NRS 310Vital Signs, Measurements and Pain assessment Chapters 4 & 6. Nancy Sanderson MSN, RN
Introduce yourself! • Wash your hands (hand sanitizer) • Ask what brought patient to • hospital, clinic, or doctor’s office • As the patient is talking, summarize their appearance: Introductions
Gives overall impression of patient’s health • Provides information about: • Physical Appearance • Hygiene (body, breath) • Body Structure • Mobility • Behavior Be careful about “assumptions” and stereotyping General Survey
Dress • Clothing appropriate to climate, looks clean & fits the body, & is appropriate to the patient’s culture & age group • Appropriate for setting, season, age, gender & social group • Personal hygiene & Grooming • Patient appears clean & groomed appropriately for his/her age, occupation, & socioeconomic group. Hair & nails neat and clean Hair groomed, brushed. Make-up appropriate. • Body odor • Unpleasant odor may result from exercise, poor hygiene or certain disease states • No body odor present Appearance
High functioning Low functioning • Feeling well • Cleanly dressed • Showered • No body odor • No smell of alcohol or other drugs • Follows the conversation well • Feeling poor or low self-esteem* • (*really sick brought in 911) • Unkempt • Dirty (no shower) • Body odor • Alcohol, marijuana or other drug smells • Can’t follow conversation Ways to summarize patient’s appearance
Introduce yourself • Observe the patient • Appearance • Behavior • Listen to concerns/complaints Summary or in a nutshell:
Height • Weight • Head Circumference • Children only • Body Mass Index Measurements
Height & weight reflects a person’s general level of health • In older adults, height & weight coupled with a nutritional assessment determine the cause of and treatment for chronic disease or helps to identify those who have difficulty feeding or other dietary issues • In children, data is used to assess both growth and development • Weight also necessary for dosing of medication Why Height & Weight?
Increased or Decreased Height • Increased • Gigantism • Decreased • Elderly (osteoporosis) • Malnutrition • Dwarfism • Hypopituitary • Achrondroplastic Gigantism & Dwarfism
How to Measure Height Use a specially designed board for measuring • Height (>2 y/o-adulthood) • Remove shoes, and outer wear • Place back to scale or wall • Look straight ahead • Document in centimeters or inches to nearest 1/8 in. • Length (< 2y/o) • Hold head midline, push down knees until legs are flat.
Increased or Decreased Weight • Increased • Excess Nutrition • Cushing’s syndrome • Fluid retention • Decreased • Malnutrition • Acute or Chronic illness • Cancer • Cystic Fibrosis • TB • Eating Disorder • Mental Illness
Weight (2 y/o-adult) • Remove shoes and heavy outer clothing • Record in pounds or kilograms (often kg for children) • Record to nearest ¼ lb • Weight (< 2y/o) • Check calibration, remove all clothing, stay very close to infant so does not fall. • Record to nearest ½ oz in infants and ¼ lb or 0.1kg for toddlers How to Measure Weight
Assess for brain growth and abnormalities • Microcephaly • Macrocephaly • Hydrocephalus Why Head Circumference?
Head Circumference • Measured at birth and each well child visit and then yearly until age 2 years. • (Well child visits: 1 wk, & months 1, 2, 4, 6, 9, 12, 15, 18, 24) or if • Anterior Fontanel (soft spot) closes around 18 – 24 months • Circle tape at widest point and record in centimeters • Above pinna or ears and around occipital prominence • May need to repeat a few times.
