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Chapter 17: Vital Signs VITAL SIGNS TEMPERATURE BLOOD PRESSURE PULSE APICAL RADIAL RESPIRATIONS PULSE OXIMETRY PAIN SCALE VITAL SIGNS ARE PART OF THE PHYSICAL ASSESSMENT Delegation of Duties to UAP Unlicensed Assistive Personnel RN is Responsible to Manage Care Based on Physical Assessment Administering medications Communicating to other members of the health care team Supervising delegated tasks EQUIPMENT RN is responsible for assuring equipment is functioning properly Appropriate equipment Must be appropriate to patient age size Thermometer Stethoscope: Diaphragm (high-pitched sounds); bell (lowpitched sounds) BP cuff Pulse oximeter PATIENT HISTORY RN must know patient medical history, including medications These facts can affect vital signs RN is responsible for knowing the patient’s usual vital sign range FREQUENCY OF VITAL SIGNS Physicians order the frequency of vital signs Could be ordered by protocol or policy The RN can increase the frequency based on his/her assessment VITAL SIGNS can be an early warning sign that complications are developing INDICATIONS FOR MEDICATION ADMINISTRATION Many medications are administered when the vital signs are within an acceptable range. Accurate VITAL SIGNS are required in order to make treatment decisions. COMPREHENSIVE ASSESSMENT FINDINGS Compare VITAL SIGNS to assessment findings and laboratory results to accurately interpret the patient status. Discuss your findings with peers and charge RN before deciding on a plan of action. Use the opportunity to teach patient/family about what VS mean, reason for assessing, meaning if appropriate TEMPERATURE Factors affecting body temp. (36-38°C/96.8100.4°F) Age Infants: 95.9 – 99.5° F [36.5-37.2C] intolerant of extremes Elderly: Average temp is 96.8° F; Sensitive to temp extremes Exercise Hormone levels Circadian rhythm Stress Environment TEMPERATURE ALTERATIONS Afebrile Pyrexia [fever] >37.5 Fever of unknown origin (FUO) Malignant hyperthermia: hereditary, occurs during anesthesia Heatstroke: medical emergency Heat exhaustion Hypothermia Frostbite TEMPERATURE Cont’d. Sites Common sites: Core temp is measured in pulmonary artery, esophagus, and urinary bladder Mouth, rectum, tympanic membrane, temporal artery, and axilla – use critical thinking to decide! Variety of types available – electronic and disposable Antipyretics = drugs that reduce fever Using an oral electronic thermometer, the nurse checks the early morning temperature of a client. The client's temperature is 36.1° C (97° F). The client's remaining vital signs are in the normally acceptable range. What should the nurse do next? A) Check the client's temperature history. B) Document the results; temperature is normal. C) Recheck the temperature every 15 minutes until it is normal. D) Get another thermometer; the temperature is obviously an error. PULSE Sites Increases in HR Temporal, Carotid, Apical, Brachial, Radial, Femoral, Popliteal, Posterior Tibial, Dorsalis Pedis Short-term exercise, fever, heat, pain, anxiety, drugs, loss of blood, standing or sitting, poor oxygenation Decreases in HR Long-term exercise, hypothermia, relaxation, drugs, lying down PULSE Cont’d. Volume of blood pumped by the heart during 1 minute is the cardiac output When mechanical, neural or chemical factors are unable to alter stroke volume, a change in heart rate will result in change in cardiac output, which affects blood pressure HR ↑, less time for heart to fill, BP ↓ HR ↓, filling time is increased, BP ↑ An abnormally slow, rapid, or irregular pulse alters cardiac output The nurse decides to take an apical pulse instead of a radial pulse. Which of the following client conditions influenced the nurse's decision? A) The client is in shock. B) The client has an arrhythmia. C) The client underwent surgery 18 hours earlier. D) The client showed a response to orthostatic changes. RESPIRATIONS Ventilation = the movement of gases in and out of lungs Diffusion = the movement of oxygen and CO2 between the alveoli and RBCs Perfusion = the distribution of RBCs to and from the pulmonary capillaries Factors Influencing Character of Respirations Exercise Acute Pain Anxiety Acid-Base balance Body Position Medications Neurological injury Hemoglobin function RESPIRATIONS Cont’d. Tachypnea = rapid breathing Apnea = cessation of breathing Cheyne-Stokes = rate and depth irregular, alternate periods of apnea and hyperventilation Kussmaul’s = abnormally deep, regular, and increased in rate (associated with DM) PULSE OXIMETER Indirect measurement of oxygen saturation Photodetector detects the amount of oxygen bound to hemoglobin molecules and oximeter calculates the pulse saturation Only reliable when SaO2 is over 70% Certain conditions may give an inaccurate reading A client is being monitored with pulse oximetry. On review of the following factors, the nurse suspects that the values will be influenced by which of the following? A) The placement of the sensor on the extremity B) A diagnosis of peripheral vascular disease C) A reduced amount of artificial light in the room D) The increased ambient temperature of the client’s room BLOOD PRESSURE Force exerted on the walls of an artery by the pulsing blood under pressure from the heart Systolic = maximum pressure when ejection occurs Diastolic = minimum pressure of blood remaining in the arteries after ventricles relax BLOOD PRESSURE Cont’d. Physiology of arterial blood pressure Factors influencing BP Cardiac Output, Peripheral resistance, Blood volume, Viscosity, Elasticity Age, Stress, Ethnicity, Gender, Daily Variation, Meds, Activity, Weight, Smoking Hypertension Hypotension Orthostatic or postural hypotension The nurse is assessing a client’s blood pressure during a routine visit. When asked, the client volunteers that when he took his pressure at home yesterday it was 126/72 mmHg. The nurse determines that the client’s pressure today is 134/70 mmHg. The nurse recognizes that the most likely cause of the elevation is due to which of the following? A) The difference between the monitoring equipment being used B) The client’s inability to hear the first Korotkoff sound C) The client may be experiencing mild anxiety regarding the check-up D) The client is not inflating the cuff sufficiently to detect the systolic pressure QUESTIONS?