Fundamental Nursing Skills and Concepts

1. Fundamental Nursing Skills and Concepts Chapter 11 page 137

2. Vital Signs • Body temperature • Pulse rate • Respiratory rate • Blood pressure • Vital signs are objective data that indicate how well or how poorly the body is functioning. These signs are measureable.

3. Body Temperature • Refers to the warmth of the human body and is produced primarily by exercise and the metabolism of food. • Body’s shell, (skin surface), temperature is lower than the core, (at the center of the body), temperature • Measured in the Fahrenheit or Centigrade scale. Box 11-2, top 139a. Need to know. • Normal body temperature 96.6 to 99.3 Fahrenheit or 35.8 to 37.4 Centigrade, for shell temps. • For core temps 97.5˚-100.4˚ F , or 36.4˚ -37.3˚ C

4. Body Temperature • The hypothalmus- (structure within the brain)- acts as the center for temp. regulation. • Temps higher than 105.8˚ F (41˚C) or lower than 93.2˚F or (34˚C) show the hypothalmus is impaired. • 110˚F or higher or lower than 84˚F is not compatible with life.

5. Body Temperature • Lost from the skin, lungs and body waste products through the process of radiation, conduction, convection, and evaporation. • Table 11-1 page 138

6. Factors Affecting Body Temperature • Food intake-affects thermogenesis,(heat production), both the amount and type eaten affect body temp. because the body requires energy to digest, absorb, transport, metabolize and store nutrients. Restrictions on diet can help decrease body heat, because of reduced processing of nutrients. • Age- infants and older adults have limited body fat which helps to maintain body temp. regulation. Fat provides insulation to prevent heat loss. The ability to shiver and perspire may also be inadequate, putting them at risk for increase body temps. . • Climate • Gender-may see slight rise when ovulating due to hormonal changes.

7. Factors Affecting Body Temperature • Exercise and activity-involves muscle contraction which produces body heat. To provide energy, metabolic rate goes up leading to combustion of calories, and increases heat production. • Circadian rhythm • Emotions • Illness or injury • Medications

8. Assessment Sites • Thermistor catheter (heat sensing device at the tip of internally placed tube) • Oral site- mouth, oral cavity • Rectal site-rectum • Axillary site-axilla • Ear-tympanic • Document site temp. was obtained. Page 141a

9. Oral site • Area under the tongue – rear sublingual pocket – most accurate. Picture top page 141 • Patient needs to be informed, cooperative, keep mouth closed, and breathe at a normal rate. • Avoid oral route if uncooperative, very young, unconscious, seizure risks, oral surgery patient, mouth breathers, and those that are talkative. • Avoid if patient has been chewing gum, has smoked or has had something cold or hot to drink. Assessment should take place after 30 minutes, for a more accurate temp. reading.

10. Assessment sites and time • Oral site-leave in place, mercury thermometer, 3 minutes to 5 minutes if feverish. • Rectal site-most accurate site. May be embarrassing. For glass mercury thermometers leave in place 2 minutes. • Axillary site-underarm site, generally 1˚ lower than oral measurement. Infants and small children can be injured rectally so the axillary is the preferred method. It is safe, readily accessible, less disturbing, but longest assessment time, 5 minutes or longer. Make sure contact is made for good transference of heat.

11. Assessment sites and time • The ear-also known as tympanic. This measurement has the closest correlation to core temperature. Considered more reliable, the electronic thermometer will beep when ready.

12. Thermometers: used to measure body temps. • Glass- slender or rounded bulbs- • Slender, for oral use, (Blue tip) • Rounded, for rectal placement, (Red tip) • For rectal temps: 1.5” adult, 1” child, .5” infant. • Mercury is used in the stem, it heats up and the highest point the mercury reaches in the stem is the reading of body temp. • To clean them is located on page 144, 11-1.

13. Thermometers: used to measure body temps. • Electronic thermometers- temperature sensative probe covered with a disposable sheath. They are portable and rechargeable. Oral and axillary probe may be utilized, which is the blue probe, rectal probe is the red probe. • The probe is connected to an electronic unit that senses the temp. . Temp. is reached. A signal is emitted to indicate the end. No specific time interval, usually 30-60 seconds. Remove probe - eject cover – read display.

