NRS 103 Vital Signs, Measurements, Cultural Diversity, and Pain assessment

1. NRS 103Vital Signs, Measurements, Cultural Diversity, and Pain assessment Chapters 4,5,6. Asst. Professor: Nancy Sanderson, MSN, RN

2. Measurements • Height • Weight • Head Circumference • Children only • Body Mass Index

3. Why Height & Weight? • Height & weight reflects a person’s general level of health • In older adults, height & weight coupled with a nutritional assessment determine the cause of and treatment for chronic disease or helps to identify those who have difficulty feeding or other dietary issues • In children, data is used to assess both growth and development • Weight also necessary for dosing of medication

4. Increased or Decreased Height • Increased • Gigantism • Decreased • Elderly • Malnutrition • Dwarfism • Hypopituitary • Achrondroplastic

5. How to Measure Height • Height (>2 y/o-adulthood) • Remove shoes, and outer wear • Place back to scale or wall • Look straight ahead • Document in centimeters or inches to nearest 1/8 in. • Length (< 2y/o) • Hold head midline, push down knees until legs are flat.

6. Increased or Decreased Weight • Increased • Excess Nutrition • Cushing’s syndrome • Fluid retention • Decreased • Malnutrition • Acute or Chronic illness • Consider cancer • Eating Disorder • Mental Illness

7. How to Measure Weight • Weight (2 y/o-adult) • Remove shoes and heavy outer clothing • Record in pounds or kilograms (often kg for children) • Record to nearest ¼ lb • Weight (< 2y/o) • Check calibration, remove all clothing, stay very close to infant so does not fall. • Record to nearest ½ oz in infants and ¼ lb or 0.1kg for toddlers

8. Why Head Circumference? • Assess for brain growth and abnormalities • Microcephaly • Macrocephaly • Hydrocephalus

9. Head Circumference • Measured at birth and each well child visit and then yearly until age 2 years. • (Well child visits: 1 wk, & months 1, 2, 4, 6, 9, 12, 15, 18, 24) or if • Anterior Fontanel (soft spot) closes around 18 – 24 months • Circle tape at widest point and record in centimeters • Above pinna or ears and around occipital prominence • May need to repeat a few times.

10. Body Mass Index (BMI) • More accurate estimate of body fat than weight alone. • Weight (kg)/Height (m²) or Weight (lbs)/height (in.²) x 703 • Underweight <18.5 • Normal 18.5-24.9 • Overweight 25.0-29.9 • Obesity I 30.0-34.9 • Obesity II 35.0-39.9 • Obesity III >40

11. BMI: Body Mass Index • More than than half of U.S. adults are overweight (>25) • More than one quarter of U.S. adults are obese (>30) • These are risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis, sleep apnea, and some forms of cancer

12. Summary (in a nutshell) • Height and Weight needed for BMI • Following trends/health status • Measure head circumference up to the age of 2

13. Vital signs

14. Vital Signs—5, 6, 7, or 8 VS • Temperature (T) • Pulse (P) • Respiratory Rate (R) • Blood Pressure (BP) • Pulse Ox • Pain • Level of consciousness • Urine out put

15. Use of Vital Sign Measurements • Establish patient’s baseline • On admission to health care facility • Before surgical or invasive diagnostic procedure, transfusion of blood products, administration of medications that affect cardiovascular, respiratory or temperature control functions • Monitor current condition & identify problems • According to routine schedule ordered by provider • During transfusion of blood products, administration of medications that affect cardiovascular, respiratory or temperature control functions • -When pt’s general physical condition changes • When pt reports nonspecific symptoms of physical distress

16. Use of Vital Sign Measurements • Evaluating Response to Intervention • After administration of medications for: Pain; Breathing treatments; Blood Transfusions: Chemotherapy; etc. • Temperature • Pulse • Blood pressure • Respiration • Pulse Ox • Pain • Level of consciousness

17. Guidelines for Nursing Practice • Can delegate, but nurse caring for the patient is responsible for analyzing vital signs & making decisions about interventions • Make sure equipment is functioning and appropriate for the size, age, and condition of the patient • Know each patient’s: • Medical history • Prescribed medications and therapies • Baseline vital signs

18. Guidelines for Nursing Practice • Know the minimum required frequency for obtaining vital sign measurements. • Appropriately judge whether more frequent assessments are necessary. • Use vital sign measurements to determine indications for medication administration • Document vital signs and communicate significant changes to healthcare provider • Develop teaching plan to instruct pt/caregiver in vital sign assessment and significance of findings.

