vital signs professor blakey nur302. vital signs temperature pulse respirations blood pressure...
TRANSCRIPT
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VITAL SIGNS
Professor Blakey
NUR302
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Vital Signs• Temperature • Pulse • Respirations• Blood Pressure• Health Status• Changes• Accuracy, Responsibility
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Vital Signs
• When are they reported?
• When are they recorded?
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Temperature
Sites:
Oral-
Taken routinely
Taken per MD order
Taken when fever is suspected
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Oral Temperature
• Contraindicated with
• Unconscious patient
• Disorders of mouth
• Recently had fluids/smoked
• Wait 15 minutes
• Receiving nasal oxygen
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Temperature• Rectal
• When?
• Assessing most accurate temp
• Alternative to oral site
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Rectal Temp• Contraindicated with:• Newborns, small children• Diarrhea• Rectal surgery• Rectal disease• Concern re: vagus nerve
stimulation• Neurological disease
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Axillary Temperature• When?
• Unable to use oral or rectal
• Newborn
• Contraindications:
• Axillary/Arm disorders
• After bathing
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Normal Values
• Average values may vary 1 degree F higher or lower
F/ C• Oral- 98.6/ 37
• Rectal- 99.5/ 37.5
• Axillary- 97.6/ 36.5
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Factors Affecting Temp• Circadian Rhythm (24 hours)
Predictable fluctuations-
Temp 1-2 degrees lower in early morning
Temp peaks late afternoon (4-7 pm)
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Factors Affecting Temp• Age- very young and old
affected
• Gender- women
Progesterone at ovulation increases temp 0.5-1 degree
Environmental
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Factors Affecting Temp• Hypothermia- low body temp
• Hyperthermia- high body temp
• Fever
Loss of appetite, headache, flushed, malaise
Severe- dehydration, alt urine output, seizures, lyte imbal
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Reducing Fever• Cooling the body
• Increase fluids
• Monitor intake
• Monitor labs
• Antipyretics
• Antibiotics
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Pulse• Normal range- 60-100
• Tachycardia- more than 100• Causes-• Decreased blood pressure• Elevated temp• Decreased oxygen• Heat, Pain, Medicatioins
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Pulse• Bradycardia- less than 60• Caused by:• Slower in men• Thin person• Sleep• Hypothermia• Aging• Medications
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Pulse Strength(Amplitude)
• 0- Absent
• 1+- Thready
• 2+- Weak
• 3+- Normal
• 4+- Bounding
• What would be reported?
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Pulse Sites• Temporal (Temple)• Carotid (Neck)• Brachial (Bend of arm)• Radial- used frequently/palpate (Wrist)• Femoral (Groin)• Popliteal (Behind knee)• Posterior tibial (Inner ankle)• Dorsalis pedis (Top of foot)• Apical- used frequently/ auscultate (heart)
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PulseEquipment
• Hands
• Doppler
• Stethoscope
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Respirations• Ventilation
• Inspiration
• Expiration
• Normal rate- Adults 12-20 breaths per minute
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Respirations• Patterns of Respiration
• Normal- 12/20 per minute
• Tachypnea- more than 24/min
(fever, anxiety, resp disease)
• Bradypnea- less than 10/min
(meds, brain injury)
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Respirations• Hyperventilation- increased rate
and depth (Kussmaul’s)• Hypoventilation- decreased rate
and depth-narcotics/anesthesia
• Cheynes-Stokes- alt. deep/rapid with apnea
• Biot’s- erratic depth and apnea (brain injury)
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RespirationsTerms
• Apnea- No breathing
• Dyspnea- Difficulty breathing
• Orthopnea- Breathing sitting upright
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Factors Affecting Respirations
• Age- decreases with older age• Gender- males- diaphragmatic• Exercise- increases respirations• Disease- brain injury• Anemia- increases respirations• Anxiety- increases respirations• Medications- narcotics lower;
amphetamines- increases• Acute pain- increases
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Respirations• Assessing:
Observation
(Other monitoring devices)
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Blood Pressure• Systolic blood pressure-
contraction of ventricles (Highest pressure on arterial walls)
• Diastolic- relaxation (lowest pressure)
• Pulse pressure (PP)-
Systolic- Diastolic= PP
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Blood PressureValues
• Normal- <120/ <80
• Prehypertension- 120-139/80-80-89
• Stage 1- 140-159/ 90-99
• Stage 2- >160/>100
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Blood Pressure• Hypertension-
Sustained, above normal
Primary/essential HTN- no causeSecondary HTN- known etiology
Risk factors- Hx, obesity, smoking, sedentary, stress, diet
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Blood Pressure• Hypotension- below normal B/P
• Orthostatic hypotension- Postural hypotension; weakness/ fainting when standing (esp when on prolonged bedrest)
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Blood Pressure• Korotkoff Sounds:
Phase I- first faint clear tapping
Phase II- Swishing
Phase III- Distinct loud sounds
Phase IV- Muffling sounds
Phase V- Last sound
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Blood PressureAssessment Sites
• Brachial Artery B/P Do not take in arm with IV, side
of mastectomy, AV shunt Popliteal Artery B/P
Systolic may be higher
Palpating B/PSystolic
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Blood Pressure• False lows:• Releasing valve rapidly• Not pumping cuff high enough• Using faulty equipment• Did not insert earpieces correctly• Cuff too wide• Looking at meniscus above eye
level
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Blood Pressure• False Highs:
• Cuff is not calibrated
• Looking at meniscus below eye level
• Cuff is too narrow
• Releasing valve too slowly
• Reinflating cuff during auscultation
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Pain- the 5th Vital Sign
• Factors Affecting Pain:• It is what the patient says it is• Culture• Ethnicity• Gender• Age• Support of Others• Anxiety• Past experiences
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Pain• JCAHO standards• Right to assessment and management• Ongoing assessment• Recorded• Policies and procedures• Pain must be managed• Education must be provided• Discharge planning includes pain mgt• Monitor effectiveness of mgt
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Pain Assessment• Patient’s description• Duration• Location• Quantity/ Intensity• Quality• Chronology• Aggravating factors• Alleviating factors• Physiologic indicators of pain• Behavioral responses• Effect on activities and lifestyle
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PainRating (p. 1384)
• Simple descriptive Pain Distress Scale
• Numeric Pain Scale
• Visual Analog Scale
• Wong-Baker Faces