > heat lost, body temperature above normal Hypothermia body temperature below normal Afebrile temperature is normal Pyrogens bacteria/virus is causing ↑ temp by triggering the immune system FUO fever of unknown origin RANGE OF TEMPERATURE VALUES  FEVERS Fluctuates minimally but always above Constant normal Alternates at regular intervals; periods of Intermittent below, normal and above normal temps Wide fluctuations over 24 hrs. but all above Remittent normal Relapsing 1-2 days of normal temp. then 1-2 days febrile Rises rapidly then returns to normal within a Spike few hours  Initial (Chill Phase) Chills SYMPTOMS Shivering ASSOCIATED Patient “feels” cold (to self WITH and to nurse’s touch) INCREASING TEMPERATUR Plateau Phase E (FEVER) Chills stop Patient feels warm and dry Temperature is elevated  SYMPTOMS RELATED TO HEAT LOSS RESPONSE Flush Phase Cause of high temperature removed Reduction of body temperature Diaphoresis Evaporative heat loss Vasodilation Skin warm and flushed (reddened)  VALUE OF A FEVER Defense mechanism Stimulates immune system ↑ WBC suppresses bacterial growth ↑ Interferon suppresses viral growth Temperature elevations up to 38.3⁰ may not be treated  THERMOMETERS Electronic Electronic unit, battery, digital read out, probe cover Temporal/Tympanic Measures infrared energy given off by heat source Chemical Dot Temperature Strip Single use; chemically impregnated dots change color Geratherm Like the old glass; NO mercury DIGITAL ORAL THERMOMETERS  TEMPORAL AND TYMPANIC Temporal Tympanic THERMOMETER STRIPS GERATHERM® MERCURY-FREE THERMOMETER  COMPARISON OF SITES FOR TEMPERATURE MEASUREMENT (PEARSON, VOLUME THREE, P. 26) Oral 37.0 Accessible, sublingual pocket—Consider hot & cold fluids (wait 15-30 min) Rectal 37.5 Core temp., reliable but inconvenient, lubricate, insert 1 ½ inches in adult Axillary 36.5 Safe, non-invasive. Tip of thermometer in contact with two two pieces of skin Tympanic 37.0 Very fast, false low readings, pull pinna up & back for adult Temporal 37.5 Very fast, safe, non-invasive. Run probe over forehead to temporal area  TEMPERATURE METHODS Oral Temperature Rectal Temperature AXILLARY TEMPERATURE  ELEVATED BODY TEMPERATURE Signs and Symptoms Nursing Actions Temperature >38.0°C Administer antipyretics Increased heart rate as ordered by HCP Increased respiratory Reduce clothing and skin rate covering Skin flushed, warm to Increase fluid intake as touch, moist ordered by HCP Apply cool washcloths  REVIEW Advantages and disadvantages of temperature measurement sites Pearson, Volume Three, Manifestations of, and nursing interventions for, elevated body temperature Pearson, Volume One, XXXX