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NRS 310 Vital Signs, Measurements and Pain assessment Chapters 4 & 6. Nancy Sanderson MSN, RN Introductions 2 Introductions 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: 3 General Survey Be careful about “assumptions” and stereotyping Gives overall impression of patient’s health Provides information about: Physical Appearance Hygiene (body, breath) Body Structure Mobility Behavior 4 Appearance 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 5 Ways to summarize patient’s appearance High functioning Feeling well Cleanly dressed Showered No body odor No smell of alcohol or other drugs Follows the conversation well Low functioning 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 6 Summary or in a nutshell: Introduce yourself Observe the patient ◦ Appearance ◦ Behavior Listen to concerns/complaints 7 Height Weight Head Circumference ◦ Children only Body Mass Index Measurements Why Height & Weight? 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 Increased or Decreased Height Gigantism & Dwarfism Increased ◦ Gigantism Decreased ◦ Elderly (osteoporosis) ◦ Malnutrition ◦ Dwarfism Hypopituitary Achrondroplastic 10 How to Measure Height Use a specially designed board for measuring Height (>2 y/oadulthood) ◦ 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 12 How to Measure Weight Weight (2 y/o-adult) Weight (< 2y/o) ◦ Remove shoes and heavy outer clothing ◦ Record in pounds or kilograms (often kg for children) ◦ Record to nearest ¼ lb ◦ 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 13 Why Head Circumference? Assess for brain growth and abnormalities ◦ Microcephaly ◦ Macrocephaly Hydrocephalus 14 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. 15 Measuring an Infant: Putting it all Together 16 BMI The Body Mass Index(BMI) formula was developed by Belgium statistician Adolphe Quetelet (1796-1874) Was known as the Quetelet Index. BMI is an internationally used measure of obesity. http://www.whathealth.com/bmi/chartimperial.html 17 Body Mass Index (BMI) More accurate estimate of body fat than weight alone. Weight (kg)/Height (m²) or Weight (lbs)/height (in.²) x 703 Underweight Normal Overweight Obesity I Obesity II Obesity III <18.5 18.5-24.9 25.0-29.9 30.0-34.9 35.0-39.9 >40 18 BMI: Body Mass Index 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 19 Summary (in a nutshell) Height and Weight needed for BMI Following trends/health status Measure head circumference up to the age of 2 20 Vital signs 21 Vital Signs—5, 6, 7, or 8 VS Temperature (T) Pulse (P) Respiratory Rate (R) Blood Pressure (BP) Pulse Ox Pain Level of consciousness Urine out put Vital Signs (VS/VTS) 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. Use of Vital Sign Measurements 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 Guidelines for Nursing Practice 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 Vital Signs: Temperature 28 Temperature Conversions Convert Fahrenheit to Celsius ◦ C = (F -32°) x 5/9 Convert Celsius to Fahrenheit ◦ F = (9/5 x C) + 32° There are graphs everywhere! How to Measure Surface Sites ◦ Oral ◦ Axillae ◦ Skin Core Sites ◦ Rectum ◦ Tympanic Membrane ◦ Temporal Artery Oral 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 Axillary Axillary temperature is 0.9°F lower 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. Rectal Temperature Higher than oral temps by 0.9 °F (average 99.399.6°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. Tympanic 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 Disadvantages ◦ 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. ◦ 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) Temporal Artery (TAT) 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. What do the Values Mean? Normal Range ◦ 96.8 – 100.4 °F Fever/Hyperthermia ◦ > 100.4 °F (36 °- 38 °C) 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 Fever (Afebrile/febrile) 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 Hyperthermia- Additional S & S Sweating/Diaphoresis 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 What do the Values Mean? 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 Hypothermia- Additional S & S 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 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 Vital Signs: Pulse Pulse Basics 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 Radial & Carotid Pulse Site 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 Sites 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 Rhythm ◦ Normal Regular Sinus Arrhythmia in children ◦ Irregular/Dysrhythmia Regularly irregular Irregularly irregular Radial & Carotid Pulse Sites Strength (Amplitude) ◦ Normal Strong (2+) ◦ Abnormal Weak or thready (1+) Bounding (3+) Equality ◦ Radial: Assess on both sides to determine if equal ◦ Carotid: Never palpate simultaneously. Only one at a time. Apical Pulse Site Listen to the Apical heart sound Although called “pulse” you want to listen w/stethoscope Auscultate with stethoscope & assess rate & rhythm—1 full minute ◦ If you feel an irregular pulse when feeling radial pulse (bounding, weak, irregular, or skipped beats ◦ Any child less than 2 years old Apical Pulse Site Auscultation of heart sounds Often used when: ◦ Heart rate is irregular ◦ Peripheral pulse is weak ◦ Patient taking medication that affects pulse rate ◦ Patient is < 2 y/o You notice that a teenager has an irregular pulse. The best action you should take includes: A. Read the history and physical. B. Assess the apical pulse rate for one full minute. C. Auscultate for strength and depth of pulse. D. Ask if the client feels any palpations or faintness of breath. 32 - 55 Vital Signs: Respiratory Rate Respiratory Rate Assess breathing pattern. Observe chest wall expansion and bilateral symmetrical movement of thorax. Assess the rate, depth, and rhythm of each breath. Count for 30 seconds & multiply by 2 if regular pattern In infants watch abdomen and count full minute So Patient isn’t aware. . . Ask patient to move arm over chest and as you “count the radial pulse” you actually count the respirations Question You are counting respirations in a male patient you notice his chest is not moving much, but his abdomen has movement with each respiration this is: A. A symptom of severe respiration problems B. Normal diaphragmatic breathing C. You need to notify the doctor D. A & C Vital Signs: Blood Pressure Blood Pressure Systolic: force of pressure in the walls of the arteries when the (L) ventricle contracts Diastolic: force of pressure on walls of arteries when the heart is filling Physiological factors controlling BP: ◦ ◦ ◦ ◦ ◦ Cardiac output Peripheral vascular resistance Volume of circulating blood Viscosity Elasticity of vessel walls Blood Pressure Blood Pressure Allow patient to sit for 5 minutes with feet flat on floor and legs uncrossed. Allow 30 minutes if just smoked or consumed caffeine. Select appropriate cuff size (see W & G pg. 34) ◦ Width of the bladder should cover 40% of the upper arm ◦ Length of the bladder should be about 80% of upper arm (almost long enough to encircle the arm) Cuff too small, the BP will be falsely elevated Cuff too large, the BP will be falsely lowered 40% Blood Pressure Place arm at heart level Palpate brachial artery and apply cuff to bare arm 1 inch above antecubital space with arrow over brachial artery Palpate the radial pulse & inflate cuff until unable to palpate the radial pulse. Read this pressure on the manometer & add 30 mmHg to it. Deflate the cuff & wait 15-30 seconds Blood Pressure Place the diaphragm lightly over the brachial artery Inflate the cuff rapidly to the level just determined, and then deflate it slowly at a rate of about 2-3 mm Hg per second. ◦ If you deflate too slowly, you can cause congestion that falsely increases the blood pressure. ◦ Too fast falsely decreased reading Note the level at which you hear the sounds of at least two consecutive beats. This is the systolic pressure Continue to lower the pressure until the sounds disappear. This is the diastolic. Read both the systolic and diastolic levels to the nearest 2 mm Hg. What makes the sounds? 160 120 110 78 Recording Blood Pressure Systolic/Diastolic Record what arm the BP was taken on Blood pressures can normally vary 5-10 mm Hg in different arms. Subsequent BP’s should be checked in the arm that has the higher value. ◦ >10-15mmHg suggests arterial compression or obstruction on side with lower pressure Blood Pressure Classification Normal <120/<80 Pre-hypertension 120-139/80-89 Hypertension stage 1 140-159/90-99 Hypertension stage 2 >160/>100 Hypotensive <90 systolic depending on baseline BP The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Blood Pressure Thigh ◦ Use if dressings, casts, double mastectomy, intravenous catheters, arterio-venous fistulas/shunts surgery, trauma or burn makes upper extremities inaccessible for blood pressure measurement ◦ With patient in prone position put cuff 1 inch above popliteal artery ◦ Systolic BP 10-40mmHg higher than UE ◦ Diastolic same as UE MAP: Mean Arterial Pressure Approximation of the average pressure in the systemic circulation throughout the cardiac cycle; reflects the components of the cardiac cycle Will be read on automatic BP cuff and on arterial lines. When assessing the blood pressure of a schoolage child, using a normal-size adult cuff will affect the reading and produce a value that is: A. Accurate B. Indistinct C. Falsely low D. Falsely high 32 - 72 Vital Signs: Pulse Oximetry Pulse Oximetry (SpO2) Indication of oxygen saturation Normal range typically 95-100% @ sea level. ◦ >92% in Colorado May place clip on: ◦ ◦ ◦ ◦ Finger Toe Nose Earlobe Include the use of any type of oxygen equipment, including route and flow rate Summary: Vital signs are one of the most important assessment you can do! Should be done after introduction and getting history (Do first if EMERGENCY) Retake per orders or if patient shows signs of going downhill. Pain Assessment The often forgotten VS Pain The assessment of pain is based primarily on subjective data gathered from the patient Use your OLDCARTS/OPQRST in gathering information http://www.ems1.com/emsproducts/education/tips/475522-RefiningOPQRST-as-an-Assessment-Tool/ Pain intensity / rating scale is a good tool to use in assessing pain What is the patient’s acceptable level of pain Find out if the pain is new Find out what helps or relieves the pain ◦ Pharmacologic ◦ Non - pharmacologic Physiology of Pain Perception Things to remember!!! Pain is subjective Different cultures will report differently Subjective – The patient’s own words Objective – What you see and can chart ◦ Crying ◦ Rigid ◦ Increase BP Standards for Pain Assessment Criteria for accreditation for hospitals Joint Commission has set a standard that patients have the right to appropriate assessment and management of pain. The standard includes: 1) Initial assessment and regular assessment of pain, taking into account personal, cultural, ethical and spiritual beliefs. 2) Education of all relevant health care personnel in pain assessment and management. 3) Education of patients and families regarding their roles in managing pain, potential limitations, & adverse effects of pain treatments. Pg. 60 W & G McGill Pain Questionnaire “OPQRST” PAIN ASSESSMENT Onset: “Did your pain start suddenly or gradually get worse and worse?” This is also a chance to ask, “What were you doing when the pain started?” Provokes or Palliates: Instead of asking, “What provokes your pain?” use real, casual words. Try, “What makes your pain better or worse?” Quality: Asking, “Is your pain sharp or dull?” limits your patient to two choices, when their pain might not be either. Instead ask, “What words would you use to describe your pain?” or “What does your pain feel like?” Radiates: This is another chance to use real, conversational words during assessment. Asking, “Does your pain radiate?” sounds silly and pompous to the patient. Instead use this question, “Point to where it hurts the most. Where does your pain go from there?” Severity: Remember, pain is subjective and relative to each individual patient you treat. Have an open mind for any response from 0 to 10. Time: This is a reference to when the pain started or how long ago it started. FLACC Acute Pain Behaviors Guarding Grimacing Rubbing/splinting of body parts Stillness Restlessness/reduced attention span Avoidance of social contact or conversation Refusing to eat, nausea, vomiting Vocalization (i.e. moaning, crying) Agitation/striking out Diaphoresis Change in vital signs ( Pulse, Resp, BP) Summary: Pain assessment is the most under assessed VS Pain is culturally dependent and subjective Several tools to help you assess pain Children in the hospital for surgery or accident this is probably their worse pain Summary Cont. A practical definition of pain is, “ Pain is whatever the experiencing person says it is, existing wherever he says it is.” Know the difference between the types of pain pg. 55. Review box 6-1 and table 6-1 pg. 57. Review Health history, Problem-based history and examination.
