FUNDAMENTALS OF NURSING

LESSON 4

VITAL SIGNS

VOCABULARY

KNOW VOCABULARY WORDS

GUIDELINES FOR VS MEASUREMENT

VITAL SIGNS INCLUDE:TEMPERATURE (T)PULSE (P)RESPIRATIONS (RR)BLOOD PRESSURE (BP)5TH VS IS PAIN

1ST SIGN THAT SOMETHING IS WRONG WITH YOUR PATIENT

VS ARE INTERRELATED—A CHANGE IN ONE WILL AFFECT ANOTHER

NURSE MUST KNOW NORMAL RANGES OF VITAL SIGNS

PROCEDURE FOR OBTAINING TEMPERATURE

VARIATIONS WNL 97-99.6 F – AGE– EXERCISE– HORMONES– DIURNAL—LOW IN AM AND PEAKS BETWEEN 4-6PM– STRESS– ENVIRONMENT– INGESTION– SMOKING

WHEN HEAT LOST = HEAT PRODUCED IT IS CALLED HOMEOSTASIS

T or thermoregulation is controlled by the HYPOTHALAMUS in the brain

**TEMPERATURE IS THE LEAST LIKELY AFFECTED BY PAIN

Figure 11-2

Disposable, single-use thermometer strip.

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

ORAL—BLUE OR CLEAR TIPPEDRECTAL—RED TIPPED

Electronic thermometer.

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

TYMPANIC—FAST AND ACCURATE

Tympanic thermometer with probe cover inserted into auditory canal.

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

TEMPERATURE

TEMPERATURE LOCATIONS– ORAL—– Do not use if:

HAD ORAL SURGERY, CANNOT HOLD THERMOMETER PROPERLY, AND IF CHILLING

– RECTAL— MOST RELIABLE, USUALLY MEASURES 1 DEGREE HIGHER USED ON NEWBORN TO ENSURE PATENT ANUS DO NOT USE:

– ON CARDIAC PATIENTS DUE TO VAGAL STIMULATION (DROPS PULSE)

– AXILLARY— (recorded AX) LEAST ACCURATE BUT NON-INVASIVE. USUALLY 1 DEGREE LOWER

– TYMPANIC— USE IF ORAL TEMP CONTRAINDICATED ACCURATE, SAFE, NONINVASIVE

TEMPERATURE RANGES– HUMAN LIFE CANNOT EXIST OUTSIDE OF 77-113 F NOT COMPATIBLE FOR CELLULAR ACTIVITY <93 OR >105.8

HYPOTHERMIA—ABNORMALLY LOW BODY TEMPERATURE

HYPERTHERMIA—TEMPERATURE ABOVE NORMAL

AFEBRILE—NO TEMPERATURE

HYPERPYREXIA—TEMP >105 F

FEVER SIGNS OF FEVER

– USUALLY 1ST SIGN OF INFECTION– THIRST– ANOREXIA– FLUSHED SKIN– GLASSY EYES– PERSPIRATION– HEADACHE– INCREASED PULSE AND RESPIRATION– RESTLESS, SLEEPY, DISORIENTATION, CONVULSIONS

CLASSIFICATIONS OF FEVER– CONSTANT– INTERMITTENT– REMITTENT

C = 9/5 + 32 F = -32 X 5/9

TEMPERATURE

FACTORS AFFECTING TEMPERATURE– AGE– EXERCISE– HORMONAL INFLUENCE– DIURNAL VARIATIONS– STRESS– ENVIRONMENT– INGESTION OF HOT OR COLD LIQUIDS– SMOKING

FACTORS TO ASSESS IN DETERMINING POTENTIAL ALTERATIONS IN PULSE

PULSE REPRESENTS THE WAVE OF PRESSURE PRODUCED WHEN THE HEART CONTRACTS

NURSE NOTES THE RATE, RHYTHM, AND VOLUME WHEN TAKING A PULSE.

