FUNDAMENTALS OF NURSING

1. FUNDAMENTALS OF NURSING LESSON 4 VITAL SIGNS

2. VOCABULARY KNOW VOCABULARY WORDS

3. 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

4. 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

5. Figure 11-2 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Disposable, single-use thermometer strip.

6. ORAL—BLUE OR CLEAR TIPPEDRECTAL—RED TIPPED (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Electronic thermometer.

7. TYMPANIC—FAST AND ACCURATE (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Tympanic thermometer with probe cover inserted into auditory canal.

8. 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

9. 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

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

11. 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.

12. 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

13. PULSE • RHYTHM • TIME BETWEEN BEATS • SHOULD BE EQUAL AND REGULAR • DYSRHYTHMIA = abnormality • ARRHYTHMIA = Irregularity

14. 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)

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

16. 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

17. 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

18. Figure 11-7 PULSE SITES

19. Figure 11-9 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Point of maximum impulse is at fifth intercostal space. B, Assessing apical pulse.

20. PROCEDURE FOR DETERMINING RESPIRATORY STATUS RESPIRATION IS TAKING IN OXYGEN AND BREATHING OUT CARBON DIOXIDE -THE PROCESS OF INHALING AND EXHALING

21. 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

22. 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

23. RESPIRATORY CONTINUED • METABOLISM • ACTIVITY • DEPTH • DIAPHRAM • RHYTHM • INTERCOSTAL MUSCLES

24. RESPIRATORY CONTINUED • RESPIRATORY TERMS • EUPNEA—NORMAL BREATHING • DYSPNEA—BREATHING WITH DIFFICULTY • SHORTNESS OF BREATH (SOB) • APNEA—LACK OF RESPIRATION

25. RESPIRATORY CONTINUED • RESPIRATORY TERMS • CHEYNE STOKES—ALTERNATING APNEA AND DEEP, RAPID BREATHING

26. RESPIRATORY CONTINUED • RESPIRATORY TERMS • KUSSMAUL—DEEP AND RAPID • ASSOCIATED WITH DKA

27. PATTERNS OF RESPIRATIONS

28. RESPIRATORY CONTINUED • RESPIRATORY TERMS • ORTHOPNEA: • DIFFICULTY BREATHING LYING DOWN • MUST SIT UP OR STAND TO BREATHE

29. RESPIRATORY CONTINUED • RESPIRATORY TERMS • HYPERVENTILATION—RATE EXCEEDS METABOLIC NEEDS • HYPOVENTILATION—RATE NOT ENOUGH FOR METABOLIC NEEDS

30. RESPIRATORY CONTINUED • RESPIRATORY TERMS • HYPOXIA—LOW CELLULAR OXYGEN • ANOXIA—LACK OF OXYGEN AT CELL LEVEL, NO SYSTEMIC O2

31. RESPIRATIONS • INFLUENCING FACTORS • DISEASE OR ILLNESS • STRESS • FEVER (HYPERPYREXIA) • AGE • GENDER • BODY POSITION

32. RESPIRATIONS • INFLUENCING FACTORS • MEDICATIONS (NARCOTICS DECREASE RR) • EXERCISE • ACUTE PAIN • SMOKING • BRAIN STEM INJURY • OCCASIONAL SIGHING IS NORMAL—AERATES ALVEOLI

33. 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

34. 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

35. 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

36. BLOOD PRESSURE • FACTORS AFFECTING BP • AGE • ANXIETY, FEAR, PAIN, EMOTIONAL STRESS • MEDICATIONS • DIURNAL FACTORS • RACE—BLACKS HAVE INCREASED RISK FOR HTN

37. 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

38. 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

39. 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

40. 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

41. Figure 11-11 (From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.) Aneroid manometer and cuff.

42. Figure 11-17 Electronic sphygmomanometer.

43. Figure 11-12 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Wall-mounted aneroid sphygmomanometer.

44. Figure 11-14 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Doppler stethoscope over brachial artery to measure blood pressure.

45. 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

46. BLOOD PRESSSURE • PLACEMENT • NEVER ON MASTECTOMY SIDE • IN LEG, SYSTOLIC & DIASTOLIC 10-40MM HG HIGHER • HOME DEVICES—NOT ALWAYS ACCURATE

47. 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

48. 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

49. Figure 11-18 (From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.) Types of scales. A, Standing scale. B, Chair scale. C, Lift scales.

50. 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