19. Vital Signs: Temperature

20. Temperature Conversions • Convert Fahrenheit to Celsius • C = (F -32°) x 5/9 • Convert Celsius to Fahrenheit • F = (9/5 x C) + 32° • There are graphs everywhere!

21. How to Measure • Surface Sites • Oral • Axillae • Skin • Core Sites • Rectum • Tympanic Membrane • Temporal Artery

22. Oral • Oral sublingual site with rich blood supply from carotid arteries • How to use: • Slide probe cover over BLUE tip probe & place in the posterior sublingual pocket with mouth completely closed. After beeps eject probe cover. • Ideally wait 20-30 minutes after patient smoked or ingests hot liquids/foods. • Advantages: Accurate & convenient • Disadvantages: Cannot be used if the patient is unconscious, confused, seizure prone, shaking chills, less than 5 years old, disease/surgery of the mouth, mouth breather, or tachypenic

23. Axillary • Axillary temperature is 0.9°Flower than oral temp • Typically used with newborns and unconscious patients • Not recommended for fever in infants or young children • How to use: • Slide probe cover over BLUE tip probe and place tip into center of unclothed axilla. Lower arm and place across patient’s chest. If child- hold child’s arm next to body • Advantages: Safe & accessible for infants & children when environment controlled • Disadvantages: Long measurement time. Lags behind core temp during rapid temperature change. Easily affected by the environment.

24. Rectal Temperature • Higher than oral temps by 0.9 °F (average 99.3-99.6°F ) • Infants/Children-Rectal temp higher than adult (100 °F) • Measures temperature from blood vessels in rectal wall • How to use: • Apply gloves, place in Sims position, separate buttocks, & dip probe cover into lubricant. Attach probe with RED tip. Insert lubricated probe cover 1-1.5 inch into rectum. Eject probe cover and wipe probe with alcohol. • No Longer recommended in infants or children*!! • *Unless a soft flexible temperature probe

25. Rectal Temperature • Advantages: Not influenced by eating, drinking, smoking, or ability of patient to hold probe, more accurate • Disadvantages: Patient discomfort & time consuming. Lags behind core temp during rapid temperature changes. Contraindicated in pre-term infants, immunosuppressed, and patients with diarrhea or rectal/GI surgery.

26. Tympanic • Higher (1°F ) than oral temperature. • Senses infrared emissions of the tympanic membrane • How to use: • Apply speculum cover. Pull ear up and back for >3y/o & down and back for <3y/o. Place covered probe tip snugly into ear canal, point speculum towards nose and press button and hold until beeps. Remove and eject cover. • Make sure patient has been indoors for at least 10 minutes • Use other ear or route if: drainage from ear, ear surgery, large amount of cerumen, pain from perforation or infection

27. Tympanic • Advantages • Fast, convenient, safe, reduced risk of injury and infection, and non-invasive. Provides accurate core reading because eardrum close to hypothalamus; sensitive to core changes. Not affected by food/drink or smoking. • Disadvantages • Requires removal of hearing aids. Only one size*. Inaccuracies reported due to incorrect positioning. Affected by ambient temp devices (incubators, radiant warmers, facial fans). Otitis media and cerumen may distort reading. Contraindicated in ear/TM surgery. • *(This is changing, pediatric size has been developed)

28. Temporal Artery (TAT) • Infrared sensor tip detects temperature of cutaneous blood flow through superficial temporal artery. • Often used for infants, newborns, and children • How to Use: • Ensure forehead is dry. Place probe flush on skin. Push button and hold as move across forehead from center of hairline and ending with a touch behind earlobe. Release button and clean probe with alcohol.

29. Temporal Artery (TAT) • Advantages: • Fast, convenient, and comfortable. No risk to patient or nurse. Reflects rapid change in core temp. Sensor cover not required. • Disadvantages: • Inaccurate with head covering or hair on forehead. Affected by diaphoresis and sweating.

30. What do the Values Mean? • Normal Range • 96.8 – 100.4 °F (36 °- 38 °C) • Fever/Hyperthermia • > 100.4 °F • Hypothermia • < 96.8 °F • Severe: • < 86.0

31. What do the Values Mean? • Increased: Fever/Hyperthermia • Infection or inflammation • Trauma or disease to hypothalamus • Spinal cord injury • Prolonged exposure to sun/ high temperatures • Fluid volume deficit • On medications that decrease body’s ability to lose heat or promote fluid loss • Have congenital absence of sweat glands or serious skin disease that impairs sweating • Decreased

32. Fever (Afebrile/febrile) • Mild temp elevation up to 102.2F (39C) enhances immune system • White blood cell production stimulated • Body decreased iron concentration in blood plasma , suppressing growth of bacteria • Stimulates interferons, bodies natural virus-fighting substance • Prolonged fever weakens patient by exhausting energy stores, increasing oxygen demands and decreasing fluid volume • Risk of Febrile seizures & dehydration in children