FACTORS TO ASSESS IN DETERMINING POTENTIAL ALTERATIONS IN PULSE

RATE– NORMAL RATE IS 60-100 BPM– TACHYCARDIA-->100 BPM

Several causes…

– HYPOVOLEMIA—LOW BLOOD VOLUME

– BRADYCARDIA--<60 BPM Several causes…

– **ALWAYS ASSESS PULSE BEFORE GIVING CARDIOTONIC MEDS

THEY USUALLY STRENGTHEN AND SLOW THE HEARTBEAT

PULSE

RHYTHM– TIME BETWEEN BEATS

SHOULD BE EQUAL AND REGULAR

– DYSRHYTHMIA = abnormality

– ARRHYTHMIA = Irregularity

PULSE

VOLUME = amount of blood with every beat– 0=ABSENT– 1+=THREADY (difficult to palpate, disappears

easily with pressure)– 2+=WEAK (difficult to palpate)– 3+=NORMAL– 4+=BOUNDING (felt easily with slight pressure)

PULSE

INFLUENCING FACTORS– AGE– EXERCISE– FEVER, HEAT– ACUTE PAIN, ANXIETY– UNRELIEVED SEVERE PAIN, CHRONIC PAIN– MEDICATIONS– HEMORRHAGE– POSTURAL CHANGES– METABOLISM– EMOTION– SIZE– HEART CONDITION

SITES FOR PULSE MEASUREMENT

TEMPORAL—TEMPORALIS ARTERY (not common)

CAROTID—COMMON FOR MONITORING DURING EXERCISE

APICAL—DESIRED SITE IF PATIENT HAVING CHEST PAIN– ALWAYS TAKE FOR 1 MINUTE

BRACHIAL—INSIDE ELBOW (excellent site for newborns, infants)

RADIAL—THUMB SIDE OF WRIST

SITES FOR PULSE MEASUREMENT

FEMORAL—INNER LEG, BEND OF LEG BY GROIN

POPLITEAL—BEHIND KNEE

PEDAL—– DORSALIS PEDIS (TOP OF FOOT) – POSTERIOR TIBIAL (BEHIND MEDIAL MALLEOLUS)

USE PADS OF INDEX FINGERS WITH LIGHT PRESSURE. DO NOT OCCLUDE BLOOD FLOW

Figure 11-7

PULSE

SITES

Figure 11-9

A, Point of maximum impulse is at fifth intercostal space. B, Assessing apical pulse.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

PROCEDURE FOR DETERMINING RESPIRATORY STATUS

RESPIRATION IS TAKING IN OXYGEN AND BREATHING OUT CARBON DIOXIDE

-THE PROCESS OF INHALING AND EXHALING

PROCEDURE FOR DETERMINING RESPIRATORY STATUS

INTERNAL RESPIRATIONS—EXCHANGE OF GAS AT THE ALVEOLAR LEVEL– DIFFUSION—EXCHANGE OF O2 AND CO2 BETWEEN

ALVEOLI AND RBCs– PERFUSION—DISTRIBUTION OF BLOOD THROUGH

PULMONARY CAPILLARIES– VENTILATION—MECHANICAL MOVEMENT OF AIR– ALVEOLAR—TINIEST AIR CELLS OF THE LUNGS– OXIDATION—O2 CONTENT OF COMPOUND

INCREASED

RESPIRATORY CONTINUED

EXTERNAL RESPIRATIONS– INSPIRATION—AIR IN– EXPIRATION—AIR OUT– EACH RISE AND FALL OF THE CHEST IS ONE RESPIRATION

RATE—CONTROLLED BY MEDULLA OBLONGATA IN THE BRAIN– EUPNEA—Normal Breathing

NORMAL ADULT RATE IS 12-20 BPM– TACHYPNEA—Rapid Breathing

RAPID RESPIRATIONS >20 BPM– BRADYPNEA—Slow Breathing

SLOW RESPIRATIONS <12 BPM

RESPIRATORY CONTINUED

METABOLISM– ACTIVITY– DEPTH– DIAPHRAM– RHYTHM– INTERCOSTAL MUSCLES

RESPIRATORY CONTINUED

RESPIRATORY TERMS– EUPNEA—NORMAL BREATHING

– DYSPNEA—BREATHING WITH DIFFICULTYSHORTNESS OF BREATH (SOB)

