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Vital signs

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Vital signs

  1. 1. Kozier & Erb's Fundamentals of Nursing, 8e Berman, Snyder, Kozier, Erb Copyright 2008 by Pearson Education, Inc. Chapter 29 Vital Signs
  2. 2. Copyright 2008 by Pearson Education, Inc. Vital Signs • Body temperature, pulse, respirations, and Blood Pressure • Monitor functions of the body • Should be a thoughtful, scientific assessment
  3. 3. Copyright 2008 by Pearson Education, Inc. When to Assess Vital Signs • On admission • Change in client’s health status • Client reports symptoms such as chest pain, feeling hot, or faint • Pre and post surgery/invasive procedure • Pre and post medication administration that could affect CV system • Pre and post nursing intervention that could affect vital signs
  4. 4. Copyright 2008 by Pearson Education, Inc. Body Temperature • Reflects the balance between the heat produced and the heat lost from the body • Measured by heat units called degrees
  5. 5. Copyright 2008 by Pearson Education, Inc. Factors Affecting Body Temperature • Age • Diurnal variations (circadian rhythms) • Exercise • Hormones • Stress • Environment
  6. 6. Copyright 2008 by Pearson Education, Inc. Alterations in Body Temperature • Pyrexia, Hyperthermia, Fever - body temperature above the usual range • Febrile - a client who has a fever • Afebrile - a client who does not have fever • Hypothermia - core body temperature below the lower limit of normal
  7. 7. Copyright 2008 by Pearson Education, Inc. Pulse • Is a wave of blood created by contraction of the left ventricle of the heart • Represents the amount of blood that enters the arteries with each ventricular contraction • Peripheral pulse- a pulse located away from the heart Ex. Foot or wrist • Apical pulse- is the central pulse that is located at the apex of the heart
  8. 8. Copyright 2008 by Pearson Education, Inc. Factors Affecting Pulse • Age • Gender • Exercise • Fever • Medications • Hypovolemia • Stress • Position changes • Pathology
  9. 9. Copyright 2008 by Pearson Education, Inc. Factors Affecting Respirations • Exercise • Stress • Environmental temperature • Medications
  10. 10. Copyright 2008 by Pearson Education, Inc. Factors Affecting Blood Pressure • Age • Exercise • Stress • Race • Gender • Medications • Obesity • Diurnal variations • Disease process
  11. 11. Copyright 2008 by Pearson Education, Inc. Temperature: Lifespan Considerations Infants Unstable Newborns must be kept warm to prevent hypothermia Children Tympanic or temporal artery sites preferred Elders Tends to be lower than that of middle-aged adults
  12. 12. Copyright 2008 by Pearson Education, Inc. Pulse: Lifespan Considerations Infants Newborns may have heart murmurs that are not pathological Children The apex of the heart is normally located in the fourth intercostal space in young children; fifth intercostal space in children 7 years old and older Elders Often have decreased peripheral circulation
  13. 13. Copyright 2008 by Pearson Education, Inc. Respirations: Lifespan Considerations Infants Some newborns display “periodic breathing” Children Diaphragmatic breathers Elders Anatomic and physiologic changes cause respiratory system to be less efficient
  14. 14. Copyright 2008 by Pearson Education, Inc. Blood Pressure: Lifespan Considerations Infants Arm and thigh pressures are equivalent under 1 year of age Children Thigh pressure is 10 mm Hg higher than arm Elders Client’s medication may affect how pressure is taken
  15. 15. Copyright 2008 by Pearson Education, Inc. Sites for Measuring Body Temperature • Oral • Rectal • Axillary • Tympanic membrane • Skin/Temporal artery
  16. 16. Copyright 2008 by Pearson Education, Inc. Types of Thermometers • Electronic • Chemical disposable • Infrared (tympanic) • Scanning infrared (temporal artery) • Temperature-sensitive tape • Glass mercury
