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Vital Signs

Vital Signs. By Diana Blum MSN NURS 1510. What are they? . Pulse Respirations BP Temperature Oxygen Sats. How often?. As ordered Q1hour Q2 hours Q4 hours Routine (Q8hours) Based on client condition. WHY?.

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Vital Signs

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  1. Vital Signs By Diana Blum MSN NURS 1510

  2. What are they? • Pulse • Respirations • BP • Temperature • Oxygen Sats

  3. How often? • As ordered • Q1hour • Q2 hours • Q4 hours • Routine (Q8hours) • Based on client condition

  4. WHY? • Baseline values establish the norm against which subsequent measures are compared • Nurse is • Responsible for measuring, interpreting significance and making decisions about care • Knowing normal ranges • Knowing history and other therapies that may affect VS

  5. Temperature • Degree of heat maintained by the body • Heat produced minus heat lost equals body temperature • Organs have receptors that monitor core body temperature

  6. Temperature • Core temperature • Normal • 96.2 degrees F to 100.4 degrees F • 36.2 degrees C to 38 degrees C • Surface temperature • Lower than core temperature • Use oral and axillary method

  7. Regulation of Temperature • Neural control • Hypothalmus acts as thermostat • Vascular control • Vasoconstriction ---hypothalmus directs the body to decrease heat loss and increase heat production • If cold, vasoconstriction will conserve heat—shivering will occur

  8. Regulation of temperature • Vasodilation • If body temp is above normal, the hypothalamus will direct the body to decrease heat production; • Perspiration and increased respiratory rate • Body heat production • Body’s cells produce heat from food—releasing energy. • BMR= rate of energy used in the body to maintain essential activities

  9. Changes in temperature • Conduction • Transfer of heat from a warm to cool surface by direct contact • Convection • Transfer of heat through currents of air or water • Radiation • Loss of heat through electromagnetic waves from surfaces that are warmer than the surrounding air • Evaporation • Water to vapor lost from skin or breathing

  10. Factors affecting Temperature • Age • Exercise • Hormones • Circadian cycle • Stress • Ingestion of food • Smoking • Environment • (Page 529)

  11. Variances in temperature • Fever (pyrexia) • Abnormally high body temperature (>100.4 F) • Occurs in response to pyrogens (bacteria) • Pyrogens induce secretion of prostoglandins that reset the hypothalmic thermostat to a higher temperature • Hyperpyrexia • Fever > 105.8

  12. Febrile= has fever • Afebrile= no fever • Intermittent fever: • Remittent fever: • Relapse fever: • Constant fever: • Fever spike: rises rapidly then normal within a few hours

  13. Not a true fever @$!? • Heat exhaustion • Heat stroke • Prolonged exposure to heat source (Ex. SUN) • Depression of hypothalmus • Emergency • S/S: hot, dry skin, confusion, delirium

  14. Serious variations in temperature • Hypothermia • Below 95 degrees • Uncontrolled shivering, loss of memory,LOC decreases • Limits: 77-109 degrees F

  15. Physiologic responses • Temp increases: • Immune system stimulates hypothalmus to new set point • Chills, shivers • Feels cold even though temp increasing • When body temp is reset, chills subside

  16. Physiologic responses • Metabolism increases • O2 consumption increases • HR and RR increase • Energy stores are used • Dehydration and confusion • When cause is removed, set point drops

  17. Physiologic responses • Vasodilation • Warm flushed skin and diaphoresis • Benefits • Activates the immune system • Interleukin 1 stimulates antibody production • Fights viruses by stimulating interleukin • Serves as a diagnostic tool

  18. Routes for taking temperatures • Oral • Most accessible and accurate • Do not use if unconscious, confused recent oral or facial OR • Rectal • 99 F • Avoid with MI and after lower GI • Axillary • 97 F—least accurate, most safe • Tympanic • 98 F—avoid with infection, after exercise, if hearing aid • Infrared • Temporal

  19. Pulse • The wave begins when the left ventricle contracts and ends when the ventricle relaxes • Indirect measure of cardiac output

  20. Pulse • Each contraction forces blood into the already filled aorta, causing increased pressure within the arterial system • Systole: • Diastole: • Cardiac Output=SV x HR • Stroke volume • The quantity of blood pumped out by each contraction of the left ventricle

  21. Pulse • Measured in beats per minute (bpm) • Normal • 60-100 bpm • Females slightly higher • Average • 70-80 bpm

  22. Obtaining pulse rate • Apical is most accurate • Use a standard stethescope to auscultate the number of heartbeats at the apex of the heart • A heartbeat is one series of the LUB and DUB sounds

  23. Common pulse points • Apical: at the apex of the heart • Carotid: between midline and side of neck • Brachial: medially in the antecubital space • Radial: laterally on the anterior wrist • Femoral: in the groin fold • Popliteal: behind the knee • Post tibial • Dorsalis pedis • ulnar

  24. Variances in pulse rates • Bradycardia: rate < 60 bpm • Tachycardia: rate> 100 bpm • Is the rate regular? • What is the quality? • Bounding? • Thready? • Dysrhythmia (arrhythmia) • Pulse deficit • Difference between radial and apical

  25. Factors affecting pulse rate • Exercise • Body temperature • Anxiety • Position • Age • Gender • Emotions • Medications • Hemorrhage • Pulmonary condition • Stress • Fluid Volume

