Download Chapter 32: Vital Signs

Chapter 17: Vital Signs
VITAL SIGNS
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TEMPERATURE
BLOOD PRESSURE
PULSE
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APICAL
RADIAL
RESPIRATIONS
PULSE OXIMETRY
PAIN SCALE
VITAL SIGNS ARE PART OF THE
PHYSICAL ASSESSMENT
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Delegation of Duties to UAP
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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
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EQUIPMENT
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RN is responsible for assuring equipment is
functioning properly
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Appropriate equipment
Must be appropriate to patient age size
 Thermometer
 Stethoscope: Diaphragm (high-pitched sounds); bell (lowpitched sounds)
 BP cuff
 Pulse oximeter
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PATIENT HISTORY
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RN must know patient medical history,
including medications
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These facts can affect vital signs
RN is responsible for knowing the patient’s
usual vital sign range
FREQUENCY OF VITAL SIGNS
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Physicians order the frequency of vital signs
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Could be ordered by protocol or policy
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The RN can increase the frequency based on
his/her assessment
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VITAL SIGNS can be an early warning sign that
complications are developing
INDICATIONS FOR MEDICATION
ADMINISTRATION
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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
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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
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Factors affecting body temp. (36-38°C/96.8100.4°F)
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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
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Exercise
 Hormone levels
 Circadian rhythm
 Stress
 Environment
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TEMPERATURE ALTERATIONS
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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.
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Sites
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Common sites:
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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
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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
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Sites
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Increases in HR
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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
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Long-term exercise, hypothermia, relaxation, drugs, lying
down
PULSE Cont’d.
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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
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HR ↑, less time for heart to fill, BP ↓
HR ↓, filling time is increased, BP ↑
An abnormally slow, rapid, or irregular pulse alters
cardiac output
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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
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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
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Exercise
Acute Pain
Anxiety
Acid-Base balance
Body Position
Medications
Neurological injury
Hemoglobin function
RESPIRATIONS Cont’d.
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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
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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
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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
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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.
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Physiology of arterial blood pressure
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Factors influencing BP
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Cardiac Output, Peripheral resistance, Blood
volume, Viscosity, Elasticity
Age, Stress, Ethnicity, Gender, Daily Variation,
Meds, Activity, Weight, Smoking
Hypertension
Hypotension
Orthostatic or postural hypotension
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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?