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VITAL SIGNS

VITAL SIGNS. Professor Blakey NUR302. Vital Signs. Temperature Pulse Respirations Blood Pressure Health Status Changes Accuracy, Responsibility. Vital Signs. When are they reported? When are they recorded?. Temperature. Sites: Oral- Taken routinely Taken per MD order

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VITAL SIGNS

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  1. VITAL SIGNS Professor Blakey NUR302

  2. Vital Signs • Temperature • Pulse • Respirations • Blood Pressure • Health Status • Changes • Accuracy, Responsibility

  3. Vital Signs • When are they reported? • When are they recorded?

  4. Temperature Sites: Oral- Taken routinely Taken per MD order Taken when fever is suspected

  5. Oral Temperature • Contraindicated with • Unconscious patient • Disorders of mouth • Recently had fluids/smoked • Wait 15 minutes • Receiving nasal oxygen

  6. Temperature • Rectal • When? • Assessing most accurate temp • Alternative to oral site

  7. Rectal Temp • Contraindicated with: • Newborns, small children • Diarrhea • Rectal surgery • Rectal disease • Concern re: vagus nerve stimulation • Neurological disease

  8. Axillary Temperature • When? • Unable to use oral or rectal • Newborn • Contraindications: • Axillary/Arm disorders • After bathing

  9. Normal Values • Average valuesmay vary 1 degree F higher or lower F/ C • Oral- 98.6/ 37 • Rectal- 99.5/ 37.5 • Axillary- 97.6/ 36.5

  10. Factors Affecting Temp • Circadian Rhythm (24 hours) Predictable fluctuations- Temp 1-2 degrees lower in early morning Temp peaks late afternoon (4-7 pm)

  11. Factors Affecting Temp • Age- very young and old affected • Gender- women Progesterone at ovulation increases temp 0.5-1 degree Environmental

  12. 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

  13. Reducing Fever • Cooling the body • Increase fluids • Monitor intake • Monitor labs • Antipyretics • Antibiotics

  14. Pulse • Normal range- 60-100 • Tachycardia- more than 100 • Causes- • Decreased blood pressure • Elevated temp • Decreased oxygen • Heat, Pain, Medicatioins

  15. Pulse • Bradycardia- less than 60 • Caused by: • Slower in men • Thin person • Sleep • Hypothermia • Aging • Medications

  16. Pulse Strength(Amplitude) • 0- Absent • 1+- Thready • 2+- Weak • 3+- Normal • 4+- Bounding • What would be reported?

  17. 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)

  18. PulseEquipment • Hands • Doppler • Stethoscope

  19. Respirations • Ventilation • Inspiration • Expiration • Normal rate- Adults 12-20 breaths per minute

  20. 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)

  21. 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)

  22. RespirationsTerms • Apnea- No breathing • Dyspnea- Difficulty breathing • Orthopnea- Breathing sitting upright

  23. 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

  24. Respirations • Assessing: Observation (Other monitoring devices)

  25. Blood Pressure • Systolic blood pressure- contraction of ventricles (Highest pressure on arterial walls) • Diastolic- relaxation (lowest pressure) • Pulse pressure (PP)- Systolic- Diastolic= PP

  26. Blood PressureValues • Normal- <120/ <80 • Prehypertension- 120-139/80-80-89 • Stage 1- 140-159/ 90-99 • Stage 2- >160/>100

  27. Blood Pressure • Hypertension- Sustained, above normal Primary/essential HTN- no cause Secondary HTN- known etiology Risk factors- Hx, obesity, smoking, sedentary, stress, diet

  28. Blood Pressure • Hypotension- below normal B/P • Orthostatic hypotension- Postural hypotension; weakness/ fainting when standing (esp when on prolonged bedrest)

  29. 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

  30. 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/P Systolic

  31. 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

  32. 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

  33. Pain- the 5thVital Sign • Factors Affecting Pain: • It is what the patient says it is • Culture • Ethnicity • Gender • Age • Support of Others • Anxiety • Past experiences

  34. 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

  35. 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

  36. PainRating (p. 1384) • Simple descriptive Pain Distress Scale • Numeric Pain Scale • Visual Analog Scale • Wong-Baker Faces

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