  17. 17. Copyright 2008 by Pearson Education, Inc. Nursing Care for Fever • Monitor vital signs • Assess skin color and temperature • Monitor laboratory results for signs of dehydration or infection • Remove excess blankets when the client feels warm • Provide adequate nutrition and fluid • Measure intake and output • Reduce physical activity • Administer antipyretic as ordered • Provide oral hygiene • Provide a tepid sponge bath • Provide dry clothing and bed linens
  18. 18. Copyright 2008 by Pearson Education, Inc. Nursing Care for Hypothermia • Provide warm environment • Provide dry clothing • Apply warm blankets • Keep limbs close to body • Cover the client’s scalp • Supply warm oral or intravenous fluids • Apply warming pads
  19. 19. Copyright 2008 by Pearson Education, Inc. Pulse Sites Radial Readily accessible Temporal When radial pulse is not accessible Carotid During cardiac arrest/shock in adults Determine circulation to the brain Apical Infants and children up to 3 years of age Discrepancies with radial pulse Monitor some medications
  20. 20. Copyright 2008 by Pearson Education, Inc. Pulse Sites Brachial Blood pressure Cardiac arrest in infants Femoral Cardiac arrest/shock Circulation to a leg; Popliteal Circulation to lower leg Posterior tibial Circulation to the foot Dorsalis pedis Circulation to the foot
  21. 21. Copyright 2008 by Pearson Education, Inc. Characteristics of the Pulse • Rate tachycardia- over 100 BPM bradycardia- less than 60 BPM • Rhythm dysrhytmia or arrhythmia- irregular pulse • Volume force of blood with each beat absent to bounding • Arterial wall elasticity • Bilateral equality
  22. 22. Copyright 2008 by Pearson Education, Inc. Pulse Rate and Rhythm • Rate – Beats per minute – Tachycardia – Bradycardia • Rhythm – Equality of beats and intervals between beats – Dysrhythmias – Arrhythmia
  23. 23. Copyright 2008 by Pearson Education, Inc. Characteristics of the Pulse • Volume – Strength or amplitude – Absent to bounding • Arterial wall elasticity – Expansibility or deformity • Presence or absence of bilateral equality – Compare corresponding artery
  24. 24. Copyright 2008 by Pearson Education, Inc. Measuring Apical Pulse
  25. 25. Copyright 2008 by Pearson Education, Inc. Apical-Radial Pulse • Locate apical and radial sites • Two nurse method: – Decide on starting time – Nurse counting radial says “start” – Both count for 60 seconds – Nurse counting radial says “stop” – Radial can never be greater than apical
  26. 26. Copyright 2008 by Pearson Education, Inc. Inhalation • Diaphragm contracts (flattens) • Ribs move upward and outward • Sternum moves outward • Enlarging the size of the thorax
  27. 27. Copyright 2008 by Pearson Education, Inc. Exhalation • Diaphragm relaxes • Ribs move downward and inward • Sternum moves inward • Decreasing the size of the thorax
  28. 28. Copyright 2008 by Pearson Education, Inc. Respiratory Control Mechanisms • Respiratory centers – Medulla oblongata – Pons
  29. 29. Copyright 2008 by Pearson Education, Inc. Components of Respiratory Assessment • Rate • Depth • Rhythm • Quality • Effectiveness
  30. 30. Copyright 2008 by Pearson Education, Inc. Respiratory Rate and Depth • Rate – Breaths per minute – Apnea – absence of breathing – Bradypnea- abnormally slow respirations – Tachypnea- abnormally fast respirations • Depth – Normal – Deep – Shallow
  31. 31. Copyright 2008 by Pearson Education, Inc. Components of Respiratory Assessment • Rhythm – Regular – Irregular • Quality – Effort – Sounds • Effectiveness – Uptake and transport of O2 – Transport and elimination of CO2
  32. 32. Copyright 2008 by Pearson Education, Inc. Alteratered Breathing Patterns • Rate – Tachypnea – quick, shallow breaths – Bradypnea- abnormally shallow breathing – Apnea- absence or cessation of breathing • Volume -Hyperventilation- overexpansion of the lungs characterized by rapid and deep breaths -Hypoventilation- underexpansion of the lungs characterized by shallow respirations
  33. 33. Copyright 2008 by Pearson Education, Inc. Alteratered Breathing Patterns • Rhythm – Cheyne- Stroke breathing- rhythmic waxing and waning of respirations, from very deep to very shallow breathing and temporary apnea • Ease or Effort – Dyspnea- difficult and labored breathing during which the individual has a persistent, unsatisfied need for air and feels distressed – Orthopnea- ability to breathe only in upright sitting or standing positions
  34. 34. Copyright 2008 by Pearson Education, Inc. Alteratered Breath Sounds • Stridor – a shrill, harsh sound heard during inspiration with laryngeal obstruction • Wheeze- continuous, high pitched musical squeak or whistling sound occuring on expiration
  35. 35. Copyright 2008 by Pearson Education, Inc. Systolic and Diastolic Blood Pressure • Systolic – Contraction of the ventricles • Diastolic – Ventricles are at rest – Lower pressure present at all times • Pulse Pressure = difference between systolic and diastolic pressures • Measured in mm Hg • Recorded as a fraction, e.g. 120/80 • Systolic = 120 and Diastolic = 80
  36. 36. Copyright 2008 by Pearson Education, Inc. Korotkoff’s Sounds
  37. 37. Copyright 2008 by Pearson Education, Inc. Korotkoff’s Sounds • Phase 1 – First faint, clear tapping or thumping sounds – Systolic pressure • Phase 2 – Muffled, whooshing, or swishing sound
  38. 38. Copyright 2008 by Pearson Education, Inc. Korotkoff’s Sounds • Phase 3 – Blood flows freely – Crisper and more intense sound – Thumping quality but softer than in phase 1 • Phase 4 – Muffled and have a soft, blowing sound • Phase 5 – Pressure level when the last sound is heard – Period of silence – Diastolic pressure
  39. 39. Copyright 2008 by Pearson Education, Inc. Measuring Blood Pressure • Direct (Invasive Monitoring) • Indirect – Auscultatory – Palpatory • Sites – Upper arm (brachial artery) – Thigh (popliteal artery)
  40. 40. Copyright 2008 by Pearson Education, Inc. Pulse Oximetry
  41. 41. Copyright 2008 by Pearson Education, Inc. Pulse Oximetry • Noninvasive • Estimates arterial blood oxygen saturation (SpO2) • Normal SpO2 85-100%; < 70% life threatening • Detects hypoxemia before clinical signs and symptoms • Sensor, photodetector, pulse oximeter unit
  42. 42. Copyright 2008 by Pearson Education, Inc. Pulse Oximetry • Factors that affect accuracy include: – Hemoglobin level – Circulation – Activity – Carbon monoxide poisoning
  43. 43. Copyright 2008 by Pearson Education, Inc. Pulse Oximetry • See Skill 29-7 • Prepare site • Align LED and photodetector • Connect and set alarms • Ensure client safety • Ensure accuracy
  44. 44. Copyright 2008 by Pearson Education, Inc. Resources • Audio Glossary • HyperHEART Shows the heart pumping and talks about diastolic and systolic cycles. Has tutorials for atrial systole and others. Very fun site. • Best Practice--Vital Signs Reviews research studies related to vital signs. Covers all aspects of vital signs and even gives implications for practice and recommendations. • The Medical Center--Vital Signs Provides an overview of vital signs. Nicely done.
  45. 45. Copyright 2008 by Pearson Education, Inc. Resources • The National Women's Health Information Center Good overview of blood pressure, especially high blood pressure, and its effects on women. • MEDLINEplus--Blood Pressure Describes blood pressure in detail • MEDLINEplus--Pulse Describes pulse in detail • MEDLINEplus--Temperature measurements Describes temperatures in detail • A Practical Guide to Clinical Medicine--Vital Signs An in-depth look at vital signs. Has graphic pictures to explain vital signs.

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