1 / 78

Stressors that Affect Circulation

Stressors that Affect Circulation. NUR101 LECTURE # 9 FALL 2010 K. BURGER, MSEd, MSN, RN, CNE PPP by Sharon Niggemeier RN BSN MSN. Circulatory Needs. Blood circulation affects all aspects of well being.

kaoru
Download Presentation

Stressors that Affect Circulation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Stressors that Affect Circulation NUR101 LECTURE # 9 FALL 2010 K. BURGER, MSEd, MSN, RN, CNE PPP by Sharon Niggemeier RN BSN MSN

  2. Circulatory Needs • Blood circulation affects all aspects of well being. • Circulation is monitored through assessment of Vital Signs along with other collected data. • The patient’s physiological status is reflected by their vital signs.

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

  4. 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) CNS Regulates VS

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

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

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

  8. Systematic Normal Range Baseline Recheck Client Norm Dx Treatments Monitor prn Guidelines for Assessing VS

  9. Temperature Regulation • Thermal Balance • Heat Production • Heat Loss • Core vs Surface

  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???

  16. Fever • Pyrexia100.4 – 104.0 F • HyperpyrexiaAbove 104.0 F

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

  19. Resolutions of Pyrexia • Crisis- sudden return to normal body temp. • Lysis- gradual return to normal body temp.

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

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

  22. Fever • Onset- (Chill) • Course ( Flush) • Abatement (fever subsides)

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

  24. 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

  25. Axillary Temperature • Preferred for children under 6 yrs. routinely used on infants. • Place in center of axilla against artery off the subclavian. • Blue probe -electronic thermometer • Document 102.4 A

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

  27. (Continued) Rectal Temperature • Electronic thermometers: • Red Probe only • Insert : ½ - 1 inch adult ¼ - 1/2 inch child • Left position is best • Document 102.8 R

  28. Electronic Thermometers • Check for baseline number- specific number after being turned on. • Error indicators- low battery • # completeness- digital display clearly shows entire numbers • If probe cover breaks- discard, check pt.mouth/axilla/rectum for broken pieces. • Do not use bent probes.

  29. ??? Nursing Diagnoses ???

  30. 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 Nursing Interventions Temperature

  31. Heat Stroke • Hot, dry skin • Dizziness • Abdominal pain • Delirium • Eventual LOC

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

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

  34. 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-----------------------------

  35. Pulse-Physiology • SA node- creates electrical impulses causing contraction of Left ventricle. • 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

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

  37. 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. Cardiac Output CO=SV x HR

  38. ?? CARDIAC OUTPUT ??CV (5000) = SV(70) X HR • In the above equation, what would the client’s heart rate be? • 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? • 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?

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

  40. 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+

  41. 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

  42. ??? NURSING DIAGNOSES

  43. Nursing Interventions-Pulse • Monitor for symmetry • Note pulse deficit • Promote circulation – i.e. massage, TEDS, • Teaching – i.e don’t cross legs

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

  45. 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 • 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

  46. Pulse Documentation • 5/23/02 1:20am c/o palpitations. P-96 reg 3+. No pulse deficit.------------------- S.Niggemeier RN

  47. 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

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

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

  50. 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

More Related