Vital Signs Theory & Lab F2024 PDF

Vital Signs  Learning Objectives Describe nursing measures that promote heat loss and heat conservation. Discuss physiological changes associated with fever. Accurately assess temperature via multiple routes: tympanic, oral, temporal, rectal, and axillary. Accurately assess pulse, respir...

Vital Signs  Learning Objectives Describe nursing measures that promote heat loss and heat conservation. Discuss physiological changes associated with fever. Accurately assess temperature via multiple routes: tympanic, oral, temporal, rectal, and axillary. Accurately assess pulse, respirations, oxygen saturation, and blood pressure. Explain the physiology of normal regulation of blood pressure, pulse, oxygen saturation, and respirations. Identify ranges of acceptable vital sign values for an infant, a child, and an adult. Accurately record and report vital sign measurements. 2  Quebec Vital Signs -DBP Respipulse. Vital Signs ② Oz sat The most frequent measurement assessments are body temperature, pulse, blood pressure, respiratory rate, and oxygen saturation Many factors such as pain, environmental temperature, physical state, activities, or illness can cause vital signs to change Pain has been referred to as the “fifth vital sign,” which alludes to the importance of its assessment 3  Guidelines for Measuring * need to know Vital Signs the normes Nurse’s responsibility and delegation a entrust a task to someone Knowledge of Equipment Baseline and ongoing assessments Knowledge of normal values of vital signs Knowledge of the patient’s history and current status Values need to be understood, analyzed and interpreted Systematic, and organized approach Assessment for medication administration Communication of results Teaching a * pulsebefor 4  Body Temperature Body temperature - > measure ofhow well getrida your body can produces – Difference between the amount of heat produced by body processes and the amount lost to the external environment – Body’s core temperature must be kept constant 5  * need to know normal values Acceptable Temperature Ranges 36C to 38C* > - average depending on the institution Average oral or tympanic Temp: 37C Average rectal Temp: 37.5C 5005's Average axillary Temp: 36.5C > 0 5 % - , get worried at 35 when it % T tympanic = =Avilla 6 Factors Affecting Body Temperature Age Exercise Hormone levels Circadian rhythm Stress Environment Thermoregulation 7 Factors Affecting Body Temperature Afebrile Temperature alterations ↳ fever – Fever (pyrexia) (Febrile) Pyrogens pathogens causing fever > - Fever of unknown origin (FUO) – Hyperthermia Malignant hyperthermia Heatstroke Heat exhaustion – Hypothermia Frostbite 8  * measure behind the tongue Measuring Body *& talking Temperature ① * drinking , smoking , eating 30 min before Assessment – Oral temperature Advantages & Disadvantages easy access , reliable Have patient sit or lie in bed. Ask patient to open mouth; gently place thermometer probe under patient’s tongue in posterior sublingual a close · pocket lateral to centre of lower jaw (see Step 6A illustration). month O · use on kids 9  Quick Quiz! The nurse has delegated the task of measuring vital signs to an unregulated care provider. The care provider informs the nurse that the stable patient has just finished a bowl of hot soup. What would be the nurse’s most appropriate advice for the care provider? X A. Take the rectal temperature of the patient instead. B. Take the oral temperature as planned. X C. Advise the patient to drink a glass of cold water. ⑨D. Wait 30 minutes and then take the patient’s oral temperature. X E. Wait 1 hour and then take the patient’s oral temperature. 10  Measuring Body Temperature – Rectal temperature Advantages Disadvantages a curate > - internal Once positioned, thermometer probe should be left in place (see Step 6B illustration) until signal becomes audible and · · uncomfortable patient’s temperature appears on digital display; then thermometer probe is removed from anus. needs positioning · · needs ppe · needs Lubricant 11 2-3 cm  Measuring Body Temperature – Axilla temperature Advantages Disadvantages easily accessible · ① as accurate Raise patient’s arm away from torso; inspect for skin lesions and excessive perspiration. Insert probe into centre of · exposing patient’s axilla, lower patient’s arm over probe (see Step 6C illustration). require positioning · 12  Measuring Body Temperature – Tympanic temperature Advantages Disadvantages quick, very easy to access , accurate, (b) Fit otoscope probe snugly into canal and do not move (see for kids fitsStep 6D[b] illustration). very good , one size all a lot of earwax acurate hearing aids · - positioning ear · · infections - use this method 13 Temperature Assessment Sites Rectal, skin, oral, axillary, temporal artery, esophageal, pulmonary artery, urinary bladder Types of Thermometers Electronic – Tympanic, oral, rectal, axilla Chemical strip (single-use or reusable) Temporal Glass* Contactless 14 Pulse (Heart Rate) Physiology and Regulation The pulse is the bounding of arterial blood flow that is palpable at various points on the body. The pulse is an indicator of circulatory status. Electrical impulses from the sinoatrial node stimulate cardiac contraction. 