  26. Color Change= Circulation problem • Normal: pink warm dry • Cyanosis • Bluish-grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood • Pallor • Paleness of skin when compared with another part of the body

  27. Respiration=The exchange of oxygen and carbon dioxide in the body • Mechanical • Pulmonary ventilation; breathing • Ventilation: Active movement of air in and out of the respiratory system • Conduction: • Movement through the airways of the lung • Chemical • Exchange of oxygen and carbon dioxide • Diffusion • Movement of oxygen and CO2 between alveoli and RBC • Perfusion • Distribution of blood through the pulmonary capillaries

  28. Mechanics of ventilation • Inspiration • Drawing air into the lung • Involves the ribs, diaphragm • Creates negative pressure-allows air into lung • Expiration • Relaxation of the thoracic muscles and diaphragm causing air to be expelled

  29. Variations in assessment of respirations • Rate: regulated by blood levels of O2, CO2 and ph • Chemial receptors detect changes and signal CNS (medulla) • Normal: 12-20 breaths per minute • Apnea: no breathing • Bradypnea: abnormally slow • Tachypnea: abnormally fast • Observe for one full minute

  30. Variations in assessment findings • Depth • Normal: diaphragm moves ½ inch • Describe as deep or shallow • Rhythm • Assessment of the pattern • Abnormal • Cheyne stokes: • Kussmal's: • Effort • Work of breathing • labored or unlabored • Observe for retractions, nasal flaring and restlessness

  31. Variations in breath sounds • Wheeze • High pitched continuous musical sound; heard on expiration • Rhonchi • Low pitched continuous sounds caused by secretions in large airways • Crackles • Discontinuous sounds heard on inspiration; high pitched popping or low pitched bubbling

  32. Variations in breath sounds • Stridor • Piercing, high pitched sound heard during inspiration • Stertor • Labored breathing that produces a snoring sound • Both may indicate obstruction

  33. Hyperventilation • Rapid and deep breathing resulting in loss of CO2 (hypocapnea); light headed and tingly • Hypoventilation • Rate and depth decreased; CO2 is retained

  34. Tools to measure oxygenation • ABG • directly measures the partial pressures of oxygen, carbon dioxide and blood ph • normal= paCO2 80-100) • Pulse oximetry • non invasive method for monitoring respiratory status; measures O2 saturation • normal= >95-100%

  35. Blood pressure • Force exerted by blood against arterial walls • Work of the heart reflected in periphery via BP • Measured in millimeters of mercury (mm Hg) • Recorded as systolic over diastolic

  36. BP regulation • The body constantly adjusts arterial pressure to supply blood to body tissues • Influenced by three factors • Cardiac function • Peripheral vascular resistance • Blood volume • Normal = 5000 ml • Volume increases=BP increases • Volume decreases= BP decreases • Viscosity= reaction same as volume

  37. Potential Misreads • Palpation • Used when BP is too weak to hear • Errors • Wrong size cuff, deflating too rapidly, incorrect placement • Thigh • Measures 30-40 mm HG less than normal

  38. Factors affecting BP • Diurnal • Medications • Nutrition • Obesity • Disease • Age • Stress • Gender • Race • Exercise

  39. Variations in BP • Values • Normal: < 120/80 mm Hg • Hypotension: SBP< 100mm HG • Pre hypertension: > 120/80 mm Hg • Hypertension: 140/90= Stage 1 160/100= Stage 2 • Persistant increase in BP • Damage to vessels; loss of elasticity; decrease in blood flow to vital organs

  40. Korotkoff’s sounds • Phase 1 • As you deflate the cuff; occurs during systole • Phase 2 • Further deflation of the cuff; soft swishing sound • Phase 3 • Begins midway through; sharp tapping sound • Phase 4 • Similar to 3rd sound but fading • Phase 5 • Silence, corresponding with diastole • Auscultatory Gap: occurs in HTN pts • The sound disappears at high cuff pressure • And reappears at low levels

  41. Measurement of BP • Indirect • Most common, accurate estimate • Direct • In patient setting only • Catheter is threaded into an artery under sterile conditions • Attached to tubing that is connected to monitoring system • Displayed as waveform on monitoring screen

  42. Other BP issues • Orthostatic or postural hypotension • Sudden drop in BP on moving from lying to sitting or standing position • Primary or essential hypertension • Diagnosed when no known cause for increase • Accounts for at least 90% of all cases of hypertension

  43. Nurses can delegate the activity of VS, but are responsible for interpretation, trending and decisions based on the findings

  44. Pain • 5th vital sign • It is what the client says it is • Nurse must know • how to assess for it • Establish acceptable comfort levels • Follow up within appropriate time frame after intervention

  45. Data to be collected • Location (place and position) • Intensity • 1-10 • Strength and severity • What is your pain at present? What makes it worse? What is the best that it gets? • Describe • Aching, stabbing, tender, tiring, numb,…….. • Duration • When did it start? Is is always there? • Aggrevate/alleviate • What makes it better/worse?

  46. How does the pain affect… • Nurse checks for • VS • Knowledge of pain • Med history • Side effects of meds • Use of non pharmacological therapies • Energy • Appetite • Sleep • Activity • Mood • Relationships • Memory • concentration

  47. ANY QUESTIONS????

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