14. Thermometers: used to measure body temps. • Infrared (Tympanic) thermometers-hand held covered probe- inserted into ear canal, detects warmth through sensor from the eardrum converted to temp. measurement in 2-5 seconds. • Contraindicated for children younger than 2, due to small ear canals.

15. Thermometers: used to measure body temps. • Chemical thermometers- heat sensitive tapes, or patches can be reused before being discarded, placed on forehead or abdomen. • Changes color according to body temp., easily read. Other varieties of strips are held in the mouth and dots change color to indicate temp.. One use and discard. • Page 145 bottom has some examples.

16. Thermometers: used to measure body temps. • Automated monitoring devices-allows, B/P, temp., and pulse to be taken at same time. Usually rolled from room to room. • Be careful of ?????????? • Continuous monitoring device- usually in critical care areas. Probes placed within the esophagus of anesthetized pts. Or a sensor attached to a pulmonary artery catheter. • Skill 11-1 assessing body temp. pg 164.

17. Fever • Body temp is elevated @99.3˚F or above. • Fever = pyrexia • Febrile, with fever • Afebrile, with out fever, no fever • Hyperthermia, high core temp. , usually exceeding 105.8˚F or 40.6˚C at risk for brain damage or death due to high metabolic demands. • Symptoms- restless, flushed, irritable, poor appetite, glassy eyes, increased perspiration, headache, increased pulse & resp. rate.

18. Fever con’t. • May be disoriented, confused and have fever blisters. • A fever of less than 102.˚F may be a good thing to fight off infection, body’s own defenses, fighting microbes. • Provide lots of fluids and or rest. • Fever of 102-104˚F, antipyretics may need to be used. Aspirin(ASA), or acetaminophen. • See nursing care plan guidelines for pts. with a fever, pg.148

19. Hypothermia • Core body temp. less than 95˚F, or 35˚C. , best taken with a tympanic thermometer. Why???? • What will you be seeing in a pt. that is hypothermic? • What will you do for a hypothermic pt. ? • Nursing guidelines 11-2 page 149.

20. Phases of a Fever • Prodromal Phase: The client has nonspecific symptoms just before the temperature rises. • Onset or Invasion Phase: Obvious mechanism for increasing body temperature, such as shivering develops. • Stationary phase: The fever is sustained. • Resolution or defervescence phase: Temperature returns to normal • Fig 11.11 page 147

21. Subnormal Temperature • Hypothermia-core temperature less than 95 degrees • Mild hypothermia-temperature 95 to 93.2 degrees • Moderate hypothermia-93 to 86 degrees • Severe hypothermia-below 86 degrees

22. Pulse • A wavelike sensation that can be palpated in a peripheral artery, produced by the movement of blood during the heart’s contraction. • Normal heart rate is 60-100 beats per minute at rest, table 11.5 page 149 • Pulse rate (number of peripheral pulsations palpated in 1 minute) is counted by compressing a superficial artery against an underlying bone with the tips of the fingers, never, never the thumb.

23. Factors Affecting Pulse and Heart Rates • Age • Circadian Rhythm (lower in am) • Gender • Body build • Exercise and activity • Stress and emotions

24. Factors Affecting Pulse and Heart Rates • Body temperature--- for 1˚F temp. elevation the heart and pulse rate increases 10 BPM. • Blood volume---excessive blood loss causes heart rate to increase. Why??? ( task is to deliver O to cells, so speeds up the action, due to lower circulating volume). • Drugs---some slow, some speed up rate. Very important to know what meds do that you are giving.

25. Alterations in Pulse Rate • Tachycardia-100-150 bpm---heart is overworked, cells may not get the O they need. Monitor closely, report & document according to agency policy. • Palpitation-Awareness of one’s heart contraction without having to feel the pulse. • Bradycardia-<60 bpm---warrants monitoring, reporting & documenting. • Arrhythmia or dysrhythmia-irregular pattern of heartbeats, need to report promptly.