The Body Mass Index(BMI) formula was developed by Belgium statistician AdolpheQuetelet (1796-1874) • Was known as the Quetelet Index. • BMI is an internationally used measure of obesity. • http://www.whathealth.com/bmi/chart-imperial.html BMI
More accurate estimate of body fat than weight alone. • Weight (kg)/Height (m²) or Weight (lbs)/height (in.²) x 703 • Underweight <18.5 • Normal 18.5-24.9 • Overweight 25.0-29.9 • Obesity I 30.0-34.9 • Obesity II 35.0-39.9 • Obesity III >40 Body Mass Index (BMI)
More than than half of U.S. adults are overweight (>25) • More than one quarter of U.S. adults are obese (>30) • These are risk factors for diabetes, heart disease, stroke, hypertension, osteoarthritis, sleep apnea, and some forms of cancer BMI: Body Mass Index
Height and Weight needed for BMI • Following trends/health status • Measure head circumference up to the age of 2 Summary (in a nutshell)
Temperature (T) • Pulse (P) • Respiratory Rate (R) • Blood Pressure (BP) • Pulse Ox • Pain • Level of consciousness • Urine out put Vital Signs—5, 6, 7, or 8 VS
There is a variety of vital signs to be established in an acute care setting. • Base line data include measurement of temperature, pulse, respirations, blood pressure and oxygen saturation. • Assessing pain is also considered standard baseline data to be collected on all patients and is often included with vital signs. • Other measurements may need to be included when calling a physician or discussing care with another health care provider. Vital Signs (VS/VTS)
Establish patient’s baseline • On admission to health care facility • Before surgical or invasive diagnostic procedure, transfusion of blood products, administration of medications that affect cardiovascular, respiratory or temperature control functions • Monitor current condition & identify problems • According to routine schedule ordered by provider • During transfusion of blood products, administration of medications that affect cardiovascular, respiratory or temperature control functions • -When pt’s general physical condition changes • When pt reports nonspecific symptoms of physical distress Use of Vital Sign Measurements
Evaluating Response to Intervention • After administration of medications for: Pain; Breathing treatments; Blood Transfusions: Chemotherapy; etc. • Temperature • Pulse • Blood pressure • Respiration • Pulse Ox • Pain • Level of consciousness Use of Vital Sign Measurements
Can delegate, but nurse caring for the patient is responsible for analyzing vital signs & making decisions about interventions • Make sure equipment is functioning and appropriate for the size, age, and condition of the patient • Know each patient’s: • Medical history • Prescribed medications and therapies • Baseline vital signs Guidelines for Nursing Practice
Convert Fahrenheit to Celsius • C = (F -32°) x 5/9 • Convert Celsius to Fahrenheit • F = (9/5 x C) + 32° • There are graphs everywhere! Temperature Conversions
Surface Sites • Oral • Axillae • Skin How to Measure • Core Sites • Rectum • Tympanic Membrane • Temporal Artery
Oral sublingual site with rich blood supply from carotid arteries • How to use: • Slide probe cover over BLUE tip probe & place in the posterior sublingual pocket with mouth completely closed. After beeps eject probe cover. • Ideally wait 20-30 minutes after patient smoked or ingests hot liquids/foods. • Advantages: Accurate & convenient • Disadvantages: Cannot be used if the patient is unconscious, confused, seizure prone, shaking chills, less than 5 years old, disease/surgery of the mouth, mouth breather, or tachypnea Oral
Axillary temperature is 0.9°Flower than oral temp • Typically used with newborns and unconscious patients • Not recommended for fever in infants or young children • How to use: • Slide probe cover over BLUE tip probe and place tip into center of unclothed axilla. Lower arm and place across patient’s chest. If child- hold child’s arm next to body • Advantages: Safe & accessible for infants & children when environment controlled • Disadvantages: Long measurement time. Lags behind core temp during rapid temperature change. Easily affected by the environment. Axillary
Higher than oral temps by 0.9 °F (average 99.3-99.6°F ) • Infants/Children-Rectal temp higher than adult (100 °F) • Measures temperature from blood vessels in rectal wall • How to use: • Apply gloves, place in Sims position, separate buttocks, & dip probe cover into lubricant. Attach probe with RED tip. Insert lubricated probe cover 1-1.5 inch into rectum. Eject probe cover and wipe probe with alcohol. • No Longer recommended in infants or children*!! • *Unless a soft flexible temperature probe Rectal Temperature
Advantages: Not influenced by eating, drinking, smoking, or ability of patient to hold probe, more accurate • Disadvantages: Patient discomfort & time consuming. Lags behind core temp during rapid temperature changes. Contraindicated in pre-term infants, immunosuppressed, and patients with diarrhea or rectal/GI surgery. Rectal Temperature
Higher (1°F ) than oral temperature. • Senses infrared emissions of the tympanic membrane • How to use: • Apply speculum cover. Pull ear up and back for >3y/o & down and back for <3y/o. Place covered probe tip snugly into ear canal, point speculum towards nose and press button and hold until beeps. Remove and eject cover. • Make sure patient has been indoors for at least 10 minutes • Use other ear or route if: drainage from ear, ear surgery, large amount of cerumen, pain from perforation or infection Tympanic
Advantages • Fast, convenient, safe, reduced risk of injury and infection, and non-invasive. Provides accurate core reading because eardrum close to hypothalamus; sensitive to core changes. Not affected by food/drink or smoking. • Disadvantages • Requires removal of hearing aids. Only one size*. Inaccuracies reported due to incorrect positioning. Affected by ambient temp devices (incubators, radiant warmers, facial fans). Otitis media and cerumen may distort reading. Contraindicated in ear/TM surgery. • *(This is changing, pediatric size has been developed) Tympanic
Infrared sensor tip detects temperature of cutaneous blood flow through superficial temporal artery. • Often used for infants, newborns, and children • How to Use: • Ensure forehead is dry. Place probe flush on skin. Push button and hold as move across forehead from center of hairline and ending with a touch behind earlobe. Release button and clean probe with alcohol. Temporal Artery (TAT)
Advantages: • Fast, convenient, and comfortable. No risk to patient or nurse. Reflects rapid change in core temp. Sensor cover not required. • Disadvantages: • Inaccurate with head covering or hair on forehead. Affected by diaphoresis and sweating. Temporal Artery (TAT)
Normal Range • 96.8 – 100.4 °F (36 °- 38 °C) • Fever/Hyperthermia • > 100.4 °F • Hypothermia • < 96.8 °F • Severe: • < 86.0 What do the Values Mean?