33. Hyperthermia- Additional S & S • Sweating/Diaphoresis • Skin warm to touch • Inactivity • Confusion • Excessive thirst • Nausea • Muscle cramps • Visual disturbances • Incontinence • Increased heart rate • Decreased BP If progresses • Unconscious • Nonreactive pupils • Permanent neurological damage

34. What do the Values Mean? • Decreased: Hypothermia • Trauma or disease to hypothalamus • Spinal cord injury • Prolonged exposure to cold temperatures • Unintentional exposure to cold (falling through ice at lake) • Intentional- surgical to reduce metabolic demands and oxygen requirements

35. Hypothermia- Additional S & S • Skin cool to touch • Voluntary muscle contraction • Shivering • Memory loss • Poor judgment • Decreased heart rate • Decreased respiratory rate • Decreased blood pressure • Skin cyanotic If progresses • Cardiac dysrhythmias • Loss of consciousness • Unresponsive to painful stimuli

36. You have delegated vital signs to assistive personnel. The assistant informs you that the client has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to: A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the client to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature. 32 - 36

37. Vital Signs: Pulse

38. Pulse Basics • Pulse is the palpable bounding of blood flow created by ejection of blood into the aorta. • Peripheral pulses felt by palpating arteries lightly against underlying bone or muscles • Provides clinical data regarding the heart’s pumping action (cardiac output) • Cardiac output = heart rate x stroke volume • Abnormally slow, rapid, or irregular pulse alters CO

39. Pulse Basics • Changes in pulse rate caused by: • Heart disease/dysrhythmias (decreased CO) • Age • Exercise • Positions changes • Fluid balance (i.e. hemorrhage) • Medications • Temperature • Sympathetic stimulation

40. Radial & Carotid Pulse Site • Radial • Place patient’s forearm straight alongside body or across lower chest or abdomen. If sitting bend elbow at 90°and support • Place pads of first 2-3 fingers in groove along thumb side (radius) • Carotid • Place pads of first 2-3 fingers along medial edge of sternocleidomastoid muscle in neck

41. Radial & Carotid Pulse Sites • Rate (beats/minute) • If pulse is regular then count for 30 seconds and multiply by 2. • If pulse irregular or weak count for 1 minute at apical site • Normal Range • Adult 60-100 bpm • Infants/Children (less than or 2 years of age: apical pulse—brachial in BLS) • Adults Abnormal • > 100 bpm = Tachycardia • < 60* bpm = Bradycardia (*exception: extreme athletic person)

42. Radial & Carotid Pulse Sites • Rhythm • Normal • Regular • Sinus Arrhythmia in children • Irregular/Dysrhythmia • Regularly irregular • Irregularly irregular

43. Radial & Carotid Pulse Sites • Strength (Amplitude) • Normal • Strong (2+) • Abnormal • Weak or thready (1+) • Bounding (3+) • Equality • Radial: Assess on both sides to determine if equal • Carotid: Never palpate simultaneously. Only one at a time.

44. Apical Pulse Site • Listen to the Apical heart sound • Although called “pulse” you want to listen w/stethoscope • Auscultate with stethoscope & assess rate & rhythm—1 full minute • If you feel an irregular pulse when feeling radial pulse (bounding, weak, irregular, or skipped beats • Any child less than 2 years old

45. Apical Pulse Site • Auscultation of heart sounds • Often used when: • Heart rate is irregular • Peripheral pulse is weak • Patient taking medication that affects pulse rate • Patient is < 2 y/o

46. You notice that a teenager has an irregular pulse. The best action you should take includes: • A. Read the history and physical. • B. Assess the apical pulse rate for one full minute. • C. Auscultate for strength and depth of pulse. • D. Ask if the client feels any palpations or faintness of breath. 32 - 46

47. Vital Signs: Respiratory Rate

48. Respiratory Rate • Assess breathing pattern. • Observe chest wall expansion and bilateral symmetrical movement of thorax. • Assess the rate, depth, and rhythm of each breath. • Count for 30 seconds & multiply by 2 if regular pattern • In infants watch abdomen and count full minute

49. So Patient isn’t aware. . . • Ask patient to move arm over chest and as you “count the radial pulse” you actually count the respirations

50. Question • You are counting respirations in a male patient you notice his chest is not moving much, but his abdomen has movement with each respiration this is: • A. A symptom of severe respiration problems • B. Normal diaphragmatic breathing • C. You need to notify the doctor • D. A & C