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Vital Signs

Vital Signs. Guidelines for Measuring Vital Signs. Establish a baseline for future assessments. Be able to understand and interpret values. Appropriately delegate measurement. Communicate findings. Ensure equipment is in working order. Accurately document findings. Circulatory Needs.

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Vital Signs

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  1. Vital Signs

  2. Guidelines for Measuring Vital Signs • Establish a baseline for future assessments. • Be able to understand and interpret values. • Appropriately delegate measurement. • Communicate findings. • Ensure equipment is in working order. • Accurately document findings.

  3. Circulatory Needs • Circulation is monitored through assessment of Vital Signs along with other collected data. • The patient’s physiological status is reflected by their vital signs.

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

  5. CNS Regulates VS • 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)

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

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

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

  9. Guidelines for Assessing VS • Systematic • Normal Range • Baseline • Recheck • Client Norm • Treatments • Monitor prn

  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??? • URINE • FECES • RESPIRATIONS

  16. Fever

  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 • CONSTANT • Fluctuates but does not come down to normal • REMITTANT • Returns to normal for a day or two, but then goes up again • RELAPSING • Alternates between normal and fever • INTERMITTANT

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

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

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

  22. 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

  23. Axillary Temperature • Preferred for children under 6 yrs. routinely used on infants. • Place in center of axilla against artery off the subclavian.

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

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

  26. ??? Nursing Diagnoses ??? • HYPERTHERMIA • HYPOTHERMIA • RISK FOR IMBALANCED BODY TEMPERATURE

  27. Nursing Interventions Temperature • 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

  28. Nursing Interventions Temperature • Check VS frequently • Assess skin • Note change in LOC • Seizure precautions ? • Monitor I & O • REDUCE COVERINGS

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

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

  31. 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-----------------------------

  32. Pulse-Physiology • SA node- creates electrical impulses causing contraction of atria. • 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

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

  34. Cardiac Output CO=SV x HR • 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.

  35. ?? CARDIAC OUTPUT ??CV (5000) = SV(70) X HR • In the above equation, what would the client’s heart rate be? • APPROXIMATELY 71 BPM • 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? • IT WOULD RAISE TO 100 BPM • 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? • IT WOULD DECREASE TO 50 BPM

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

  37. 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+

  38. 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

  39. ??? NURSING DIAGNOSES • Decreased cardiac output • Ineffective tissue perfusion • Activity intolerance

  40. Nursing Interventions-Pulse • Monitor for symmetry • Note pulse deficit • Promote circulation – i.e. massage

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

  42. 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

  43. Terminology • 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

  44. Pulse Documentation • 23/11/2010 1:20am : palpitations. P-96 reg 3+. • No pulse deficit.------------------- S.Niggemeier RN

  45. 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

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

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

  48. 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

  49. ??Other signs of dyspnea?? • ANXIOUS LOOK • FLARED NOSTRILS • USE OF ACCESSORY MUSCLES • INTERCOSTAL RETRACTIONS

  50. Neurological state • Hypoxia results in neurological changes • alert • becomes anxious • then irritable • progresses to drowsiness • eventually a coma

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