Increased: Fever/Hyperthermia • Infection or inflammation • Trauma or disease to hypothalamus • Spinal cord injury • Prolonged exposure to sun/ high temperatures • Fluid volume deficit • On medications that decrease body’s ability to lose heat or promote fluid loss • Have congenital absence of sweat glands or serious skin disease that impairs sweating • Decreased What do the Values Mean?
Mild temp elevation up to 102.2F (39C) enhances immune system • White blood cell production stimulated • Body decreased iron concentration in blood plasma , suppressing growth of bacteria • Stimulates interferon's, bodies natural virus-fighting substance • Prolonged fever weakens patient by exhausting energy stores, increasing oxygen demands and decreasing fluid volume • Risk of Febrile seizures & dehydration in children Fever (Afebrile/febrile)
Sweating/Diaphor-esis • Skin warm to touch • Inactivity • Confusion • Excessive thirst • Nausea • Muscle cramps • Visual disturbances • Incontinence • Increased heart rate • Decreased BP If progresses • Unconscious • Nonreactive pupils • Permanent neurological damage Hyperthermia- Additional S & S
Decreased: Hypothermia • Trauma or disease to hypothalamus • Spinal cord injury • Prolonged exposure to cold temperatures • Unintentional exposure to cold (falling through ice at lake) • Intentional- surgical to reduce metabolic demands and oxygen requirements What do the Values Mean?
Skin cool to touch • Voluntary muscle contraction • Shivering • Memory loss • Poor judgment • Decreased heart rate • Decreased respiratory rate • Decreased blood pressure • Skin cyanotic If progresses • Cardiac dysrhythmias • Loss of consciousness • Unresponsive to painful stimuli Hypothermia- Additional S & S
You have delegated vital signs to assistive personnel. The assistant informs you that the client has just finished a bowl of hot soup. The nurse’s most appropriate advice would be to: A. Take a rectal temperature. B. Take the oral temperature as planned. C. Advise the client to drink a glass of cold water. D. Wait 30 minutes and take an oral temperature. 32 - 45
Pulse is the palpable bounding of blood flow created by ejection of blood into the aorta. • Peripheral pulses felt by palpating arteries lightly against underlying bone or muscles • Provides clinical data regarding the heart’s pumping action (cardiac output) • Cardiac output = heart rate x stroke volume • Abnormally slow, rapid, or irregular pulse alters CO. Pulse Basics
Changes in pulse rate caused by: • Heart disease/dysrhythmias (decreased CO) • Age • Exercise • Positions changes • Fluid balance (i.e. hemorrhage) • Medications • Temperature • Sympathetic stimulation Pulse Basics
Radial • Place patient’s forearm straight alongside body or across lower chest or abdomen. If sitting bend elbow at 90°and support • Place pads of first 2-3 fingers in groove along thumb side (radius) • Carotid • Place pads of first 2-3 fingers along medial edge of sternocleidomastoid muscle in neck Radial & Carotid Pulse Site
Rate (beats/minute) • If pulse is regular then count for 30 seconds and multiply by 2. • If pulse irregular or weak count for 1 minute at apical site • Normal Range • Adult 60-100 bpm • Infants/Children (less than or 2 years of age: apical pulse—brachial in BLS) • Adults Abnormal • > 100 bpm = Tachycardia • < 60* bpm = Bradycardia (*exception: extreme athletic person) Radial & Carotid Pulse Sites