Geriatric Nursing Vital Signs Assessment PDF

### At the end of the lesson, the student will be able to: #### [ Perform vital signs correctly.] 1. Determine if core temperature is within normal range 2. Provide baseline data for further evaluation 3. Determine alteration in disease condition. 4. Monitor the client response to procedure...

### At the end of the lesson, the student will be able to: #### [ Perform vital signs correctly.] 1. Determine if core temperature is within normal range 2. Provide baseline data for further evaluation 3. Determine alteration in disease condition. 4. Monitor the client response to procedure or therapy. 5. Describe factors that affect the vital signs and accurate measurement of them. 6. Identify the variations in normal body temperature, pulse, respirations and blood pressure that occur from infancy to old age. ### Make a video and write the range of normal values of the following vital signs taken from your elderly client. Upload and screenshot the data you have taken and upload it on our googleclassroom. -- -- -- -- - also referred to as cardinal signs - composed of temperature, pulse, respiration, and blood pressure, abbreviated TPR B/P. - are indicative of the general health and well-being of a patient - with regular monitoring, may measure patient response to treatment. - obtained during the patient's initial visit. These baseline results are used as a reference point for future readings, differentiating between what is normal and abnormal for the patient - to ascertain a baseline, medical practitioner may be required to take vital signs more than once 1. Aseptic technique in the form of hand washing and recognition 2. Correction of factors that may influence results of vital signs. - patients may exhibit anxiety over potential test results or findings of the provider - they may be angry or may have rushed into the office - A patient may have had something to eat or drink before the visit/ examination Patient apprehension and mood a. a new disease process b. patient's response to treatment c. patient's compliance with a treatment plan 1. heat production 2. heat loss. - The delicate balance between heat production and heat loss is maintained by the hypothalamus in the brain. - the actions of voluntary and involuntary muscles. - Cellular metabolic activities, such as the process of breaking down food sugars into simpler components (catabolism), are another source of heat. 1. *Convection.* 2. *Conduction.* 3. *Radiation.* 4. *Evaporation.* 5. *Elimination.* a. bacterial infection b. increased physical activity c. food intake d. exposure to heat e. Pregnancy f. drugs that increase metabolism g. stress and severe emotional reactions h. Age a. viral infections b. decreased muscular activity c. Fasting d. a depressed emotional state e. exposure to cold f. drugs that decrease metabolic activities, g. age - age in this instance refers to older adults, in that older adults have decreased metabolic activity resulting in a decrease in body temperature. - During sleep and early morning, the temperature is at its lowest, - whereas later in the day with muscular and metabolic activity, the temperature increases. 1. **Afebrile:** absence of fever 2. **Febrile:** fever is present 3. **Fever:** body temperature increased beyond normal range; **pyrexia** is another term for fever 4. **Intermittent:** a fluctuating fever that returns to or below baseline, then increases again 5. Remittent: a fluctuating fever that does not return to the baseline temperature; it fluctuates but remains increased 6. **Continuous:** a fever that remains above the baseline; it does not fluctuate but remains fairly constant ### Disposable Thermometers. - are individually wrapped strips with heat-sensitive dots that change color to indicate temperature - are used once and then discarded - there are strips for use on the forehead and others for oral use - although strips are easy to use and prevent patient cross contamination , accuracy is questionable. ### Electronic and Digital Thermometers - are widely used, handheld, battery-operated or plug-in units that have easy-to-read electronic display screens - to indicate results Electronic thermometers in Fahrenheit or Celsius scales are available - Probes are attached and are color-coded blue for oral and red for rectal. The probes have disposable plastic covers. The plastic cover acts as a barrier to prevent contamination of the probe and is replaced for each patient to prevent cross contamination - An accurate result can be obtained in approximately 10 seconds. ### 2. Tympanic Thermometers - More popular because they are fast, provide no discomfort to the patient, can be used on patients over 2 years of age as well as adults, and usually are accurate. - They consist of a handheld unit with a probe tip that is inserted into the ear securely to make a seal Disposable tips