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Vital SignsMeasurements of
physiologic functioning, specifically body
temperature, pulse, respirations, and blood
pressure; may include pain and pulse oximetry
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When to Assess Vital SignsOn admissionChange in client’s health statusClient reports symptoms such as chest
pain, feeling hot, or faintPre and post surgery/invasive
procedurePre and post medication administration
that could affect CV systemPre and post nursing intervention that
could affect vital signs
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Body Temperature
Two kinds of body temperature Core temperature – temperature on deep
tissue on the body, such as abdominal cavity an pelvic cavity
Surface temperature – temperature of the skin, subcutaneous tissue and fat; rises and falls in response to the environment
Thermoregulation center Hypothalamus
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Alterations in body temperature Pyrexia, hyperthermia, Fever (in lay terms)
○ a body temperature above the usual range○ A client who has fever is referred to as febrile,
the one who has not is afebrile. Hyperpyrexia
○ A very high fever such as 41 oC (105.8 OF)
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Four Common types of feverIntermittent – alternates at regular interval – periods
of fever and periods of normal (malaria) Remittent – a wide range of temperature fluctuations
occurs over 24 hour period (colds, influenza) Relapsing – short febrile episodes of few days,
interspersed – 1 to 2 days of normal temp. Constant - fluctuates minimally; always remain in
above normal (typhoid fever)
○ Fever spike – temp. rises to fever rapidly following a normal temp and then returns to normal within few hours.
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Temperature: Lifespan ConsiderationsInfants Unstable
Newborns must be kept warm to prevent hypothermia
Children Tympanic or temporal artery sites preferred
Elders Tends to be lower than that of middle-aged adults
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Sites for Measuring Body Temperature
Oral Rectal Axillary Tympanic membrane Skin/Temporal artery
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Types of Thermometers
Electronic Chemical disposable Infrared (tympanic) Scanning infrared (temporal artery) Temperature-sensitive tape Glass mercury
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Nursing Care for Fever
Monitor vital signs Assess skin color
and temperature Monitor laboratory
results for signs of dehydration or infection
Remove excess blankets when the client feels warm
Provide adequate nutrition and fluid
Measure intake and output
Reduce physical activity
Administer antipyretic as ordered
Provide oral hygiene Provide a tepid
sponge bath Provide dry clothing
and bed linens
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Nursing Care for Hypothermia Provide warm environment Provide dry clothing Apply warm blankets Keep limbs close to body Cover the client’s scalp Supply warm oral or intravenous fluids Apply warming pads
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Pulse Sites
Radial Readily accessible
Temporal When radial pulse is not accessible
Carotid During cardiac arrest/shock in adultsDetermine circulation to the brain
Apical Infants and children up to 3 years of ageDiscrepancies with radial pulseMonitor some medications
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Pulse Sites
Brachial Blood pressureCardiac arrest in infants
Femoral Cardiac arrest/shockCirculation to a leg;
Popliteal Circulation to lower leg
Posterior tibial
Circulation to the foot
Dorsalis pedis
Circulation to the foot
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Factors Affecting Pulse Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology
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Pulse: LifespanConsiderations
Infants Newborns may have heart murmurs that are not pathological
Children The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old and older
Elders Often have decreased peripheral circulation
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Characteristics of the Pulse Rate Rhythm Volume Arterial wall elasticity Bilateral equality
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Pulse Rate and Rhythm Rate
Beats per minuteTachycardiaBradycardia
RhythmEquality of beats and
intervals between beats
DysrhythmiasArrhythmia
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Characteristics of the Pulse Volume
Strength or amplitudeAbsent to bounding
Arterial wall elasticityExpansibility or deformity
Presence or absence of bilateral equality Compare corresponding artery
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Measuring Apical Pulse
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Apical-Radial Pulse Locate apical and radial sites Two nurse method:
Decide on starting timeNurse counting radial says “start”Both count for 60 seconds Nurse counting radial says “stop”Radial can never be greater than apical
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Inhalation Diaphragm contracts
(flattens) Ribs move upward
and outward Sternum moves
outward Enlarging the size of
the thorax
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Exhalation Diaphragm relaxes Ribs move downward
and inward Sternum moves
inward Decreasing the size
of the thorax
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Respirations:Lifespan Considerations
Infants Some newborns display “periodic breathing”
Children Diaphragmatic breathers
Elders Anatomic and physiologic changes cause respiratory system to be less efficient
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Respiratory Control Mechanisms
Respiratory centersMedulla oblongataPons
ChemoreceptorsMedullaCarotid and aortic bodies
Both respond to O2, CO2, H+ in arterial blood
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Components of Respiratory Assessment Rate Depth Rhythm Quality Effectiveness
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Respiratory Rate and Depth
RateBreaths per minuteEupneaBradypneaTachypnea
DepthNormalDeepShallow
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Components of Respiratory Assessment Rhythm
Regular Irregular
Quality Effort Sounds
Effectiveness Uptake and transport of
O2
Transport and elimination of CO2
CO2 Major Chemical Stimuli for respirations
Hypoxemia or Hypoxia Hyperventilation Hypoventilation
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Systolic and Diastolic Blood Pressure Systolic
Contraction of the ventricles
Diastolic Ventricles are at restLower pressure
present at all times Pulse Pressure =
difference between systolic and diastolic pressures
Measured in mm Hg Recorded as a
fraction, e.g. 120/80 Systolic = 120 and
Diastolic = 80
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Blood Pressure:Lifespan Considerations
Infants Arm and thigh pressures are equivalent under 1 year of age
Children Thigh pressure is 10 mm Hg higher than arm
Elders Client’s medication may affect how pressure is taken
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Korotkoff’s Sounds
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Korotkoff’s Sounds
Phase 1First faint, clear tapping or thumping soundsSystolic pressure
Phase 2Muffled, whooshing, or swishing sound
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Korotkoff’s Sounds Phase 3
Blood flows freely Crisper and more intense soundThumping quality but softer than in phase 1
Phase 4Muffled and have a soft, blowing sound
Phase 5Pressure level when the last sound is heardPeriod of silence Diastolic pressure
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Measuring Blood Pressure
Direct (Invasive Monitoring) Indirect
Auscultatory Palpatory
SitesUpper arm (brachial artery)Thigh (popliteal artery)
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Pulse Oximetry
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Pulse Oximetry Noninvasive Estimates arterial blood oxygen
saturation (SpO2) Normal SpO2 85-100%; < 70% life
threatening Detects hypoxemia before clinical signs
and symptoms Sensor, photodetector, pulse oximeter
unit
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Pulse Oximetry
Factors that affect accuracy include:Hemoglobin levelCirculationActivityCarbon monoxide poisoning
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Pulse Oximetry
See Skill 29-7 Prepare site Align LED and photodetector Connect and set alarms Ensure client safety Ensure accuracy
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Delegation of Measurement of Vital Signs General considerations prior to
delegationNurse assesses to determine stability of
clientMeasurement is considered to be routineInterpretation rests with the nurse
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Documentation of Plan of Care/Reporting Documenting
A process of making entry on a client record; also know as recording, or charting.
Clinical record, also called a chart or client record, is a formal, legal documents that provides evidence of a client’s care.
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Ethical and Legal Considerations The nurse has a duty to maintain
confidentiality of all patient information (American N urses Association Code of Ethics 2001)
Clients record if protected legally as private record of the clients care
Access to the record is restricted to health professionals involved in giving care to the client.
The institution, agency, or hospital is the rightful owner of the clients record.
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Purposes of client Records Purpose is for education and research Students and graduate health
professionals are allowed to access to the clients record.
The records are used in client conferences, clinics, rounds, clients studies, and written papers.