26. Alterations in Pulse Rate • Palpitation- awareness of one’s own heart contraction without having to feel the pulse. • Pulse volume- table 11-6 page 150-quality of pulsation felt. • Peripheral pulse sites-fig. 11-12---know these… • Assessing radial pulse---skill 11-2 page 172

27. Alterations in Pulse Rate • Fig. 11-13, page 151b. Apical heart rate– point of maximum impulse. Point of maximum impulse, slightly below the left nipple in line with the middle of the clavicle. • Listening to the apical, lub dub will be heard, this is equal to one beat. • The lub will be heard louder than the dub if the stethoscope has been placed correctly. • Taking a radial pulse this lub dub will come across as 1 beat.

28. Pulse Assessment Sites • Peripheral pulses-radial artery • Apical heart rate-number of ventricular contractions per minute that occur. • Apical-radial heart rate-number of sounds heard at the heart’s apex and the rate of the radial pulse during the same period. 2 nurses, (1 nurse counts the apical beats, the other counts radial), 1 clock is used. They start counting at the same time. They should get the same total, if not the difference between is called the pulse deficit. Should be reported to charge nurse and doctor.

29. DOPPLER • Doppler ultrasound device- conductive jelly is used to hear very faint sounds. Document “D”, for doppler. • Doppler is used when slight pressure occludes pulsation. • Page 152 shows a doppler being used.

30. Pulse rate and respiratory rate • Factors that influence the pulse rate usually affect the respiratory rate such as temp., activity, anxiety, stress and fright.

31. Respiration • Exchange of oxygen and carbon dioxide • External respiration- exchange between alveolar & capillary membranes • Internal or tissue respiration- exchange between blood & body cells • Ventilation-movement of air in and out of the chest • Inhalation-breathing in • Exhalation-breathing out • Respiratory rate-number of ventilations per minute

32. Respiration • The medulla is the respiratory center in the brain and controls ventilation. It is sensitive to the CO, (carbon dioxide), in the blood. • Count the number of ventilations in one minute. • Table 11-7 page 152—need to know normal respiratory rates. • Ratio of 4-5 heartbeats to 1 respiration is fairly normal.

33. Breathing Patterns and Abnormal Characteristics • Cheyne-Stokes Respiration-Breathing pattern in which the depth of the respirations gradually increases followed by gradual decrease, and then a period when breathing stops before resuming again. Usually seen as death approaches. • Hyperventilation-Rapid or deep breathing • Hypoventilation-Diminished breathing • Changes in ventilation may occur in clients with airway obstruction, pulmonary or neuromuscular disease.

34. Breathing Patterns and Abnormal Characteristics • Dyspnea-Difficult or labored breathing. May see nostrils flare, or widen, pt. appears anxious, or worried. Fight for breath. Abdominal, and neck muscles used to breathe, seen in anxious pt. along with fast heart rate. • Orthopnea-Breathing facilitated by sitting or standing up, page 412 shows the examples. The abdominal organs move away from the diaphram with gravity so breathing is easier.

35. Breathing Patterns and Abnormal Characteristics • Apnea-Absence of breathing. Lasts 4-6 minutes, life threatening. Prolonged apnea there will be brain damage. Skill 11-3, pg 174. • Tachypnea-fast respiratory rate • Bradypnea-slower than normal resp. rate. Drugs such as MS can slow rate so count 1 full minute.

36. Sounds to be aware of: • Stertorous breathing- noisy ventilation • Stridor- harsh, hi-pitched sound heard on inspiration when there is a laryngeal obstruction. Children often have stridor with croup. • Anterior and posterior lung assessments are well demonstrated on page 199, you will need to know these well.

37. Blood Pressure • Force that the blood exerts within the arteries • Circulating blood volume averages 4.5 to 5.5 L in adult men • Contractility of the heart is influenced by the stretch of cardiac muscle fibers. If the muscle tissues are damaged and scar tissue happens, less stretch and reduced contractility occurs. • Cardiac output-volume of blood ejected from the left ventricle per minute is approximately 5 to 6 liters, average stroke volume in adults is 70 ml x heart rate x minute or time.

