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Chapter 19 Vital Signs Copyright © 2016 by Mosby, an imprint of Elsevier Inc. Vital Sign Measurement Baseline values, or initial vital signs, are used to identify changes in patient status. A series of vital sign measurements establishes patient trends. The frequency of assessing vital signs is determined individually for each patient and is dependent on patient status. Vital signs are interpreted on the basis of current health status and previously established (baseline) normal values for the patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 2 Vital Sign Measurement (Cont.) Factors influencing vital signs: Infection Renal disease Respiratory disease Cardiovascular disease The physical environment Emotional state of the patient Medications Food and fluid intake Activity level and tolerance Accuracy depends on precise measurement Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 3 Vital Sign Documentation Both normal and abnormal vital sign results are appropriately documented and communicated to all members of the health care team. Values are recorded on the specified form or the electronic medical record used by the facility. With such documentation, multiple sets of vital signs typically are easily visible at a time, thereby showing trends for the patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 4 Situations that Require Vital Sign Measurement • On admission to a health care agency, to establish baselines • As part of a physical assessment • During an inpatient stay, as routine monitoring • With any change in health status, especially complaints of chest pain and shortness of breath or feeling hot, faint, or dizzy • Before and after surgery or invasive procedures to establish baselines and monitor effects • Before and after administration of medications that impact cardiac, respiratory, or thermal regulation systems • Before and after interventions such as ambulation • In ongoing care, to detect improvement in patient condition • Before discharge or transfer from a unit, to validate patient readiness Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 5 Health Assessment Questions Focus on temperature Focus on pulse Focus on respiratory rate Focus on blood pressure Focus on pain: S-O-C-R-A-T-E-S: • • • • • • • • Site Onset Character Radiation Associations Time course Exacerbating/relieving factors Severity Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 6 Collaboration and Delegation The task of taking vital signs may be delegated to unlicensed assistive personnel (UAPs), but before delegating this task, the nurse assesses patients to determine that they are medically stable. UAPs may measure, record, and report vital signs for the stable patient, but interpretation of vital signs remains the responsibility of the licensed or registered nurse. Interpreting vital signs is done in relation to other assessment findings. The nurse ensures that the UAP knows the proper technique for taking vital signs and knows what values need to be reported immediately for each patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 7 Informatics and Safety QSEN focus Nurses use informatics when identifying essential information such as vital signs that must be available in a common database to support patient care. Nurses must be able to navigate the electronic health record (EHR) to view baseline patient data, and they must understand the technology that supports clinical decision making. Safety alert! Sudden alterations in vital signs or values outside the normal range are indicators of a priority situation for the nurse. Further assessments and emergency measures should be initiated as indicated by the patient’s status. The health care provider is notified of alterations in vital signs. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 8 Temperature Healthy people are able to maintain body temperature within the normal range even when exposed to temperature extremes for short periods. A person’s ability to manage body temperature depends on certain behavioral abilities and thought processes, such as adequate mobility to leave an area of extreme heat or cold, the capacity to sense temperature discomfort, and the physical ability to add or remove clothing. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 9 Normal Parameters of Body Temperature Temperature is measured in degrees, represented by the symbol °. The core body temperature remains relatively constant within the range of 97.6° to 99.6° F (36.5° to 37.5° C) The average oral temperature is 98.6° F (37° C). A person who maintains this normal body temperature is considered to be afebrile. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 10 Physiology of Heat Production and Loss Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment. Thermoregulation comprises the physiologic and behavioral mechanisms that regulate the balance between heat production and heat loss. Heat is generated by metabolic processes in core tissues of the body and is transferred by circulating blood to the skin, where it is dissipated into the environment. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 11 Heat Production Food is the primary fuel source for metabolism. The amount of heat produced is related to the rate of metabolism. Factors that can increase heat production: Exercise Increased release of epinephrine and norepinephrine Increased production of thyroid hormones Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 12 Heat Loss Core temperature: temperature of deep tissues Heat loss is constant through: Radiation, or the transfer of heat as waves or particles of energy Conduction, or the transfer of and reaction to heat through direct contact Convection, or the transfer of heat by movement or circulation of warm matter such as air or water Evaporation, or the process by which a liquid is changed to a vapor through heat • Evaporation lowers body temperature Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 13 Factors Affecting Body Temperature Age Newborns’ temp unstable; baseline temp drops with age; infants and elderly more susceptible to environmental temp extremes Exercise Hormonal fluctuations Circadian rhythms Stress Increases body temperature Women’s temp higher at ovulation; thyroxine, epinephrine and norepinephrine increase temp Lowest temp around 3 A.M.; highest around 6 P.M. Levels of epinephrine and norepinephrine increase during stress Environment Extended extreme temps affects core body temp Causes vasoconstriction can decrease temp of skin Smoking Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 14 Temperature Terminology Hypothermia = low body temperature Frostbite results from exposure to subnormal temperatures Hypotension = decreased blood pressure Hyperthermia = high body temperature Fever = rise in body temperature above normal Febrile describes a person with a fever Heat stroke = when prolonged exposure to high environmental temps overwhelms the body’s heat loss mechanisms Heat exhaustion = when extreme or prolonged exposure to high environmental heat leads to profuse sweating and consequent water and electrolyte loss Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 15 Evidence-Based Practice and Informatics To prevent hypothermia in older adults: Dress in layers, even while at home. Long underwear may be worn under clothing, along with socks and slippers. Use a blanket or throw to keep legs and shoulders warm. When outside in cold weather, wear a scarf and gloves. A hat is especially important to maintain body heat. Keep extremities covered to prevent heat loss. Keep the thermostat at a minimum of 68° F. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 16 Assessment of Temperature Measured in degrees of Fahrenheit or Celcius Reliability dependent upon: Selecting the most appropriate site Using the correct equipment Using the correct procedure Five common sites = mouth, ear, rectum, forehead, axilla Site selection affected by patient age, state of consciousness, pain level, treatment Measuring device used depends on the site Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 17 Types of Thermometers Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 18 Temperature Variation by Site Oral Axillary Rectal Tympanic Temporal 36.0°-37.6° C (96.8°99.68° F) 35.5°-37.0° C (95.9°98.6° F) 34.4°-37.8° C (93.92°100.04° F) 35.6°-37.4° C (96.08°99.32° F) 36.1°-37.3° C (96.98°99.14° F) Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 19 Oral Temperature Advantages of this site are that it is readily accessible and comfortable for the patient. Eating, drinking, smoking, and the use of oxygen by cannula or mask can affect measurements obtained at the oral site. The patient must be able to close the mouth around the thermometer. It is not a preferred site for infants and young children, unconscious patients, post–oral surgery patients, or people with seizure disorders. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 20 Rectal Temperature Rectal temperature readings are considered to be very accurate. The rectum, however, is not a site preferred by patients. The rectal route is contraindicated in newborns, in patients who are neutropenic (low white blood cell count), and in patients with spinal cord injury. It should not be used for patients with diarrhea or rectal disease, post–rectal surgery patients, or quadriplegic patients. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 21 Rectal Temperature (Cont.) Safe Practice Alert! Taking rectal temperatures can cause rectal perforation in young infants, and the site should be used only when no other feasible option is available. If a rectal temperature must be taken, a welllubricated thermometer, inserted no more than the length of the thermometer’s bulb, should be used. Taking the patient’s temperature using the rectal route can cause bleeding in people with hemorrhoids. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 22 Ear (Tympanic) Temperature The tympanic membrane temperature is a core temperature. Thermometer does not touch the tympanic membrane. Easily accessed; not appropriate with drainage Readings not significantly affected by otitis media An accurate tympanic reading is obtained by grasping the pinna and gently pulling up and back for the adult, or down and back for a child younger than 3 years of age; placing the covered probe snugly in the ear canal; and angling it toward the jaw line before activating the sensor. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 23 Forehead (Temporal Artery) and Axillary Temperature Temporal artery site Well tolerated by infants and young children Not affected by perspiration when performed correctly Small, handheld unit A covering on the head can affect accuracy Axillary site Used when oral and rectal sites inaccessible Often used for healthy newborns Sensor must maintain skin contact Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 24 Electronic Thermometers Electronic and digital thermometers measure oral, rectal, or axillary temperature in less than 1 minute. Battery-powered Readings on digital screen within several seconds Temperature-sensitive probe • Disposable probe cover • Same probe can be used for oral and axillary locations • Separate probe (red) for rectal measurements Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 25 Disposable Thermometers and Temperature-Sensitive Strips Disposable paper thermometers Single-use or reusable Contain liquid crystal dots or bars + sensor Nurse reads highest reading among the dots that have changed color. Excellent choice for maintaining asepsis Can be used for oral or axillary sites Temperature-sensitive strips Give general indication of body surface temp Perspiration affects reading. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 26 Implementation and Evaluation Treatment for increased temperatures Nonsteroidal antipyretic drugs Cool sponge baths, cooling blankets, and packs Avoid aspirin Antibiotics as prescribed if bacterial infection Oxygen may be needed Monitoring vital signs Monitoring intake and output Increasing fluid intake Maintaining oral hygiene Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 27 Implementation and Evaluation (Cont.) Treatment for hypothermia Gradual warming through external wraps, a head covering to prevent heat loss, and warm intravenous fluids are means of warming the body. Patients who are alert can drink hot liquids such as soup. Alcohol and caffeine beverages should be avoided. Some facilities have blanket warmers. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 28 Implementation and Evaluation (Cont.) When evaluating a temperature reading, the nurse must compare the temperature measurement obtained against any baseline data, previous readings, and the normal range for the patient. The nurse interprets the findings by considering the patient’s diagnosis, time of day, and other factors such as medications administered. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 29 Skill 19-1: Measuring Body Temperature PURPOSE is to determine the patient’s baseline temperature. Body temperature may be measured in degrees Fahrenheit or Celsius. Identify whether the body temperature is within normal range. Monitor the patient for fever or an inability to maintain normal body temperature. Monitor the patient for change in physical condition. Monitor temperature changes for response to medications. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 30 Skill 19-1: Measuring Body Temperature (Cont.) Collaboration and delegation Measuring a temperature may be delegated to UAPs after the initial assessment of the patient. Assistive personnel should report the following to the nurse: • Deviations from baseline temperature • Complaints related to temperature regulation • Sores, wounds, irritations, and/or lesions in the area where the temperature is being measured • Any difficulties performing the procedure Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 31 Skill 19-1: Measuring Body Temperature (Cont.) Collaboration and Delegation (Cont.) UAPs should be instructed in: • Appropriate placement of the thermometer/probe • Appropriate use of equipment (verifying accurate results) • Appropriate documentation Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 32 Skill 19-1: Measuring Body Temperature (Cont.) Evidence-based practice Bradypnea may cause high temperature readings. Hot and cold beverage intake influences oral temperature assessment. • Both situations require an average of 15 minutes for a return to baseline measurements. Baseline oral temperature does not deviate between older and younger cohorts, but room temperature affects elderly adults’ oral temperature readings more than it does those of younger people. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 33 Skill 19-1: Measuring Body Temperature (Cont.) Evidence-based practice (Cont.) All noninvasive temperature measurement methods have been shown to be just as accurate as the rectal temperature method (core temperature), provided the nurse or caregiver is using the equipment properly and has been well-trained on the procedure, including the anatomy and physiology involved. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 34 Pulse The number of pulsing sensations occurring in 1 minute is the pulse rate (beats per minute, or bpm) The apical pulse is a central pulse that can be auscultated over the apex of the heart at the point of maximal impulse (PMI). Peripheral pulses are Normal Pulse Rates those that can be Newborn 80-160 palpated over arteries 1-year-old 80-140 located away from the 6-year-old 75-110 heart—at the wrist or 15-year-old 50-90 foot, for example. Adult and Older adult Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 60-100 35 Factors Affecting Pulse Rate The pulse rate is variable and is dependent on physiologic and emotional factors. Age Medications Gender Hypovolemia Fever Pathology Stress Electrolyte balance Hypoxia and hypoxemia Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 36 Sites for Assessing Pulse Never palpate both carotid arteries at the same time. Doing so could limit blood flow to the brain, causing the patient to experience syncope (fainting). If the peripheral pulse is irregular, count an apical pulse for 1 full minute to ensure accurate measurement. In infants and children younger than 2 years of age, the pulse rate is obtained by auscultating the apical pulse. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 37 Pulse Sites Temporal Carotid Apical or PMI Brachial Radial Femoral Popliteal Posterior tibial Pedal (dorsalis pedis) Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 38 Assessment of Pulse Pulse assessment = measuring Rate Rhythm Volume And comparing findings on both sides of the body Assessed by Palpation Auscultation (listening with a stethoscope) Electronic monitoring Too much or too little pressure gives inaccurate readings Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 39 Evidence-Based Practice A stethoscope is a medical device that is critical in listening to internal sounds of the body. It commonly is used to listen to lung and heart sounds. It also is used to listen to intestinal activity and blood flow in arteries and veins. In combination with a sphygmomanometer, it is used for measurements of blood pressure. It is important that a stethoscope be used and cared for correctly. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 40 Nursing Care Guideline Using a Doppler ultrasound unit to obtain a pulse Background • A Doppler ultrasound unit may be used to assess peripheral circulation when a pulse cannot be palpated. • Each pulse wave makes a sound that the Doppler ultrasound unit amplifies. • Pulses may be difficult to palpate for many reasons, including poor circulation, edema, obesity, and other obstructive issues. Documentation concerns • Note the rate and rhythm of the pulse. • Note the location of the pulse and use of the ultrasound unit for the assessment. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 41 Pulse Rate An excessively fast heart rate (>100 bpm in the adult) is termed tachycardia. A slow heart rate (<60 bpm in the adult) is called bradycardia. The radial pulse is palpated by placing the first two or three fingers of one hand over the radial artery at the groove along the radial, or thumb, side of the patient’s inner wrist. A pulse deficit results when the apical pulse rate exceeds the radial pulse rate. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 42 Pulse Rhythm Rhythm is the regularity of the heartbeat. An irregular rhythm in the pulse, caused by an early, late, or missed heartbeat, is referred to as a dysrhythmia or an arrhythmia. When an irregular rhythm is detected, the apical pulse is assessed. An electrocardiogram (ECG) is necessary to define the specific dysrhythmia. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 43 Pulse Volume Scale Description of Pulse 0 Absent pulse 1+ Weak and thready pulse, difficult to palpate 2+ Normal pulse, able to palpate with normal pressure 3+ Bounding pulse, may be able to see pulsation Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 44 Skill 19-2: Assessing Pulses PURPOSE is to determine the baseline heart rate and rhythm. Monitor the heart rate and rhythm. Assess blood flow from the heart to the body. Monitor the patient for changes in physical condition. Monitor the patient’s response to medications. Monitor the patient’s response to therapy. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 45 Skill 19-2: Assessing Pulses Collaboration and delegation Assessing a radial or peripheral pulse may be delegated to UAPs after the initial assessment of the patient. Assessing an apical pulse usually is not delegated unless the UAP has received special training. Check with the facility’s guidelines and procedures. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 46 Skill 19-2: Assessing Pulses (Cont.) Collaboration and delegation (cont’d) UAPs should report the following to the nurse: • • • • • • Deviations from normal pulse range Complaints related to chest pain or discomfort Irregular pulse, including a weak or thready pulse Pulse less than 60 bpm or greater than 100 bpm Difficulties in obtaining pulse (strength and/or quality) Any changes in pulse rate, rhythm, or strength Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 47 Skill 19-2: Assessing Pulses (Cont.) Collaboration and delegation (Cont.) UAPs should be instructed in: • The appropriate technique and method required for obtaining a pulse • Appropriate use of equipment (verification of accurate results, Doppler, stethoscope, electronic vital sign machines) • Appropriate documentation Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 48 Implementation and Evaluation Hand hygiene is performed before caring for a patient. After selection of the appropriate site and method, the pulse rate is measured. An irregular pulse of new onset should be reported to the primary care provider. Interventions for an increased pulse rate include identification and treatment of the cause. Evaluation is accomplished by comparing the pulse rate with baseline data or to the normal range for the age of the patient. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 49 Respirations Respiration is the act of breathing. Inspiration (inhalation) is the act of breathing in, and expiration (exhalation) is the act of breathing out. The process that is measured as a vital sign is pulmonary ventilation, or respirations. A normal respiratory rate is 12 to 20 bpm for an adult. The purpose of respiration is to allow the exchange of oxygen and carbon dioxide among the alveoli, circulating blood, and tissue cells. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 50 Physiology and Regulation of Breathing and Ventilation Respiratory centers in the medulla and pons are stimulated by impulses from chemoreceptors located throughout the body. Chemoreceptors located in the aortic arch and carotid arteries are especially sensitive to low oxygen levels in the blood (hypoxemia). Respiratory rate and depth change on the basis of input from these receptors, but the strongest respiratory stimulant is an increase in carbon dioxide, which causes an increase in respiratory rate and depth. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 51 Factors Affecting Respiration Environmental or physiologic factors may cause increases or decreases in respiratory rate or depth. Age Illness processes Exercise Acid-base balance Pain Medications Emotions Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 52 Assessment of Respirations Respiratory status Assessment includes: • • • • Breathing rate Breathing depth Breathing rhythm Often includes oxygen saturation (amount of oxygen in arterial blood) by pulse oximetry Before assessing respirations, the nurse needs to be aware of: • • • • The patient’s normal respiratory pattern How the patient’s health status affects respirations Any medications that may affect respirations The impact of cardiovascular system factors on the respiratory system Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 53 Respiratory Rate Normal respiration with a normal rate and depth for the patient’s age is termed eupnea. Tachypnea is an increase in respiratory rate to more than 24 bpm in the adult. Bradypnea is a decrease in respiratory rate to less than 10 bpm in the adult. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 54 Depth and Quality of Respirations Depth: Hypoventilation is characterized by shallow respirations. Hyperventilation is exhibited by deep, rapid respirations. Quality: Apnea is an absence of breathing; brain damage occurs after 4 to 6 minutes of apnea. Dyspnea is difficult, labored breathing, usually with a rapid, shallow pattern, that may be painful. Difficulty breathing experienced in positions other than sitting or standing is termed orthopnea. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 55 Additional Respiratory Patterns Pattern Description Associated Factors CheyneStokes respirations Rhythmic respirations, going from very deep to very shallow or apneic periods Heart failure, renal failure, drug overdose, increased intracranial pressure, impending death Kussmaul’s breathing Respirations abnormally deep, regular, and increased in rate Diabetic ketoacidosis Biot’s breathing Respirations abnormally shallow for two or three breaths, followed by irregular period of apnea Meningitis, severe brain injury Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 56 Skill 19-3 Assessing Respirations PURPOSE is to determine the rate, rhythm, quality, and depth of respiration. Monitor the patient’s respirations and respiratory changes. Monitor for change in the patient’s physical condition. Monitor the patient’s response to medications. Monitor the patient’s response to therapy. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 57 Skill 19-3 Assessing Respirations Collaboration and delegation Assessing a respiratory rate may be delegated to UAP after the initial assessment of the patient. UAPs should be instructed in: • Appropriate technique • Appropriate documentation Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 58 Skill 19-3 Assessing Respirations (Cont.) Collaboration and delegation (Cont.) UAPs should report any of the following findings to the nurse: • Difficulty breathing or any change in respiratory rate, rhythm, or depth (report immediately) • Patient’s complaints related to breathing difficulty or chest discomfort • Irregular respiratory rhythm • Rates less than 12 or greater than 20 bpm • Any difficulties in obtaining respiratory rates Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 59 Oxygen Saturation Measurement of respiratory rate is not a measurement of how much oxygen actually enters the bloodstream. Saturation of peripheral oxygen, abbreviated SpO2, reflects the percentage of hemoglobin that combines with oxygen, usually 95% to 100%. Cyanosis, bluish discoloration of the skin and mucous membranes, results from decreased oxygen levels in arterial blood. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 60 Oxygen Saturation (Cont.) The level of consciousness is affected by changes in oxygen levels. Patients displaying signs of reduced oxygen require additional assessment of mental status, activity tolerance, and measurement of oxygen saturation. Measurement of oxygen saturation is performed noninvasively and painlessly by means of pulse oximetry. A pulse oximeter is a small device that is clipped to a fingertip, a toe, the nose, or an earlobe, or applied to the forehead. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 61 Skill 19-4: Assessing Pulse Oximetry PURPOSE is to determine the patient’s baseline SpO2 (saturation of peripheral oxygen). Monitor any underlying respiratory disease. Monitor the patient’s recovery from anesthesia. Assess the patient for any change in physical condition. Assess complaints of respiratory difficulty. Monitor patient response to medications. Monitor patient response to oxygen therapy. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 62 Skill 19-4: Assessing Pulse Oximetry (Cont.) Collaboration and delegation Assessing SpO2 may be delegated to UAPs after initial assessment of the patient. UAP should report any of the following to the nurse: • Readings less than 92% or other designated saturation, as determined by the nurse or PCP • Complaints related to breathing difficulty or chest discomfort • Situations in which the patient is not using oxygen or it is not at the appropriate level according to the PCP orders • Any difficulties in procedure Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 63 Skill 19-4: Assessing Pulse Oximetry (Cont.) Collaboration and delegation (Cont.) UAPs should be instructed in: • Appropriate placement of oximeter probe (finger, toe, bridge of nose, earlobe, or forehead) • Appropriate equipment use (verifying accurate results) • Patient oxygen use and frequency of monitoring • Appropriate documentation Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 64 Arterial Blood Gases Measurement of arterial blood gases (ABGs) is a way of assessing the respiratory component of acid-base balance and the adequacy of oxygenation. ABG values include the carbon dioxide level and pH, and they are used to determine the need for and response to treatment. ABG studies are used to establish baseline values, identify respiratory disorders, and evaluate the effectiveness of interventions. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 65 Safe Practice Alert Signs of respiratory distress include the use of accessory muscles of the chest and neck and/or an exaggerated effort to breathe. Children and infants may exhibit nasal flaring or sternal retractions if they are having trouble breathing. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 66 Implementation and Evaluation Interventions for the underlying disorder should improve an altered respiratory pattern, and they include positioning, supplemental oxygen, suctioning, and medications such as bronchodilators. Evaluation of respiration must be done in conjunction with the other vital signs obtained and the medical status of the patient. A respiratory rate significantly above or below normal, any notable changes in pattern, and inadequate oxygenation must be reported to the PCP. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 67 Blood Pressure Blood pressure can adapt to various stimuli and still remain within a normal range. Knowing the baseline, or usual, blood pressure of an individual is important to be able to interpret a single measurement in a potential illness process. An increase or decrease of 20 to 30 mm Hg in a person’s blood pressure is considered a significant change. Sustained change in blood pressure is considered abnormal. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 68 Physiology of Blood Pressure Blood pressure, the force of the blood against arterial walls, rises as the ventricle contracts, and it falls as the heart relaxes, creating a pressure wave through the arterial system. The peak of the pressure wave is systolic pressure. The lowest pressure on arterial walls, which occurs when the heart rests, is diastolic pressure. The numerator, or top number, is the systolic pressure, and the denominator, or bottom number, is the diastolic pressure. Pulse pressure is the difference between the diastolic and systolic pressures. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 69 Physiology of Blood Pressure (Cont.) Body regulates blood pressure Arterioles regulate the distribution of blood to the organs, tissues, and cells; they supply resistance. • To respond to the body’s needs at any given moment, the arterioles are normally partially contracted, creating peripheral resistance. • This resistance is a major factor affecting blood pressure. Arteries stretch with systolic pressure and relax with diastolic pressure; they provide compliance. • A certain amount of pressure is always present in the arteries. • This constant pressure maintains a continuous flow into capillaries rather than intermittent bursts of circulation. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 70 Physiology of Blood Pressure (Cont.) The autonomic nervous system (ANS) manages mechanisms to maintain short-term regulation of blood pressure. The renin-angiotensin-aldosterone system controls vasoconstriction and water retention that affects circulatory fluid volume. The cardiac output is the amount of blood pumped per minute. An increase in cardiac output results in increased blood pressure; a decrease in cardiac output leads to a decrease in blood pressure. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 71 Hypotension Hypotension is systolic blood pressure of Less than 90 mm Hg --or 20 to 30 mm Hg below the patient’s normal blood pressure-Or diastolic blood pressure of 60 mm Hg or less Cause = disruption in cardiovascular dynamics Decreased blood volume (hemorrhage) Decreased cardiac output (heart attack or heart failure) Decreased peripheral vascular resistance (shock). Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 72 Hypotension (Cont.) Orthostatic hypotension is a sudden drop of 20 mm Hg in systolic pressure and 10 mm Hg in diastolic pressure when the patient moves from a lying to sitting to standing position. The low pressure occurs from peripheral vasodilation with no rise in cardiac output for compensation. It occurs with aging and is a common side effect of several medications Other risk factors include prolonged immobility, dehydration, and blood loss. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 73 Hypertension Hypertension = elevated blood pressure The leading cause of cardiovascular disorders The most important risk factor for stroke The leading cause of death in the U.S. Origins Dysfunction in neurohormonal system • Overstimulation of angiotensin and aldosterone raises blood pressure • May be permanent thickening of blood vessels, leading to peripheral resistance Classification Prehypertension = 120-139 / 80-89 Higher values are stage 1 or stage 2 hypertension Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 74 Hypertension (Cont.) Primary (essential) hypertension occurs when there is no known cause for the high blood pressure. Secondary hypertension is caused by a known illness process, such as renal failure. Risk factors for hypertension: Smoking Ongoing stress Obesity Sedentary lifestyle Family history of the disorder Alcohol use