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Purposes : Communication – serves as the vehicle Planning Client Care – baseline and ongoing data to
evaluate the effectiveness of the NCP.Auditing Health Agencies – review of client records for quality assurance Research – information contained in record can be a
valuable source of data for research. Education – provide comprehensive view of the client,
illness, effective treatment strategies. Reimbursement – to facilitates payment from the
federal government and other insurance companies. Legal Documentation – admissible in court as evidence;
order from the court – “ Subpoena Ducestecum ” Health Care Analysis – health care planners to identify
agencies needs.
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Documentation System
Source-Oriented Record – traditional client record – different department or persons makes notations in a separate sections – narrative charting.
Problem Oriented Medical Record (POMR) – data arranged according to problems Four basic components – database,
problem list, plan of care, progress notes.
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Source-oriented Records
Traditional client record Each discipline makes notations in a
separate section Information about a particular problem
distributed throughout the record Narrative charting used
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Problem-oriented Medical Records (POMR)
Data arranged according to client problem Health team contributes to the problem list,
plan of care, and progress notes for each problem
Uses SOAP, SOAPIE, SOAPIER documentation
Encourages collaboration Easier to track status of problems Vigilance required to maintain problem list Less efficient documentation process
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PIE Documentation
Groups information into three categories: Problem, Interventions, Evaluation
Consists of client assessment, flow sheet, and progress notes
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Focus Charting
Focus on client concerns and strengths Progress notes organized into DAR
format Holistic perspective of client and client’s
needs Nursing process framework for the
progress notes
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Charting by Exception (CBE) Incorporates flow sheets, standards of
nursing care, bedside chart forms Agencies develop standards of nursing
practice Documentation according to standards
involves a check mark Exceptions to standards described in
narrative form on nurses’ notes
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Sample Vital Signs Graphic Record
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Computerized Documentation
Developed to manage volume of information
Use of computers to store the client’s database, new data, create and revise care plans and document client’s progress
Information easily retrieved Possible to transmit information from
one care setting to another
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Computerized Charting
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Legal and Ethical Standards for Documentation Client’s record is a legal document May be used to provide evidence in
court
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Factors to Consider
Timing Legibility Permanence Accepted
terminology Correct spelling Signature
Accuracy Sequence Appropriateness Completeness Conciseness Legal prudence
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Guidelines for Reporting Client Data Should be concise, including pertinent
information but no extraneous detail Types of reporting:
Change-of-shift reportTelephone reportsCare plan conferenceNursing rounds
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Guidelines for Change-of-Shift Report Follow a particular order Provide basic identifying information For new clients provide the reason for
admission or medical diagnosis/es, surgery, diagnostic tests and therapies in the past 24 hours
Significant changes in client’s condition
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Guidelines for Change-of-Shift Report Provide exact information Report client’s need for emotional support Include current nurse and physical-prescribed
orders Provide a summary of newly admitted clients,
including diagnosis, age, general condition, plan of therapy, and significant information about the client’s support people
Report on clients who have been transferred or discharged
Clearly state priorities of care and care due after the shift begins
Be concise
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Guidelines for Receiving a Telephone Report Document date and time Record the name of person giving the
information Record the subject of the information
received Repeat information to ensure accuracy Sign the notation
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Guidelines for Giving a Telephone Report Be concise and accurate State name and relationship to client State the client’s name, medical diagnosis,
changes in nursing assessment, vital signs related to baseline, significant laboratory data, related nursing interventions
Have chart ready to give any further information needed
Document the date, time, and content of the call
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Guideline for Receiving Telephone and Verbal Orders Know the state nursing board’s position
on who can give and accept Know the agency policy Ask prescriber to speak slowly and
clearly Ask prescriber to spell out the
medication if unfamiliar Question the drug, dosage, or changes
if seem inappropriate
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Guideline for Receiving Telephone and Verbal Orders Write the order down or enter into a
computer Read the order back to the prescriber Use words instead of abbreviations Write the order on the physician’s order
sheet, record date, time, indicate it was a telephone order, and sign name with credentials
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Guideline for Receiving Telephone and Verbal Orders When writing a dosage always put a
number before a decimal, but never after a decimal
Write out units Transcribe the order Follow agency protocol about signing
the telephone order Never follow a voice-mail order
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Prohibited Abbreviations, Acronyms, and Symbols JCAHO National Patient Safety Goals
(2004) “Do Not Use” list Many banned abbreviations refer to
medications Others derived from Latin
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Health and Illness Health – presence or absence of
diseases“A state of complete physical, mental and
social well-being, and not merely the absent of disease or infirmity. (WHO 1948)
Wellness – a state of well-being. The whole being of the individual
Illness – highly personal state in which persons holistic views of functioning is thought to be diminished
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Dimensions of Wellness Variables influencing health status
Health status Health beliefsHealth behaviors/practices
Internal Variables – non-modifiable variables Biologic dimension – genetic, gender, agePsychological dimension (emotional) – mind-body
interactions and self conceptCognitive dimensions – intellectual factors, lifestyle choices
and spiritual and religious belief. External Variables – modifiable, variables affecting
Environment, standards of living, family and cultural beliefs and social support network.
