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Nursing 1510: Vital Signs

Nursing 1510: Vital Signs. Metro Community College Nursing Program Nancy Pares, RN, MSN. T-P-RP- BP. Objective data that contributes to all other nursing and medical information Baseline values establish the norm against which subsequent measures are compared

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Nursing 1510: Vital Signs

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  1. Nursing 1510: Vital Signs Metro Community College Nursing Program Nancy Pares, RN, MSN

  2. T-P-RP- BP • Objective data that contributes to all other nursing and medical information • Baseline values establish the norm against which subsequent measures are compared • Accurate information is essential • Information must be obtained and recorded accurately.

  3. Vital Signs • One of the most frequent assessments made as a nurse • Nurse is • Responsible for measuring, interpreting significance and making decisions about care • Knowing normal ranges • Knowing history and other therapies that may affect VS

  4. Vital Signs • Nurse must • Know environmental factors that affect vital signs • Exercise, stress, etc. • Use a systematic, organized approach • Verify and communicate changes in vital signs • Monitor VS regularly • Frequency determined by • MD order; nursing judgement, client condition and facility standards

  5. Vital Signs: Facility standards • Hospital: • Every 4-8 hours • Home health: • each visit • Clinic: • Each visit • Skilled facility • Daily and as needed

  6. Temperature • Degree of heat maintained by the body • Heat produced minus heat lost equals body temperature • Organs have receptors that monitor core body temperature

  7. Temperature • Core temperature • Normal • 96.2 degrees F to 100.4 degrees F • 36.2 degrees C to 38 degrees C • Surface temperature • Lower than core temperature • Use oral and axillary method

  8. Regulation of Temperature • Neural control • Hypothalmus acts as thermostat • Vascular control • Vasoconstriction ---hypothalmus directs the body to decrease heat loss and increase heat production • If cold, vasoconstriction will conserve heat—shivering will occur

  9. Regulation of temperature • Vasodilation • If body temp is above normal, the hypothalmus will direct the body to decrease heat production; • Perspiration and increased respiratory rate • Body heat production • Body’s cells produce heat from food—releasing energy. • Kilocalorie= energy value; • BMR= rate of energy used in the body to maintain essential activities

  10. Heat production • If metabolism increases, more heat is produced • More muscle= greater metabolism • Shivering is an early response for thermoregulation that increases heat production.

  11. Changes in temperature • Conduction • Transfer of heat from a warm to cool surface by direct contact • Convection • Transfer of heat through currents of air or water • Radiation • Loss of heat through electromagnetic waves from surfaces that are warmer than the surrounding air • Evaporation • Water to vapor lost from skin or breathing

  12. Factors affecting Temperature • Age • Exercise • Hormones • Circadian cycle • Stress • Ingestion of food • smoking

  13. Variances in temperature • Fever (pyrexia) • Abnormally high body temperature (>100.4 F) • Occurs in response to pyrogens (bacteria) • Pyrogens induce secretion of prostoglandins that reset the hypothalmic thermostat to a higher temperature • Hyperpyrexia • Fever > 105.8

  14. Physiologic responses • Temp increases: • Immune system stimulates hypothalmus to new set point • Chills, shivers • Feels cold even though temp increasing • When body temp is reset, chills subside

  15. Physiologic responses • Metabolism increases • O2 consumption increases • HR and RR increase • Energy stores are used • Dehydration and confusion • When cause is removed, set point drops

  16. Physiologic responses • Vasodilation • Warm flushed skin and diaphoresis • Benefits • Activates the immune system • Interleukin 1 stimulates antibody production • Fights viruses by stimulating interleukin • Serves as a diagnostic tool

  17. Nursing interventions • Chill stage: • Temp every 1-4 hours • Reduce activity • Warm blankets • Throughout course • Fluids, tepid baths, limit activity, keep dry • Provide oral hygiene • Provide air circulation

  18. Serious variations in temperature • Heat stroke • Prolonged exposure to heat • Depression of hypothalmus • Emergency • S/S: hot, dry skin, confusion, delirium • Hypothermia • Below 95 degrees • Uncontrolled shivering, loss of memory,LOC decreases • Limits: 77-109 degrees F

  19. Routes for taking temperatures • Oral • Most accessible and accurate • Do not use if unconscious, confused recent oral or facial OR • Rectal • 99 F • Avoid with MI and after lower GI • Axillary • 97 F—least accurate, most safe • Tympanic • 98 F—avoid with infection, after exercise, w hearing aid

  20. Pulse • The wave begins when the left ventricle contracts and ends when the ventricle relaxes • Indirect measure of cardiac output

  21. Pulse • Each contraction forces blood into the already filled aorta, causing increased pressure within the arterial system • Systole: • Peak of the wave; contraction of the heart • Diastole • Resting phase of the heart

  22. Pulse • Rate • Measured in beats per minute (bpm) • Normal • 60-100 bpm • Females slightly higher • Average • 70-80 bpm

  23. Obtaining pulse rate • Apical is most accurate • Use a standard stethescope to auscultate the number of heartbeats at the apex of the heart • A heartbeat is one series of the LUB and DUB sounds

  24. Common pulse points • Apical: at the apex of the heart • Carotid: between midline and side of neck • Brachial: medially in the antecubital space • Radial: laterally on the anterior wrist • Femoral: in the groin fold • Popliteal: behind the knee • Post tibial • Dorsalis pedis • ulnar