High-salt, high-fat-calorie diet Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 75 Categories for Blood Pressure Levels in Adults Category Systolic (mm Hg) Diastolic (mm Hg) Hypotension Less than 90 Normal Less than 120 Prehypertension 120-139 or 80-89 Stage I hypertension 140-159 or 90-99 Stage II hypertension Greater than 160 or Greater than 100 or Less than 60 and Less than 80 High blood pressure Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 76 Home Care Considerations Lifestyle changes shown to lower blood pressure: Maintain normal body weight. Adopt the Dietary Approaches to Stop Hypertension (DASH) eating plan, which includes reduced fat intake and increased intake of fruits and vegetables. Reduce dietary sodium intake to 2.4 g daily. Engage in regular aerobic physical activity at least 30 minutes a day, on most days of the week. Limit alcohol consumption: for men, two drinks a day; for women, one drink a day. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 77 Factors Affecting Blood Pressure Age Race Emotions Pain Gender Head injury Weight Circadian rhythm Medications Food intake Increased blood volume Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 78 Assessment of Blood Pressure Measurement During physical examination At initial admission With routine vital signs When patient status changes Requires excellent technique, correctly calibrated equipment, and proper interpretation of the sounds obtained Should be taken after the patient rests for at least 5 minutes and has not smoked or ingested caffeine for at least 30 minutes before the measurement. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 79 Sites for Assessing Blood Pressure Blood pressure can be measured in the upper or lower extremity. It is usually assessed manually, or indirectly. The most common site for indirect blood pressure measurement is the upper arm at the brachial artery. Use clinical judgment to choose a side. If the brachial artery is not accessible, the popliteal artery behind the knee can be used for blood pressure measurement. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 80 Skill 19-5: Measuring Blood Pressure: Manual and Electronic PURPOSE is to determine the baseline blood pressure. Monitor blood pressure. Assess the heart’s pumping ability and the patency of blood vessels. Monitor for changes in physical condition. Monitor the patient’s response to medications. Monitor the patient’s response to therapy. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 81 Skill 19-5: Measuring Blood Pressure: Manual and Electronic (Cont.) Collaboration and delegation Electronic measurement of blood pressure may be delegated to UAP after initial assessment of the patient. Manual measurement of blood pressure may be delegated if the UAP has received special training. Check the facility’s guidelines and procedures. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 82 Skill 19-5: Measuring Blood Pressure: Manual and Electronic (Cont.) Collaboration and delegation (Cont.) UAPs should report any of the following findings to the nurse: • Deviations from normal range of blood pressure • Complaints related to chest pain or discomfort • Systolic blood pressure greater than 140 or less than 90 or diastolic blood pressure greater than 100 or less than 70 • Difficulties in obtaining blood pressure Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 83 Skill 19-5: Measuring Blood Pressure: Manual and Electronic (Cont.) Collaboration and delegation (Cont.) UAPs should be instructed in: • The appropriate technique and method required for the patient • Appropriate equipment use (verifying accurate results with stethoscope, sphygmomanometer, electronic vital sign devices, appropriate cuff size, and site choice) • Sites and conditions that are contraindicated: intravenous lines, arteriovenous (AV) fistulas or shunts, amputations, breast surgery, and casts or bandages • Appropriate documentation Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 84 Skill 19-5: Measuring Blood Pressure: Manual and Electronic (Cont.) Evidence-Based Practice Blood pressure does not always rise in response to emotion. The patient’s culture may affect whether blood pressure is elevated or lowered from normal range in response to emotion. Automated blood pressure measurements are not always accurate, especially in hypertensive patients and the elderly population. The two-step method, palpating a systolic pressure, is the most accurate technique, especially in hypertensive and geriatric populations in whom the auscultatory gap may be widened considerably. When the two-step method is not used, manual blood pressures are frequently inaccurate. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 85 Blood Pressure Devices Electronic blood pressure devices use an electronic sensor to detect vibrations caused by blood moving through the artery. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 86 Nursing Care Guideline Assessing orthostatic hypotension Orthostatic hypotension, also known as postural hypotension, is a condition in which there is an abrupt decline in blood pressure when a person moves from a supine to a sitting or standing position. An accompanying increase in heart rate is typical. An accurate assessment of orthostatic hypotension requires identifying a blood pressure decline of 20 mm Hg in the systolic pressure or 10 mm Hg in the diastolic pressure, or an increase in heart rate of 20 bpm, within 1 to 3 minutes of postural change. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 87 Nursing Care Guideline (Cont.) Assessing orthostatic hypotension (Cont.) Background (Cont.) • Orthostatic hypotension can be indicative of dehydration (leading to low blood volume) or anemia, or it may occur in conjunction with prolonged immobilization. • Orthostatic hypotension is most commonly due to a problem with the autonomic nervous system and/or a delay of the circulatory response to adjust to rapid movement. • Symptoms may include dizziness, fainting, changes in mental status, and anxiety. Nausea, rapid onset of pallor, and fast, shallow breathing also are common during an episode of orthostatic hypotension. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 88 Nursing Care Guideline (Cont.) Assessing orthostatic hypotension (Cont.) Delegation • Assessment cannot be delegated to a UAP, but UAPs may assist in obtaining the measurements and in positioning the patient for safety. Documentation concerns • Vital signs are documented in conjunction with the position and time. • Any signs, symptoms, or other complaints during the procedure should be documented. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 89 Nursing Care Guideline (Cont.) Assessing orthostatic (Cont.) Evidence-based practice • An official diagnosis of orthostatic hypotension requires a 20 mm Hg drop in systolic blood pressure or a 10 mm Hg drop in diastolic blood pressure, with or without symptoms, within 3 minutes of the positional change. • There usually is a corresponding increase in heart rate, although certain medications may prevent the heart rate from increasing. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 90 Korotkoff Sounds The sounds for which the nurse listens when assessing blood pressure are called Korotkoff sounds. An auscultatory gap may occur in the latter part of phase I and during phase II. The auscultatory gap is the absence of Korotkoff sounds noted in some patients after the initial systolic pressure; the gap may cover a range as wide as 40 mm Hg. Failure to recognize an auscultatory gap may lead to major errors in measuring blood pressure. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 91 Korotkoff Sounds (Cont.) Phase Description Phase I The initial presentation of faint but clearly audible tapping sounds, which gradually increase in intensity to a thud or loud tap; the first sound is recorded as the systolic pressure Phase II Muffled, swishing sounds Phase III Crisp, loud sounds as the blood flows through an opening artery Phase IV A distinct, abrupt muffling sound Phase V The last sound heard before silence—this is the diastolic measurement Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 92 Implementation and Evaluation The most common equipment used by the nurse is a stethoscope and sphygmomanometer (blood pressure cuff). Blood pressure can be measured with a Doppler stethoscope, estimated by palpation (assessment by feeling with the hand or fingers), or measured by an electronic, or automated, cuff. A stethoscope is used to hear the sounds created by blood flowing through the artery. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 93 Blood Pressure Cuff Sizes Cuff sizes range from neonate to adult thigh sizes. The width of the cuff should be approximately 40% of the circumference of the extremity being used, and the bladder of the cuff should be approximately 60% to 80% of the circumference of the extremity being used. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 94 Blood Pressure Assessment Errors Inaccurate Reading Falsely Low Reading Falsely High Reading •Defective equipment •Equipment not calibrated •Improper use of equipment •Patient not positioned correctly •Hearing deficit in assessing person •Arm positioned above heart level •Extraneous noise in surrounding environment •Use of a cuff that is too wide •Ear tips of stethoscope placed incorrectly •Breaks or kinks in cuff tubing •Cuff deflated too rapidly •Stethoscope bell not placed directly over artery •Failure to follow all steps in recommended procedure •Assessing blood pressure too soon after patient smoking or exercise •Use of a cuff that is too narrow •Releasing the pressure valve too slowly •Reinflating the bladder before it has completely deflated Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 95 Pain Pain is a subjective experience, and the intensity and quality of pain are whatever the patient says they are. Pain may be acute (it resolves when the underlying injury heals) or chronic (it lasts longer than the healing period). The perception of pain can be intensified by the emotional state of the patient. Poor assessment of pain is the primary barrier to effective pain management. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 96 Assessment of Pain Although pain is subjective, varying from one patient to another and from one day to the next, health care providers attempt to measure pain as objectively as possible. Pain usually is determined by asking the patient to describe the pain and rate the pain level on a scale. In adult patients, this pain rating often is a numeric measurement between 0 and 10, with 0 meaning “no pain” and a score of 10 indicating “the worst pain imaginable.” Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 97 Implementation and Evaluation Choice of assessment scale important for patient’s subjective report of pain Physiologic and objective signs assessed Nursing interventions to address pain: Positioning with support Complementary interventions Ongoing assessment Evaluation of pain focuses on the patient’s report of pain relief and effectiveness of treatment. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 98