520 likes | 1.2k Views
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
E N D
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 Taken when fever is suspected
Oral Temperature • Contraindicated with • Unconscious patient • Disorders of mouth • Recently had fluids/smoked • Wait 15 minutes • Receiving nasal oxygen
Temperature • Rectal • When? • Assessing most accurate temp • Alternative to oral site
Rectal Temp • Contraindicated with: • Newborns, small children • Diarrhea • Rectal surgery • Rectal disease • Concern re: vagus nerve stimulation • Neurological disease
Axillary Temperature • When? • Unable to use oral or rectal • Newborn • Contraindications: • Axillary/Arm disorders • After bathing
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
Factors Affecting Temp • Circadian Rhythm (24 hours) Predictable fluctuations- Temp 1-2 degrees lower in early morning Temp peaks late afternoon (4-7 pm)
Factors Affecting Temp • Age- very young and old affected • Gender- women Progesterone at ovulation increases temp 0.5-1 degree Environmental
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
Reducing Fever • Cooling the body • Increase fluids • Monitor intake • Monitor labs • Antipyretics • Antibiotics
Pulse • Normal range- 60-100 • Tachycardia- more than 100 • Causes- • Decreased blood pressure • Elevated temp • Decreased oxygen • Heat, Pain, Medicatioins
Pulse • Bradycardia- less than 60 • Caused by: • Slower in men • Thin person • Sleep • Hypothermia • Aging • Medications
Pulse Strength(Amplitude) • 0- Absent • 1+- Thready • 2+- Weak • 3+- Normal • 4+- Bounding • What would be reported?
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)
PulseEquipment • Hands • Doppler • Stethoscope
Respirations • Ventilation • Inspiration • Expiration • Normal rate- Adults 12-20 breaths per minute
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)
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)
RespirationsTerms • Apnea- No breathing • Dyspnea- Difficulty breathing • Orthopnea- Breathing sitting upright
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
Respirations • Assessing: Observation (Other monitoring devices)
Blood Pressure • Systolic blood pressure- contraction of ventricles (Highest pressure on arterial walls) • Diastolic- relaxation (lowest pressure) • Pulse pressure (PP)- Systolic- Diastolic= PP
Blood PressureValues • Normal- <120/ <80 • Prehypertension- 120-139/80-80-89 • Stage 1- 140-159/ 90-99 • Stage 2- >160/>100
Blood Pressure • Hypertension- Sustained, above normal Primary/essential HTN- no cause Secondary HTN- known etiology Risk factors- Hx, obesity, smoking, sedentary, stress, diet
Blood Pressure • Hypotension- below normal B/P • Orthostatic hypotension- Postural hypotension; weakness/ fainting when standing (esp when on prolonged bedrest)
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
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
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
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
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
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
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
PainRating (p. 1384) • Simple descriptive Pain Distress Scale • Numeric Pain Scale • Visual Analog Scale • Wong-Baker Faces