NURSING NURSING INTERVENTIONSINTERVENTIONS

VITAL SIGN VITAL SIGN MEASUREMENMEASUREMEN

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SJ/LAC FFP YEAR ONE - VITAL SIGNS 2

VITAL SIGNSVITAL SIGNS

Vital signs are indicators of theVital signs are indicators of the

body's:body's: Physiological status Physiological status Response to Physical stressorsResponse to Physical stressorsEnvironmental stressorsEnvironmental stressorsPsychological stressorsPsychological stressors

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VITAL SIGNSVITAL SIGNS

Temperature, Pulse Blood Pressure & Temperature, Pulse Blood Pressure & respiration rate can REVEAL the respiration rate can REVEAL the patients ability to:patients ability to:

Maintain body temperature regulationMaintain body temperature regulation Maintain local & systemic blood flowMaintain local & systemic blood flow Maintain oxygenation of the tissuesMaintain oxygenation of the tissues

SJ/LAC FFP YEAR ONE - VITAL SIGNS 4

VITAL SIGNSVITAL SIGNSAny difference between a clientsAny difference between a clientsNORMAL EXPECTEDNORMAL EXPECTED baseline baselinemeasurement and the ACTUALmeasurement and the ACTUALPRESENTPRESENT vital sign is an indication for vital sign is an indication forthe nurse to the nurse to PURSUE APPROPRIATEPURSUE APPROPRIATEnecessary care and necessary care and INITIATEINITIATE nursingnursingaction/therapies.action/therapies.

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VITAL SIGNSVITAL SIGNSTemperature & RespirationTemperature & Respiration

Vital sign changes may reveal sudden Vital sign changes may reveal sudden changes as well as progressive changeschanges as well as progressive changes

raised temperature may indicate an raised temperature may indicate an infection; infection;

raised pulse - ?bleeding;raised pulse - ?bleeding; lowered blood pressure - ?bleedinglowered blood pressure - ?bleeding

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CCONSIDERATIONS OF VITAL SIGN ONSIDERATIONS OF VITAL SIGN MEASUREMENTMEASUREMENT

From a nursing viewpointFrom a nursing viewpoint Measurement provides information used to determine a Measurement provides information used to determine a

patient / clients baseline data & response to medical ./ patient / clients baseline data & response to medical ./ nursing therapynursing therapy

Vital sign recording is a quick, efficient way of monitoring Vital sign recording is a quick, efficient way of monitoring a condition or identifying problems. Can be used as a basis a condition or identifying problems. Can be used as a basis for clinical problem solvingfor clinical problem solving

Vital sign measurement is incorporated into Practice for Vital sign measurement is incorporated into Practice for assessment & determining the need for intervention(s), assessment & determining the need for intervention(s), Viewed as routine care measuresViewed as routine care measures

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TEMPERATURETEMPERATURE

In health, tissues & cells function best within a In health, tissues & cells function best within a relatively narrow range of temperature - relatively narrow range of temperature - controlled by the hypothalamus.controlled by the hypothalamus.

Body CoreBody Core temperature is maintained within + or - temperature is maintained within + or - 0.6 of a degree Celsius / centigrade0.6 of a degree Celsius / centigrade..

Surface body temperatureSurface body temperature fluctuates according to fluctuates according to environmental changes.environmental changes.

Skin temperatureSkin temperature can range between 20can range between 20oo - 40 - 40ooC C without causing tissue damage.without causing tissue damage.

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TEMPERATURETEMPERATURE

Temperature range is balanced & regulated to allow for changes that Temperature range is balanced & regulated to allow for changes that result from Exercise, Activity and Rest.result from Exercise, Activity and Rest.

Temperature regulatory mechanisms include: Vasodilatation, Temperature regulatory mechanisms include: Vasodilatation, Vasoconstriction, Sweating & avoiding environmental extremes Vasoconstriction, Sweating & avoiding environmental extremes hot/cold.hot/cold.

For body temperature to stay constant For body temperature to stay constant HEAT PRODUCED must equal HEAT PRODUCED must equal HEAT LOSTHEAT LOST to the environment. to the environment.

When internal control mechanisms fail the nurse may initiate measures When internal control mechanisms fail the nurse may initiate measures to to CONTROL the immediate environmentsCONTROL the immediate environments REMOVE or ADD coveringsREMOVE or ADD coverings GIVE MEDICATIONS - antipyreticsGIVE MEDICATIONS - antipyretics

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Monitoring temperaturesMonitoring temperatures

Types of thermometersTypes of thermometers

Glass with a mercury column; Glass with a mercury column;

Electronic; Electronic;

Disposable; Disposable;

Tympanic ThermometryTympanic Thermometry..