15 Normal Pulse Rates normal :60-100 ppm & 16  * 2-3 fingers & thump Assessment of Pulse (heart rate) * support on table or on pillow (heart level) Radial pulse – most common site Carotid pulse Apical pulse – requires a stethoscope Character of the pulse – Rate regular count to 30 sec multiply 42 > - > - + – Rhythm regular or irregular > - – Strength go to apical pulse & then – Equality 17 Assessing a radial pulse 18 Landmarking an Apical Pulse (AP) measure for a full min left side intercostal 5th - 6th ribs between ribs 19 20 Doppler 21 Factors Influencing the Pulse Rate Exercise Temperature Emotions Pain Medications Hemorrhage Postural changes Pulmonary conditions 22  Quick Quiz! Adult The nurse notices that an 18-year-old male patient has an irregular pulse. What would be the nurse’s best decision at this time? A. Review the history & the previous physical examination findings of the patient. & B. Assess the apical pulse rate for one full minute. C. Assess the temporal artery pulse rate for one full minute. D. Ask the patient whether he feels any palpitations. 23 Pulse - Heart Rate Lub Dub Apical pulse– Heart Sounds (S1 and S2) Tachycardia Fast HR 100 = > Bradycardia = SLOW HR:60 Pulse deficit 24  Pulse - Strength Strength of the pulse describes both the volume of blood ejected with each cardiac contraction and the condition of the arterial function at the assessment site. Described as – bounding strong weak thready absent 25  Respiration Three components of respiration – 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 26 Respiration Physiological control – Oxygen – Carbon dioxide Mechanics of breathing – Inspiration – Expiration – Tidal volume 27 28 29 Normal Respiratory Rates Age Rate (breaths/min) Newborn 30-60 Infant (6 months) 30-50 Toddler (2 years) 25 - 32 Child (3 -12years) 20 - 30 Adolescent (13 – 18 years) 16 - 19 Adult (older than 18 years) 10 - 20 normal 30 Respiration – Rate > - I minute – Depth > - Shallow or Deep – Rhythm > - regular or irregular * pt must be unaware 31 Alterations in Breathing Patterns Bradypnea WRR G12 Tachypnea ↑ RRO 20 ⑧Apnea I respiration > - Hyperventilation RR like Panic attacks ⑰12 ↑ Hypoventilation ↓ RR due to meds 012 32  Quick Quiz! A postoperative patient is breathing very rapidly (respiratory rate of 36 breaths per minute). What should the nurse immediately do next? A. Call the prescribing health care provider. B. Count the respirations again. C. Administer oxygen. D. Ask the patient if he or she feels uncomfortable. & E. Measure the 02 sat. 33  normal : 95% -100% Pulse Oxymetry O2 saturation Why is it necessary? How does it work? Assessment sites Normal values Interventions when < 90% ignore heart rate on monitor 34  Blood Pressure (BP) ↳ veins Force exerted on the walls of an artery Standard unit for measuring: millimetres of mercury (mm Hg) – Recorded as systolic reading over diastolic reading example 120/70 ↑ ↑ – Systolic = contraction of the ventricles – Diastolic = resting phase of ventricles Canadian target value for Adults = 130/80* Or less 35 rest contraction s 36 Physiology of Arterial Blood Pressure Cardiac output Peripheral resistance Blood volume 4) L to 6L Viscosity thickness > - Elasticity 37  systolic Diastolic 38 Factors Influencing Blood Pressure Age Stress ⑦ BP Ethnicity African = MBP Gender men = BP Daily variation ↓ BP-morningBP evening - Medications Activity① NBP = Weight usually Digger = BPM Smoking BPM 39  * a caffine and before 30 min smoking Measuring Blood Pressure  Ensure correct size cuff and accurate technique - > the side should cover 40%  Common mistakes in BP assessment * talking = BP  Most common site = upper arm (brachial artery) * cross leg &BP =  Lower leg (popliteal artery) can be used if brachial access is unavailable  White coat syndrome  Home self-measurement 40  Quick Quiz! When assessing the BP of a very thin person, using a normal-sized adult cuff will affect the reading and produce ________ value. A. an Accurate B. an indistinct G C. a falsely low D. A falsely high 41  Quick Quiz! The fifth Korotkoff sound indicates a. the Systolic pressure reading ⑧ b. the Diastolic pressure reading c. An error in BP measurement d. The BP cuff is fully deflated 42  test #2 Pain assessment (a vital sign?) P- Q- R- S- T- U- 43 Documenting Vital Signs Record vital signs immediately after the assessment* Relay any changes to health care provider Record any accompanying or precipitating symptoms. Document interventions. 44 Example of a Vital Signs Flow sheet (electronic chart) 45 Example of a Vital Signs Flow chart (paper copy) 46