38. Blood Pressure • Preload –volume of blood that fills the heart and stretches the heart muscle fibers during its resting phase. • Afterload-force against which the heart pumps when ejecting blood. Resistance increases when valves of the heart and arterioles are narrowed or calcified. Afterload is decreased when arteries dilate. • Systolic and diastolic are expressed as a fraction in millimeters of mercury, (abbreviated mmHg). • Generally a B/P of 140/90 is considered the beginning of high B/P. Optimal B/P for adult 120/80 mmHg.

39. Factors Affecting Blood Pressure • Age-tends to rise with age • Circadian rhythm-lowest @ 12 to 4 or 5 a.m. • Gender – women tend to have lower B/P • Exercise and activity • Emotions and pain- B/P rises • Arteriosclerosis-arteries loose elasticity • Athersclerosis-narrowed arteries due to deposits • Miscellaneous factors • Drugs-heart stimulants-nicotine,caffiene,cocaine

40. Pressure Measurements • Systolic pressure-Pressure within the arterial system with the heart contracts. Is higher than the Diastolic pressure- Pressure within the arterial system when the heart relaxes and fills with blood • Pulse pressure-Difference between systolic and diastolic pressure measurements • A pulse pressure between 30-50 mmHg when diastolic is subtracted from systolic blood pressure is said to be in the normal range.

41. Assessment of the Blood Pressure • Over the brachial artery at the inner aspect of the elbow is usually used. When there is a problem with taking it at this location, then the lower arm can be used, using the radial artery. • Popliteal artery- behind the knee. Always document site used. • Equipment for Measuring Blood Pressure: Sphygomomanometer- mercury or aneroid • Inflatable cuff that encircles at least 2/3 of the limb at mid point • Stethoscope

42. Assessment of the Blood Pressure • Table 11-9 page 157 – B/P assessment errors • First time a B/P is measured it needs to be taken in each arm. Should not vary 5-10 mmHg. Doctors may request a lying, sitting and standing B/P. • Too wide cuff will give a false low reading • Too narrow cuff will give a false high reading • Stethoscope ear tips need to be positioned downward and forward in ears. Tips need to be cleaned between uses. Best length of tubing for sound conduction 20 inches.

43. Measuring Blood Pressure • Korotkoff Sounds-Sounds that result from the vibrations of blood within the arterial wall or changes in blood flow, fig 11-21, page 158 • Phase I-begins with the first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff. This is the systolic pressure measurement. Note the placement of the gauge mark. • Auscultatory gap-Period during which sound dissappears • Phase II-is characterized by a change form tapping sounds to swishing sounds • Phase III-is characterized by change to loud and distinct sounds, described as crisp knocking sounds

44. Measuring Blood Pressure • Phase IV-sounds are muffled and have a blowing quality • Phase V-Last sound is heard, this is the diastolic pressure reading. • Palpating the B/P- instead of using a stethoscope use fingers over the artery, when the first palpation is felt after the release of the cuff pressure, this is the systolic B/P. No diastolic is perceptible. Document systolic B/P palpated and the number. • Doppler stethoscope used, please document “D”.

45. Abnormal Pressure Measurements • Hypertension-High blood pressure-140/90 or above for adults 18 or over for sustained amount of time is considered HTN. HTN often associated with anxiety, obesity, vascular diseases, stroke, heart failure, kidney disease. • Whitecoat Hypertension-Condition in which the blood pressure is elevated when taken by a health care worker, but normal other times. • A sudden rise or fall of 20-30 mmHg is significant- take B/P on both arms and report it to your charge nurse.

46. Abnormal Pressure Measurements • Hypotension-Low blood pressure- may indicate shock, hemorrhage, drugs, orthostatic hypotension or postural hypotension, which is a sudden but temporary drop in B/P when rising from a reclining position. Commonly seen in patients with circulatory problems, dehydration, patients on diuretics. Patient will present with dizziness, going weak, and fainting. Postural or orthostatic hypotension-Sudden temporary drop in blood pressure when rising from a reclining position. • Report any abnormal vital signs!!!! • Skill 11-4 assessing the B/P page 176 • Please look over general gerontologic considerations