  25. Variances in pulse rates • Bradycardia: rate < 60 bpm • Tachycardia: rate> 100 bpm • Is the rate regular? • What is the quality? • Bounding? • Thready? • Dysrhythmia (arrhythmia) • Pulse deficit • Difference between radial and apical

  26. Factors affecting pulse rate • Emotions • Medications • Hemorrhage • Pulmonary condition • Exercise • Body temperature • Anxiety • position

  27. Cardiac effeciency • Stroke volume • The quantity of blood pumped out by each contraction of the left ventricle • Cardiac output • Stroke volume x pulse (heart) rate

  28. Inadequate circulation • Pallor • Paleness of skin when compared with another part of the body • Cyanosis • Bluish-grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood

  29. Respiration • The exchange of oxygen and carbon dioxide in the body • Two separate process • Mechanical • chemical

  30. respiration • Mechanical • Pulmonary ventilation; breathing • Ventilation: • Active movement of air in and out of the respiratory system • Conduction • Movement through the airways of the lung

  31. Respiration • Chemical • Exchange of oxygen and carbon dioxide • Diffusion • Movement of oxygen and CO2 between alveoli and RBC • Perfusion • Distribution of blood through the pulmonary capillaries

  32. Mechanics of ventilation • Inspiration • Drawing air into the lung • Involves the ribs, diaphragm • Creates negative pressure-allows air into lung • Expiration • Relaxation of the thoracic muscles and diaphragm causing air to be expelled

  33. Variations in assessment of respirations • Rate: regulated by blood levels of O2, CO2 and ph • Chemial receptors detect changes and signal CNS (medulla) • Normal: 12-20 breaths per minute • Apnea: no breathing • Bradypnea: abnormally slow • Tachypnea: abnormally fast • Observe for one full minute

  34. Variations in assessment findings • Depth • Normal: diaphragm moves ½ inch • Deep • Shallow • Rhythm • Assessment of the pattern • Abnormal • Cheyne stokes, Kusmaul,

  35. Variations in assessment of respirations • Effort • Work of breathing • Dypsnea: labored breathing • Orthopnea: inability to breath when horizontal • Observe for retractions, nasal flaring and restlessness

  36. Variations in breath sounds • Wheeze • High pitched continuous musical sound; heard on expiration • Rhonchi • Low pitched continuous sounds caused by secretions in large airways • Crackles • Discontinuous sounds heard on inspiration; high pitched popping or low pitched bubbling

  37. Variations in breath sounds • Stridor • Piercing, high pitched sound heard during inspiration • Stertor • Labored breathing that produces a snoring sound

  38. oxygenation • Hyperventilation • Rapid and deep breathing resulting in loss of CO2 (hypocapnea); light headed and tingly • Hypoventilation • Rate and depth decreased; CO2 is retained • Cheyne Stokes • Irregular, alternating periods of apnea and hyperventilation

  39. Tools to measure oxygenation ABG directly measures the partial pressures of oxygen, carbon dioxide and blood ph normal= paCO2 80-100) Pulse oximetry non invasive method for monitoring respiratory status; measures O2 saturation normal= >95%

  40. Blood pressure • Force exerted by blood against arterial walls • Work of the heart reflected in periphery via BP • Systolic • Peak pressure exerted against arterial walls as the ventricles contract and eject blood • Diastolic • Minimum pressure exerted against arterial walls between contraction when the heart is at rest

  41. Blood pressure • Measured in millimeters of mercury (mm Hg) • Recorded as systolic over diastolic • Pulse pressure • Difference between systolic and diastolic

  42. BP regulation • The body constantly adjusts arterial pressure to supply blood to body tissues • Influenced by three factors • Cardiac function • Peripheral vascular resistance • Blood volume • Normal = 5000 ml • Volume increases=BP increases • Volume decreases= BP decreases • Viscosity= reaction same as volume

  43. BP regulation • Elasticity • Less elasticity creates greater resistance to blood flow= > systolic BP • Decreased in smokers and increased cholesterol

  44. Additional considerations for BP • Palpation • Used when BP is too weak to hear • Errors • Wrong size cuff, deflating too rapidly, incorrect placement • Thigh • Measures 30-40 mm HG less than normal

  45. Factors affecting BP • Circadian • Medications • nutrition • Age • Stress • Gender • race

  46. Variations in BP • Values • Normal: < 120/80 mm Hg • Hypotension: < 100mm HG • Pre hypertension: > 120/80 mm Hg • Hypertension: 140/90= Stage 1; 160/100= Stage 2 • Persistant increase in BP • Damage to vessels; loss of elasticity; decrease in blood flow to vital organs

  47. Measurement of BP • Indirect • Most common, accurate estimate • Direct • In patient setting only • Catheter is threaded into an artery under sterile conditions • Attached to tubing that is connected to monitoring system • Displayed as waveform on monitoring screen

  48. Tools • Indirect • Equipment • Sphygomanometer and stethescope • Korotkoff’s sounds • 1st • 2nd • 3rd • 4th • 5th

  49. Korotkoff’s sounds • 1st • As you deflate the cuff; occurs during systole • 2nd • Further deflation of the cuff; soft swishing sound • 3rd • Begins midway through; sharp tapping sound • 4th • Similar to 3rd sound but fading • 5th • Silence, corresponding with diastole

  50. Other BP issues • Orthostatic or postural hypotension • Sudden drop in BP on moving from lying to sitting or standing position • Primary or essential hypertension • Diagnosed when no known cause for increase • Accounts for at least 90% of all cases of hypertension

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