are used to prevent cross contamination. - tympanic method of measuring body temperature, the procedure is complete in a few seconds - It is comfortable for the patient, nonthreatening to infants and children, and can be used when other methods are inappropriate - It is the thermometer of choice for pediatric patients older than 2 years. ##### In accurate readings can result if patients: a. have impacted cerumen in the ear of which they may be unaware b. has otitis media, a middle ear infection, the reading tends to be inaccurate and the procedure is painful. ### Subtract 32 from F temperature, then multiply by 5/9 97-32= 65x5=325/9 97 ***°*** F = 36.1 °C ASSESSING BODY TEMPERATURE ========================== Assessment : ------------ 1. Assess for signs and symptoms of temperature alterations and for factors that influences body temperature. 2. Determine any previous activity that would interfere with accuracy of temperature measurement. 3. Determine appropriate temperature site and device for client. 4. Determine number of times temperature needs to be taken. 5. Assess temperature in relationship to time of day and age of patient. 6. Compare temperature with other vital signs to establish data. Objectives: ----------- 1. To determine body temperature 2. To assist in diagnosis 3. To evaluate patient's recovery from illness 4. To determine if immediate measures should be implemented to reduce dangerously elevated body temperature or converse body heat when body temperature is dangerous low 5. To evaluate patient's response once heat conserving or heal reducing measures have been implemented Equipment --------- 1. Digital thermometer 2. Tissue 3. Gloves (optional) 4. Blue or black pen  -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- PULSE ===== - PULSE is the beat of the heart felt at an artery as a wave of blood passes through the artery - is felt every time the heart beats - The pulse is the same as the heart rate - can be felt in areas of the body where an artery is close to the surface ##### Pulse Sites ##### Radial pulse - is located at the thumb side of the wrist approximately 1 inch above the base of the thumb. - the most commonly used site for obtaining a pulse rate. ##### Carotid pulse - used during emergency situations and when performing cardiopulmonary resuscitation (CPR) - is found between the larynx and sternocleidomastoid muscle in the front side of the neck on either side of the trachea - when measuring the pulse at the carotid site, compress only one side at a time. ##### Brachial pulse - is found in the inner aspect of the elbow called the antecubital space - this pulse site is the most commonly used site to obtain blood pressure measurements ##### Temporal pulse - is located at the temple area of the head - rarely used to obtain a pulse rate but may be used to monitor circulation, control bleeding from the head and scalp, and to take a temporal artery temperature ##### Femoral pulse - is located in the groin area - a deep artery and must be compressed firmly to be felt. ##### Popliteal pulse - is located at the back of the knee - patient must be in a supine position with the knee flexed for it to be felt because the artery is deep within the knee - this artery is used for leg blood pressure measurements and to monitor circulation ##### Dorsalis pedis - is felt on the top of the foot slightly to the side of midline next to the extensor ligament of the great toe, between the first and second metatarsal bones - commonly used to monitor lower limb circulation. ##### Apical pulse - is found at the apex of the heart, located at the fifth intercostal space left side, midclavicular line, that is, between the fifth and sixth ribs perpendicular to the middle of the clavicle, left of the sternum - A stethoscope is required to obtain an apical pulse. Apical pulse is used for cardiac patients and patients with an arrhythmia, and to obtain infant pulse rates because they are difficult to obtain by the usual methods. - The rate is lower when sleeping and higher when active or exercising. - Rates for infants and children are greater than for adults. ##### Pulse Abnormalities - a pulse rate less than 60 beats per minute ##### Tachycardia - a pulse rate greater than 100 beats per minute ##### Assessment 1. Assess appropriate site to obtain pulse. 2. Check pulse with health status changes 3. Assess for rate, rhythm, pattern and volume. 