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Factors influencing / Factors influencing / affecting temperatureaffecting temperature

General General -- age; exercise; hormones; stress; environment;age; exercise; hormones; stress; environment;medications; daily fluctuation / time / gendermedications; daily fluctuation / time / gender

SpecificSpecific - - diagnosed infections; burns / open wounds; diagnosed infections; burns / open wounds; Low white cell count <5,000; High WBC > 12,000; Low white cell count <5,000; High WBC > 12,000; immunosuppresive drug therapy; post operative state; immunosuppresive drug therapy; post operative state; hyperthermic therapy; hypothermic therapy; hyperthermic therapy; hypothermic therapy; injury to the hypothalamus; infusion of blood productsinjury to the hypothalamus; infusion of blood products

Nurses asses for Fever or HypothermiaNurses asses for Fever or Hypothermia

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Show Video on Genius Show Video on Genius thermometersthermometers

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RESPIRATIONSRESPIRATIONS

Human survival depends on the ability for Human survival depends on the ability for Oxygen to reach the body cells and Carbon Oxygen to reach the body cells and Carbon Dioxide to be removed from the cells.Dioxide to be removed from the cells.

Factors affecting character of respirationsFactors affecting character of respirations - -Exercise; acute pain; anxiety; smoking;Exercise; acute pain; anxiety; smoking;anaemia; body position; medications; brainanaemia; body position; medications; brainstem injury.stem injury.

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ASSESSMENT OF RESPIRATIONSASSESSMENT OF RESPIRATIONS

Easiest of all vital signs to measure but most often Easiest of all vital signs to measure but most often haphazardly recorded. haphazardly recorded.

NEVER estimate a respiratory rateNEVER estimate a respiratory rate Accurate measurement of the chest wall rising and Accurate measurement of the chest wall rising and

falling is required. falling is required. Any change may be importantAny change may be important Respiration is tied to the function of numerous Respiration is tied to the function of numerous

body systems, therefore the nurse must consider body systems, therefore the nurse must consider all variables when change occurs.all variables when change occurs.

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MEASUREMENTMEASUREMENT

RATERATE - determined by a full inspiration and - determined by a full inspiration and expiration, will vary with ageexpiration, will vary with age

DEPTHDEPTH - - assessed by observing the degree of assessed by observing the degree of movement in the chest wall and is usually movement in the chest wall and is usually considered to be deep, normal or shallow.considered to be deep, normal or shallow.

RHYTHMRHYTHM - regular occurrence of respiration will - regular occurrence of respiration will depict a normal range. During assessment the depict a normal range. During assessment the nurse estimates the time interval; after each nurse estimates the time interval; after each respiration cycle. Respiration is then either regular respiration cycle. Respiration is then either regular or irregular in rhythmor irregular in rhythm

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ALTERATIONS IN BREATHING ALTERATIONS IN BREATHING PATTERNPATTERN

Bradypnoea rate regular, but abnormally slow < 12 b/min

Tachypnoea rate regular, but abnormally fast > 20 b/min Hyperpnoea laboured respirations, increased depth, increased

rate > 20 breaths / minute Hyperventilation rate & depth increased Hypoventilation rate & depth abnormally low Cheyne-Stokerate & depth irregular, alternating periods

of apnoea and hyperventilation Kussmaul resp. abnormally deep, regular but increased in

rate Biots resp. abnormally shallow for 2-3 breaths,

followed by irregular periods of apnoea

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WHEN TO RECORD VITAL WHEN TO RECORD VITAL SIGNSSIGNS

On clients admission to a health care facilityOn clients admission to a health care facility In hospital, on routine or schedule according to In hospital, on routine or schedule according to

physicians order or hospital policyphysicians order or hospital policy During clients visit to clinic or physicians officeDuring clients visit to clinic or physicians office Before & after any surgical procedureBefore & after any surgical procedure Before & after any invasive diagnostic procedureBefore & after any invasive diagnostic procedure Before & after administration of medications that Before & after administration of medications that

affect cardiovascular, respiratory & temperature affect cardiovascular, respiratory & temperature control functioncontrol function

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WHEN TO RECORD VITAL WHEN TO RECORD VITAL SIGNSSIGNS

When the clients general physical condition changes - When the clients general physical condition changes - e.g. loss of consciousness or increased intensity of pain e.g. loss of consciousness or increased intensity of pain

Before & after nursing interventions influencing any Before & after nursing interventions influencing any one of the vital signs - one of the vital signs - e.g. before ambulating client previously on e.g. before ambulating client previously on bed rest or bed rest or before client performs range of before client performs range of movement exercisesmovement exercises

Whenever client reports to nurse any non- specific Whenever client reports to nurse any non- specific symptoms of physical distress - symptoms of physical distress - e.g. "feeling funny or different" e.g. "feeling funny or different"

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Patient at risk score.Patient at risk score.

PARPAR Research completed in Swansea Research completed in Swansea

NHS trust.NHS trust. Reduced observation of Reduced observation of

Respiratory recording.Respiratory recording. Aim = Early indications of Aim = Early indications of

deteriation.deteriation.

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References:References: Potter,A. Perry,A. (1997) Fundamentals of Fundamentals of

Nursing, Concepts, Process & PracticeNursing, Concepts, Process & Practice St Louis: Mosby Ch 32 p 594

Taylor,C. Lillis,C. LeMonde,P. (1997) Fundamentals of Nursing - The Art & Fundamentals of Nursing - The Art & Science of Nursing Care.Science of Nursing Care. Philadelphia: Lippincott Ch25 p432