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Dimensions of Wellness
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Physical Dimension
Ability to carry out daily tasks Achieve fitness
Maintain nutrition Avoid abuses
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Social Dimension
Interact successfully Develop and maintain intimacy
Develop respect and tolerance for others
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Emotional Dimension
Ability to manage stress Ability to express emotion
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Intellectual Dimension
Ability to learn Ability to use information effectively
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Spiritual Dimension
Belief in some force that serves to unite
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Occupational Dimension
Ability to achieve balance between work and leisure
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Environmental Dimension
Ability to promote health measure that improvesStandard of livingQuality of life
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Health – Illness Continua
Grids or graduated scales – used to measure persons perceived level of wellnessDunn’s High Level wellness (environmental
axis)
Travi’s Illness-Wellness Continuum
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Health-Illness Continuum Measure person’s perceived level of wellness Health and illness/disease opposite ends of a health
continuum Move back and forth within this continuum day by day Wide ranges of health or illness
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Three levels of Prevention Prevention – avoiding the development of
diseases in the future.
Primary Prevention Health promotionProtection against specific health problems Purpose is to decrease the risk or exposure of
individual or community to disease. ○ Example of primary prevention
Stop smoking, avoid prolong exposure to the sunSupport antipollution legislationPractice safe sex, monogamy, or abstinence
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Secondary preventions Early identifications of health problems Prompt intervention o alleviate health
problems Goal is to identify client in an early stage of
disease process and limiting future disabilityExamples:
○ Undergo screening for tuberculosis ○ Have yearly, papinicolaou smears and
mammograms per recommended guidelines . ○ Practice monthly SBE & STE
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Tertiary level of prevention Focuses on restoration and rehabilitation Returning the individual to an optimal level
of functioning. Examples:
○ Have a speech therapy after stroke○ Have a complete blood count before
chemotherapy○ Participate in stroke or coma rehabilitation ○ Substance abuse or drug addict rehabilitation
center.
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Levels of Care
Health Promotion Behavior motivated by the desire to increase
well being and actualize human health potential (Pender, Murdaugh, Parsons; 2006)
Not disease orientedSeeks to expand positive potential for health
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Disease Prevention Also known as Health protection Illness of injury specific Motivated by avoidance of illnessSeeks to thwart the occurrence of insults to health and
well being
Health Maintenance Maintaining the current healthy status
Curative cures diseases or condition
Rehabilitative Assisting clients to restore their health and recuperate
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Health Promotion Model (HPM)
Link to HPM Figure 16-4 pg. 279 Competence or approach-oriented
model Motivational source for behavior
changes based on individual’s subjective value of the change
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Variables of HPM Individual characteristics and experiences
Prior related behaviorsPersonal factors
Behavior-specific cognitions and affectPerceived benefits of actionPerceived barriers to actionPerceived self-efficacyActivity-related affectInterpersonal factorsSituational influences
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Variables of HPM
Commitment to a plan of action Immediate competing demands and
preferences Behavioral outcome
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