4. Take an apical pulse on patients with irregular rhythm or those on heart medications. ##### Objectives 1. To determine number of heart beats occurring per minute( rate) 2. To gather information about heart rhythm and pattern of beats 3. To evaluate strength of pulse 4. To assess heart\'s ability to deliver blood to distant areas of the blood viz. fingers and lower extremities 5. To assess response of heart to cardiac medications, activity, blood volume and gas exchange 6. To assess vascular status of limbs ##### Equipment - Wristwatch with second hand - Blue or red pen +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | body with | | | | | | extended | | | | | | straight | | | | | +-------------+-------------+-------------+-------------+-------------+ | or upper | | | | | | abdomen | | | | | | with | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | B. If | | | | | | sitting, | | | | | | bend | | | | | | client's | | | | | | elbow | | | | | | | | | | | | 90 degrees | | | | | | and support | | | | | +-------------+-------------+-------------+-------------+-------------+ | lower arm | | | | | | on chair or | | | | | | on | | | | | +-------------+-------------+-------------+-------------+-------------+ | examiner's | | | | | | arm | | | | | | slightly | | | | | | flex | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | on the | | | | | | armrest of | | | | | | chair and | | | | | +-------------+-------------+-------------+-------------+-------------+ | putting | | | | | | your the | | | | | | fingertips | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | straight of | | | | | | across the | | | | | | chest | | | | | +-------------+-------------+-------------+-------------+-------------+ | or upper | | | | | | abdomen and | | | | | +-------------+-------------+-------------+-------------+-------------+ | putting the | | | | | | fingertips | | | | | | over | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ RESPIRATION =========== - Each breath includes inspiration and expiration - **One inspiration** (inhalation) drawing in of air and **one expiration** (exhalation) expelling air together equals one respiration - Measure by **observing** chest **rise and fall**. - Measured in breaths per minute. ##### NORMAL RESPIRATORY RATES - Respiratory rate is the number of - respirations per minute. - Normal range **12-20 breaths per minute.** - **Eupnea -** normal breathing - **Tachypnea** - breathing more than 24 cycles per minute; respiratory rate greater than - 40 respirations per minute - **Bradypnea -** breathing less than 16 cycles per minute - **Dyspnea -** difficulty in breathing - **Apnea** is the temporary complete absence of breathing. - If using electronic -- take the temperature first, then proceed to the pulse and respiration - When taking the pulse and respiration, do not drop the wrist until both the pulse and respiration are taken. This way the person does not know when his/her respirations are being measured -- insuring a more accurate measurement - When measuring axillary temperature, remove any clothing that could impede the accuracy of the temperature - Also clean the axilla if there is excessive deodorant or perspiration present. 1. To determine number of respiration occurring per minute 2. To gather information about rhythm and depth 3. To assess response of patient to any related therapy/ medication  +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | comfortable | | | | | | , | | | | | | preferably | | | | | +-------------+-------------+-------------+-------------+-------------+ | sitting or | | | | | | lying with | | | | | | the | | | | | +-------------+-------------+-------------+-------------+-------------+ | head of the | | | | | | elevated 45 | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | 2. Prepare | | | | | | count | | | | | | respiration | | | | | | s | | | | | +-------------+-------------+-------------+-------------+-------------+ | by keeping | | | | | | your | | | | | +-------------+-------------+-------------+-------------+-------------+ | fingertips | | | | | | on the | | | | | | client's | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | a. b. | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ | | | | | | +-------------+-------------+-------------+-------------+-------------+ BLOOD PRESSURE ============== - Blood pressure measures cardiovascular function by measuring the force of blood exerted on **peripheral** - The measurement consists of two components. The first is the force exerted on the arterial walls during cardiac contraction and is called **systole.** The second is the force exerted during cardiac relaxation and is called **diastole.** - They represent the highest (systole) and lowest (diastole) amount of pressure exerted during the cardiac cycle. 