– APNEA—LACK OF RESPIRATION

RESPIRATORY CONTINUED

RESPIRATORY TERMS– CHEYNE STOKES—ALTERNATING APNEA AND

DEEP, RAPID BREATHING

RESPIRATORY CONTINUED

RESPIRATORY TERMS

– KUSSMAUL—DEEP AND RAPID ASSOCIATED WITH DKA

PATTERNS OF RESPIRATIONS

RESPIRATORY CONTINUED

RESPIRATORY TERMS– ORTHOPNEA:

DIFFICULTY BREATHING LYING DOWN

MUST SIT UP OR STAND TO BREATHE

RESPIRATORY CONTINUED

RESPIRATORY TERMS– HYPERVENTILATION—RATE EXCEEDS

METABOLIC NEEDS– HYPOVENTILATION—RATE NOT

ENOUGH FOR METABOLIC NEEDS

RESPIRATORY CONTINUED

RESPIRATORY TERMS– HYPOXIA—LOW CELLULAR OXYGEN – ANOXIA—LACK OF OXYGEN AT CELL

LEVEL, NO SYSTEMIC O2

RESPIRATIONS

INFLUENCING FACTORS– DISEASE OR ILLNESS– STRESS– FEVER (HYPERPYREXIA)– AGE– GENDER– BODY POSITION

RESPIRATIONS

INFLUENCING FACTORS– MEDICATIONS (NARCOTICS DECREASE RR)– EXERCISE– ACUTE PAIN– SMOKING– BRAIN STEM INJURY

OCCASIONAL SIGHING IS NORMAL—AERATES ALVEOLI

FACTORS TO ASSESS IN DETERMINING ALTERATIONS IN BLOOD PRESSURE

BLOOD PRESSURE– SYSTOLIC PRESSURE: HIGHEST NUMBER

AND PRESSURE (1ST SOUND HEARD)– DIASTOLIC PRESSURE: LOWEST NUMBER

AND PRESSURE REPRESENTS PRESSURE BETWEEN

CONTRACTIONS

FACTORS TO ASSESS IN DETERMINING ALTERATIONS IN BLOOD PRESSURE

BLOOD PRESSURE– PULSE PRESSURE: DIFFERENCE BETWEEN

SYSTOLIC AND DIASTOLIC– ESSENTIAL HYPERTENSION: ELEVATED

BLOOD PRESSURE WITH NO KNOWN CAUSE

BLOOD PRESSURE REFLECTS CARDIAC OUTPUT – USUALLY 5 QTS OR 5 LITERS

BLOOD PRESSURE

HYPERTENSION: BP ABOVE NORMAL LIMITS—USUALLY >140/90– BP INCREASED BY:– INCREASED ICP– PAIN – END STAGE RENAL DISEASE (ESRD)– EXERCISE – SMOKING – VASOCONSTRICTION: NARROWING OF VESSELS– VASODILATION: WIDENING OF VESSELS

BLOOD PRESSURE

FACTORS AFFECTING BP– AGE– ANXIETY, FEAR, PAIN, EMOTIONAL STRESS– MEDICATIONS– DIURNAL FACTORS– RACE—BLACKS HAVE INCREASED RISK FOR

HTN

BLOOD PRESSURE

FACTORS AFFECTING BP– HORMONES– SEX: MEN HAVE INCREASED RISK FOR HTN– OBESITY: DUE TO MORE VESSELS TO PUMP

THROUGH– FAMILY HISTORY– HIGH CHOLESTEROL LEVELS

BLOOD PRESSURE

DIAGNOSIS OF HTN– NOT DIAGNOSED WITH ONE READING– MOST CONCERNED WITH DIASTOLIC– FALSE HIGH READINGS CAUSED BY PATIENT

TALKING OR ARM NOT BEING SUPPORTED

HYPOTENSION <90/50 IS NOT HEALTHY

BLOOD PRESSURE

CAUSES OF HYPOTENSION– SHOCK– HEMORRHAGE (DECREASED VOLUME, DECREASED

PRESSURE)– GENERAL ANESTEHESIA—DEPRESSES VASOMOTOR

CENTER IN BRAIN STEM– ALCOHOL– POSTURAL CHANGES

ORTHOSTATIC HYPOTENSION: OCCURS WHEN CHANGING POSITION TOO QUICKLY

ACTIONS NEEDED TO TAKE AN ACURATE BLOOD PRESSURE

EQUIPMENT KOROTKOFF SOUNDS ENVIRONMENTAL CONSIDERATIONS

– QUIET– CORRECT CUFF SIZE– GUAGE AT EYE LEVEL– POSITION OF PATIENT—

LYING OR SITTING WITH FEET FLAT ON FLOOR LEGS NOT CROSSED

Figure 11-11

Aneroid manometer and cuff.

(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.)

Figure 11-17

Electronic sphygmomanometer.

Figure 11-12

Wall-mounted aneroid sphygmomanometer.

(From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.)

Figure 11-14

Doppler stethoscope over brachial artery to measure blood pressure.

(From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.)

BLOOD PRESSSURE

NURSING INTERVENTIONS– AVOID TAKING BPs:

IN ARM WITH IV’S, INJURY OR DISEASE, CAST OR BANDAGED, OR PARALYZED FROM STROKE

– IF YOU HAVE DIFFICULTY TAKING A BP, RELEASE CUFF, WAIT 1-2 MINUTES AND TRY AGAIN

BLOOD PRESSSURE

PLACEMENT– NEVER ON MASTECTOMY SIDE– IN LEG, SYSTOLIC & DIASTOLIC 10-40MM HG

HIGHER

HOME DEVICES—NOT ALWAYS ACCURATE

PROCEDURE FOR OBTAINING ACCURATE HEIGHT AND WEIGHT

DEFINITIONS– HEIGHT AND WEIGHT ARE A RATIO—YOU NEED

BOTH PURPOSE

– ASSESS GROWTH AND DEVELOPMENT– CALCULATE DRUG DOSAGE– ASSESS EFFECTIVENESS OF DRUG THERAPY– S/S OF DISEASE– DETERMINE NUTRITION OR FLUID BALANCE

PROCEDURE FOR OBTAINING ACCURATE HEIGHT AND WEIGHT

TO GET ACCURATE WEIGHT:– BALANCE SCALE FIRST.– SAME TIME, SAME SCALE, SAME CLOTHES– IDEAL TIME:

AFTER VOIDING & BEFORE BREAKFAST

HEIGHT OBTAINED BY MEASUREMENT

Figure 11-18

Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.

(From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.)

FACTORS TO ASSESS IN DETERMINING POTENTIAL ALTERATIONS IN

OXYGEN SATURATION

KEY TIMES TO ASSESS PULSE OXIMETRY

– NAILBED—CLOTHESPIN– MEASURES ARTERIAL OXYGEN SATURATION

(SAO2)– <70% IS LIFE THREATENING

FREQUENCY OF VS MEASUREMENT

ADMISSION FACILITY POLICY/PHYSICIAN ORDER INSTABILITY BEFORE/AFTER SURGERY/PROCEDURE BEFORE/AFTER MEDS ROUTINELY DURING PROCEDURES WHEN CLIENT REPORTS SX OF DISTRESS

NORMAL LIMITS FOR VARIOUS AGES

SEE CHART IN QUANTUM– MUST KNOW NORMALS…

DISCUSS PATIENT/FAMILY TEACHING IN REGARDS TO VITAL SIGNS

Questions?

THE END!!!