Chapter 17: Vital Signs

1. Chapter 17: Vital Signs

2. VITAL SIGNS • TEMPERATURE • BLOOD PRESSURE • PULSE • APICAL • RADIAL • RESPIRATIONS • PULSE OXIMETRY • PAIN SCALE

3. VITAL SIGNS ARE PART OF THE PHYSICAL ASSESSMENT • Delegation of Duties to UAP • Unlicensed Assistive Personnel • RN is Responsible to Manage Care Based on Physical Assessment • Administering medications • Communicating to other members of the health care team • Supervising delegated tasks

4. EQUIPMENT • RN is responsible for assuring equipment is functioning properly • Appropriate equipment • Must be appropriate to patient age size • Thermometer • Stethoscope: Diaphragm (high-pitched sounds); bell (low-pitched sounds) • BP cuff • Pulse oximeter

5. PATIENT HISTORY • RN must know patient medical history, including medications • These facts can affect vital signs • RN is responsible for knowing the patient’s usual vital sign range

6. FREQUENCY OF VITAL SIGNS • Physicians order the frequency of vital signs • Could be ordered by protocol or policy • The RN can increase the frequency based on his/her assessment • VITAL SIGNS can be an early warning sign that complications are developing

7. INDICATIONS FOR MEDICATION ADMINISTRATION Many medications are administered when the vital signs are within an acceptable range. Accurate VITAL SIGNS are required in order to make treatment decisions.

8. COMPREHENSIVE ASSESSMENT FINDINGS Compare VITAL SIGNS to assessment findings and laboratory results to accurately interpret the patient status. Discuss your findings with peers and charge RN before deciding on a plan of action. Use the opportunity to teach patient/family about what VS mean, reason for assessing, meaning if appropriate

9. TEMPERATURE • Factors affecting body temp. (36-38°C/96.8-100.4°F) • Age • Infants: 95.9 – 99.5° F [36.5-37.2C] intolerant of extremes • Elderly: Average temp is 96.8° F; Sensitive to temp extremes • Exercise • Hormone levels • Circadian rhythm • Stress • Environment

10. TEMPERATURE ALTERATIONS • Afebrile • Pyrexia [fever] >37.5 • Fever of unknown origin (FUO) • Malignant hyperthermia: hereditary, occurs during anesthesia • Heatstroke: medical emergency • Heat exhaustion • Hypothermia • Frostbite

11. TEMPERATURE Cont’d. • Sites • Core temp is measured in pulmonary artery, esophagus, and urinary bladder • Common sites: • Mouth, rectum, tympanic membrane, temporal artery, and axilla – use critical thinking to decide! • Variety of types available – electronic and disposable • Antipyretics = drugs that reduce fever

12. Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error.

13. PULSE • Sites • Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, DorsalisPedis • Increases in HR • Short-term exercise, fever, heat, pain, anxiety, drugs, loss of blood, standing or sitting, poor oxygenation • Decreases in HR • Long-term exercise, hypothermia, relaxation, drugs, lying down

14. PULSE Cont’d. • Volume of blood pumped by the heart during 1 minute is the cardiac output • When mechanical, neural or chemical factors are unable to alter stroke volume, a change in heart rate will result in change in cardiac output, which affects blood pressure • HR ↑, less time for heart to fill, BP ↓ • HR ↓, filling time is increased, BP ↑ • An abnormally slow, rapid, or irregular pulse alters cardiac output

15. The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes.

16. RESPIRATIONS • Ventilation = the movement of gases in and out of lungs • Diffusion = the movement of oxygen and CO2 between the alveoli and RBCs • Perfusion = the distribution of RBCs to and from the pulmonary capillaries

17. Factors Influencing Character of Respirations • Exercise • Acute Pain • Anxiety • Acid-Base balance • Body Position • Medications • Neurological injury • Hemoglobin function

18. RESPIRATIONS Cont’d. • Tachypnea = rapid breathing • Apnea = cessation of breathing • Cheyne-Stokes = rate and depth irregular, alternate periods of apnea and hyperventilation • Kussmaul’s = abnormally deep, regular, and increased in rate (associated with DM)

19. PULSE OXIMETER • Indirect measurement of oxygen saturation • Photodetector detects the amount of oxygen bound to hemoglobin molecules and oximeter calculates the pulse saturation • Only reliable when SaO2 is over 70% • Certain conditions may give an inaccurate reading

20. A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by which of the following? A) The placement of the sensor on the extremityB) A diagnosis of peripheral vascular diseaseC) A reduced amount of artificial light in the roomD) The increased ambient temperature of the client’s room

21. BLOOD PRESSURE • Force exerted on the walls of an artery by the pulsing blood under pressure from the heart • Systolic = maximum pressure when ejection occurs • Diastolic = minimum pressure of blood remaining in the arteries after ventricles relax

22. BLOOD PRESSURE Cont’d. • Physiology of arterial blood pressure • Cardiac Output, Peripheral resistance, Blood volume, Viscosity, Elasticity • Factors influencing BP • Age, Stress, Ethnicity, Gender, Daily Variation, Meds, Activity, Weight, Smoking • Hypertension • Hypotension • Orthostatic or postural hypotension

23. The nurse is assessing a client’s blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mmHg. The nurse determines that the client’s pressure today is 134/70 mmHg. The nurse recognizes that the most likely cause of the elevation is due to which of the following? A) The difference between the monitoring equipment being used B) The client’s inability to hear the first Korotkoff sound C) The client may be experiencing mild anxiety regarding the check-up D) The client is not inflating the cuff sufficiently to detect the systolic pressure

24. QUESTIONS?