1. ##### Systolic Blood Pressure - measurement of the pressure when the heart is contracted (systole) - The systolic pressure indicates the maximum amount of work/force the heart has to perform with each stroke in order to move blood through the arteries. - It also may indicate how compliant the arteries are in order to accommodate blood 2. ##### Diastolic Blood Pressure - the pressure in the large arteries during the relaxation of the left ventricle (heart) - The diastolic pressure indicates the amount of pressure the heart must overcome in order to generate the next beat. 3. ##### Hypertension - PERSISTENT elevation of either diastolic or systolic blood pressure 4. **Essential (Primary) Hypertension** - high blood pressure with no identifiable cause 5. ##### Secondary Hypertension - high blood pressure with a known cause eg. Drug-induced or related causes ##### Meniscus ##### Korotkoff Sounds He identified the following [five phases in blood pressure]: ------------------------------------------------------------------------ ##### FACTORS THAT AFFECT BP 1. **Blood volume** - is the amount of blood within the arteries. - Increased volume of blood increases blood pressure, whereas a decrease in blood volume decreases blood pressure, as in the case of a hemorrhage or severe dehydration. ##### Peripheral resistance - is the resistance to blood flow within the arteries. The resistance is in direct relation to the **lumen** of the arteries. - The smaller the lumen, the more pressure needed to push blood through. The reverse is also true: the larger the lumen, the less resistance and less pressure needed to push the blood through. - The size of the lumen can become smaller from deposits of fatty cholesterol (plaque), resulting in an increase in blood pressure. 2. **Vessel elasticity** refers to the ability of arteries to 3. **Condition of the heart muscle** is extremely important to blood flow and blood pressure. A strong heart muscle provides a forceful pump resulting in efficient blood flow and normal blood pressure. A weak heart muscle results in an inefficient pumping action of the heart leading to a decrease in blood pressure and blood flow. ##### 5) Viscosity of the blood - Viscosity refers to [how sticky the blood is]. If the blood is sticky, it acts thicker. - requires a lot more work for the heart muscle to move it through the vessels, thus increasing the pressure inside the walls of the arteries. - it may be so viscous that it might not be able to reach the tiniest capillaries of the kidney, eyes, and other areas without substantial increase in blood pressure Equipment for Measuring Blood Pressure -------------------------------------- - **sphygmomanometer and** - **a stethoscope** - consists of a cuff containing a rubber bladder attached by rubber tubing to a glass column of mercury. - are the most accurate method of blood pressure measurement and are considered the standard because blood pressure is measured in millimeters of mercury. - they are not as portable as aneroid manometers, - there is always the danger of a mercury spill should the glass column break and cause health and environmental problems ##### Aneroid Manometer - is a cuff containing a rubber bladder attached to a dial. - the blood pressure is read at the point of the needle descending the dial. - Aneroid manometers need to be calibrated regularly because they do not maintain calibration easily. **Cuff sizes for manometers** - The appropriate cuff size is necessary to obtain an accurate blood pressure measurement. - A cuff that is too small will give an artificially high blood pressure reading, whereas a cuff that is too large will give an artificially low reading. - The selection of the cuff size depends on the size of the arm, not the age of the patient. ##### Stethoscope consists of: 1. ear pieces 2. tubing 3. two heads a. the bell b. the diaphragm ##### Errors in Blood Pressure Measurement Procedures 1. Improper cuff size. 2. The arm is not at heart level. Do not hold the arm up or let the patient hold up the arm. Pressure is increased when this is done. 3. Cuff is not completely deflated before use or after palpatory method, resulting in a higher pressure measurement. 4. Deflation of the cuff is faster than 2 to 4 mm Hg per heartbeat or 20--30 increments on the aneroid. Sounds are missed if this happens. 5. Reinflating the cuff during the procedure without allowing the arm to rest for 1 to 2 minutes. 6. Patient is not relaxed and comfortable. An anxious, apprehensive patient will have a reading that is higher than the actual blood pressure. 7. Improper cuff placement. Cuff is too loose, too tight, or not positioned correctly over the brachial artery. 8. Defective equipment in which there are air leaks in the bladder or valve, the mercury column is dirty, or air bubbles are present. Mercury and aneroid sphygmomanometers are not calibrated at zero. 9. Measuring blood pressure with thumb on the head of the stethoscope. Measuring Blood Pressure ------------------------ ##### Definition ##### Objective 1. To obtain baseline data for diagnosis and treatment 2. To compare with subsequent changes that may occur during care of patient 3. To assist in evaluating status of patient's blood volume, cardiac output and vascular system 4. To evaluate patient's response to changes in physical condition as a result of treatment with fluids or medications ##### Equipment -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --