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Stressors that Affect Circulation

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  1. Stressors that Affect Circulation NUR101 LECTURE # 9 FALL 2010 K. BURGER, MSEd, MSN, RN, CNE PPP by Sharon Niggemeier RN BSN MSN

  2. Circulatory Needs • Blood circulation affects all aspects of well being. • Circulation is monitored through assessment of Vital Signs along with other collected data. • The patient’s physiological status is reflected by their vital signs.

  3. VitalSigns • Signs of Vitality and Life • Deviations from normal ranges can indicate chg in health status. • TPR & BP = VS • T-temperature • P-pulse • R-respirations • BP- blood pressure • VS-vital signs

  4. Hypothalamus: Controls temperature Anterior Hypothalamus -Dissipation of heat Posterior Hypothalamus-conservation of heat Medulla: Vasomotor center controls BP through vasoconstriction or vasodilation Cardiac center controls pulse Respiratory center controls respirations(rate and depth) CNS Regulates VS

  5. R = 1/4 P R 20 = P 80 P = diastolic BP P 80 = 120/80 T increases = an increase in P R and BP Relationship Between VS

  6. Factors Influencing VS • Age • Gender • Race • Diet • Weight • Heredity • Medications • Activity

  7. More Factors Influencing VS • Pain • Hormones • Stress • Emotions • Circadian Rhythms

  8. Systematic Normal Range Baseline Recheck Client Norm Dx Treatments Monitor prn Guidelines for Assessing VS

  9. Temperature Regulation • Thermal Balance • Heat Production • Heat Loss • Core vs Surface

  10. Heat Production • By product of metabolism • B.M.R.- Basal Metabolic Rate • Muscle activity • Exposure to increased temperature • Hormones: Thyroxine, Epinephrine

  11. Heat Loss (Transfer) • Conduction - direct transfer of heat by contact

  12. Heat Loss-Convection • Heat dissemination via motion. A fan blows warm air across a warm body.

  13. Heat Loss-Radiation • Heat given off by rays from the body. Heat loss from an uncovered head. • Main form of heat loss.

  14. Heat Loss-Evaporation • Conversion of a liquid to a vapor. Perspiration vaporizes from the skin. • Diaphoresis

  15. ????What are some other ways heat is lost from body???

  16. Fever • Pyrexia100.4 – 104.0 F • HyperpyrexiaAbove 104.0 F

  17. Fever Patterns • Intermittent • Remittent • Constant • Relapsing

  18. ?? Fever Terminology ??Which term can be used to describe a fever that: • Is constantly elevated with little fluctuation • Fluctuates but does not come down to normal • Returns to normal for a day or two, but then goes up again • Alternates between normal and fever

  19. Resolutions of Pyrexia • Crisis- sudden return to normal body temp. • Lysis- gradual return to normal body temp.

  20. S/S of Fever • Loss of appetite Delirium • Headache Seizures • Dehydration Thirst • Flushed face ????? • Rapid pulse • Decreased urinary output(OLIGURIA)

  21. Temperature ranges • Oral- 96.8 – 100.4 F • 98.6 = average norm • Axillary- approximately 1 degree lower • Rectal- approximately 1 degree higher

  22. Fever • Onset- (Chill) • Course ( Flush) • Abatement (fever subsides)

  23. Assessing Temperature • Glass • Electronic • Tympanic • Tape/Patch • Disposable (ie: Clinidot)

  24. Oral Temperature • Most common site • Place against sublingual artery • Contraindicated in oral surgery/infection • Wait 15 min. if pt. ate/drank or smoked • Electronic- blue probe

  25. Axillary Temperature • Preferred for children under 6 yrs. routinely used on infants. • Place in center of axilla against artery off the subclavian. • Blue probe -electronic thermometer • Document 102.4 A

  26. Rectal Temperature • Last resort for assessing temperature • Place against inferior rectal artery • Contraindicated rectal surgery/cardiac pt. • Lubricate thermometers • REMEMBER PPE

  27. (Continued) Rectal Temperature • Electronic thermometers: • Red Probe only • Insert : ½ - 1 inch adult ¼ - 1/2 inch child • Left position is best • Document 102.8 R

  28. Electronic Thermometers • Check for baseline number- specific number after being turned on. • Error indicators- low battery • # completeness- digital display clearly shows entire numbers • If probe cover breaks- discard, check pt.mouth/axilla/rectum for broken pieces. • Do not use bent probes.

  29. ??? Nursing Diagnoses ???

  30. Check VS frequently Assess skin Note change in LOC Seizure precautions ? Monitor I & O REDUCE COVERINGS Encourage fluids Tepid baths Administer antipyretics Promote comfort & REST Hypothermia blanket Nursing Interventions Temperature

  31. Heat Stroke • Hot, dry skin • Dizziness • Abdominal pain • Delirium • Eventual LOC

  32. Hypothermia • Mild (93.2 – 96.8 F) • Moderate (86.0-93.2 F) • Severe ( below 86.0 F)

  33. Evaluations-Temperature • Is patient afebrile? • Are interventions working? i.e cool compresses, tepid bath, antipyretics? • S/S of infection present?

  34. Nurse’s Notes 5/31/02 4:15pm Reports headache, feeling “on fire”, face flushed, skin warm, T-104.6 A P-100 R- 20 BP- 150/80. Dr. Arrid notified. Tylenol 650mg po administered as per telephone order. Fluids encouraged, tepid bath given. S.Niggemeier RN----------------------------- 4:45pm T-102.2 A P- 88 R-18 BP 130/78 taking fluids, feels “better than before”. S.Niggemeier RN-----------------------------

  35. Pulse-Physiology • SA node- creates electrical impulses causing contraction of Left ventricle. • A wave of blood is pumped into the arteries. • Throbbing sensation is felt - Pulse • Pulse rate should = the heart rate • Pulse rate is the number of pulsations felt in a minute. • Pulse usually = diastolic pressure

  36. Pulse Rates • Newborn 120-150 • Infant 80-140 • Child 75-110 • Adult 60-100 • Pulse rates ????? as age increases

  37. Cardiac output (CO) is the amount of blood pumped/min by the heart and = approximately 5000ml or 5L/min Stroke Volume (SV) is the amount of blood ejectedfrom the L ventricle with each contraction. Heart rate (HR) is the number of times the heart contracts. Inversely related- when SV goes up the HR goes down. Cardiac Output CO=SV x HR

  38. ?? CARDIAC OUTPUT ??CV (5000) = SV(70) X HR • In the above equation, what would the client’s heart rate be? • If a client had a weak heart (ie:CHF) that was only able to eject a SV of 50, what would happen to the client’s HR? • If a client had a well-conditioned heart muscle (ie: athlete) that was able to eject a SV of 100, what would their HR be?

  39. Pulse Sites • Temporal • Carotid • Apical • Brachial • Radial • Femoral • Popliteal • Dorsalis Pedis • Posterior Tibia

  40. Pulse assessment • Rate -number of beats /min • Rhythm- pattern of the rate. Regular or Irregular. Count irregular rhythm for 1 min. • Quality- strength of the pulse 0-4+

  41. Pulse - Quality Scale • 4+ bounding very strong, does not disappear with moderate pressure • 3+ normal, easily felt, • 2+ weak, light pressure causes it to disappear • 1+ thready, not easily felt, disappears with slight pressure • 0- no pulse

  42. ??? NURSING DIAGNOSES

  43. Nursing Interventions-Pulse • Monitor for symmetry • Note pulse deficit • Promote circulation – i.e. massage, TEDS, • Teaching – i.e don’t cross legs

  44. Evaluations • Is pulse with normal range? • All pulses present • Equally Bilateral? • Are interventions to promote circulation working? i.e. massage, TEDS etc.

  45. Terminology • Bradycardia- HR below 60/min • Tachycardia- HR above 100/min • Sinus Arrhythmia- HR increases on inspiration and decreases on exhalation common in children and young adults • Dysrhythmia- abnormal rhythm • Palpitation-aware of your HR without feeling for it…usually rapid • Pulse deficit- difference between apical and radial pulses Apical-100 Radial-80 then the Pulse deficit is 20

  46. Pulse Documentation • 5/23/02 1:20am c/o palpitations. P-96 reg 3+. No pulse deficit.------------------- S.Niggemeier RN

  47. Respirations Physiology Process whereby CO2 and O2 are exchanged in the tissues. • Oxygenation of the body • CO2 is the stimulus for breathing • Inspiration - breathing inDiaphragm contracts – pulls down • Expiration- breathing outDiaphragm relaxes – moves up • Normal Tidal Volume = 500 ml

  48. Respiration Rates • Newborn 40-60/min • Child 20-30 • School age 18-26 • Adult 16-20 • Respirations decrease as age increases

  49. Assessing Respiratory Status • Oxygenation status • Neurological state • Musculoskeletal status

  50. Oxygenation status • Note S/S of hypoxia (oxygen deprivation • Cyanosis - bluish tinge caused by decrease in O2 in RBC. • Cyanosis is assessed by checking the mucous membranes of the conjunctiva (lower eyelids), under the tongue and inside the mouth..should be pink not pale or bluish