Download Vital Signs

Vital Signs
Taylor, ch 24
Jensen, ch 6
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General Guidelines
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Nurse’s responsibility/delegation
Equipment
Knowledge of client’s range
Knowledge of client’s history and current
status
• Environmental factors
• Systematic approach
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Guidelines (cont'd)
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Approach with the client
Frequency of assessment
Assessment for medications
Analysis and verification of results
Communication of results
Teaching
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Temperature Regulation
• Regulated by hypothalamus which has
one part for heat loss, one for conservation
• Hypothalamus receives info from
thermoreceptors in skin and body core
• Sends info to cerebral cortex (voluntary),
sweat glands, blood vessels, and skeletal
muscles (shivering)
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Temperature Maintenance
• Maintenance—heat loss = heat production
• Heat loss can occur through vasodilation,
sweating, increased RR, increased fluid
intake, moving to cooler environment, or
putting water on skin.
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Maintenance cont’d
• Heat production can occur in three ways:
– Shivering
– Exercising
– Increased metabolic rate
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Factors Affecting Temperature
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Age
Exercise
Hormone level
Circadian rhythm
Stress
Environment
Disease conditions
Nutritional status
Drugs, anesthesia, alcohol, cigarettes
Hot and cold liquids
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Temperature Terms
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Pyrexia, febrile (fever)
Afebrile
Hyperthermia (heatstroke, exhaustion)
Hypothermia (frostbite)
Antipyretic
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Temperature Courses
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Intermittent
Remittent
Constant
Relapsing
Crisis
Lysis
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Assessment of Temperature
• Symptoms—HA, anorexia, hot dry skin,
flushed face, thirst, malaise, delirium
• Sites—oral, rectal, axillary
• Thermometers—glass, electronic,
tympanic, tape. Oral and rectal
thermometers and probes should be
clearly delineated.
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Guidelines for Oral Temps
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97.6—99.6
Sublingual pocket
2-5 minutes or 20 secs
Contraindications:
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Children < 6
Confused, combative
Seizure-prone
Mouth breathers
Smoking, chewing, eating < 15 min
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Guidelines for Rectal Temps
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98.6—100.6
Insert ½ to 1 ½ inches, L side and lubricated
2-3 minutes or 20 secs
Contraindications:
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Rectal surgery
Cardiac patients
Diarrhea
Combative
Children < 6
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Guidelines for Axillary Temps
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96.6—98.6
Midaxilla and held tightly
10 minutes or 20 secs
Contraindications:
– Area just washed
– Shoulders or arms impaired
– Deeply recessed axilla
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Treating Febrile Conditions
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Antipyretics
Hypothermia blankets
IV fluids
Irrigations of stomach and bowel
Tepid and alcohol baths and ice packs
may increase shivering
• Know conversions of Fahrenheit to
centigrade and vice versa
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Asepsis and Safety
• Use personal glass thermometers or
disposable covers for glass and electronic
• Before using glass, clean bulb to stem; after
using, clean stem to bulb using twisting
motion each way
• Wash glass with soap, rinse, place in
antiseptic
• Right bulb for right site
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Pulse Physiology
• Contraction of left ventricle forcing blood
into aorta
• Surge on elastic arteries causes wavelike
distention and recoil—this is the pulse
• Terms:
– Bradycardia
– Tachycardia
– Dysrhythmia
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Pulse Sites
• Temporal
• Carotid—CPR site
• Apical—PMI; use if radial is out of range,
irregular, not palpable, and in children<2
• Radial—most common
• Brachial—CPR in infants
• Femoral
• Popliteal—difficult to palpate
• Pedal—diff to palpate in pts with circ probs,
casts
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Pulse Characteristics
• Rate—only necessary in radial and
apical
• Rhythm—same as rate
• Strength—important at all sites
• Equality—important at all sites
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Guidelines for Assessing Pulse
• Assess 4 characteristics and for pulse
deficit. 30” x 2 if regular; 1’ if not (x apical)
• 70-72 in males; 78-82 in females
• Use three fingers with light pressure for
peripheral sites
• Apical at 5th intercostal space,
midclavicular line (4th in children <=7).
• Pulses located distal to trauma,
procedures, and surgery are important to
assess for perfusion
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Factors Affecting Pulse
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Emotions, pain
Exercise
Fever
Eating
Drugs/smoking
Hypoxemia
Illness, injury
Obesity
Pregnancy
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Physiology of Respiration
• Controlled by chemoreceptors in the
carotid and aorta that respond to
increased levels of CO2 in the blood.
• These chemoreceptors stimulate the
respiratory center in the brain (medulla
oblongata) to increase RR.
• Respirations are voluntary when we take
deep breaths or when we realize someone
is counting them.
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Respiration Terms
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External/internal respiration (cellular)
Ventilation—hypo/hyper
Inspiration/expiration
Bradypnea/tachypnea/eupnea
Apnea/dyspnea/orthopnea
Cheyne-Stokes/Biots/Kussmaul
Adventitious—rales, rhonchi, wheeze, rubs
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Factors Influencing
Respirations
Same as pulse +:
– Brain injury
– High altitudes
– Low hemoglobin
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Guidelines for Assessing
Respirations
• Rate, rhythm, depth
• Do not let patient know you are taking
respirations—take with pulse
• Look for cyanosis, restlessness, confusion,
reduced LOC, pain, dyspnea, orthopnea,
coughing, sputum production, noisy
breathing
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Blood Pressure Physiology
• Pressure the blood exerts against the arterial wall
(usually brachial)
• Pressure is measured in mms of Hg by
sphygmomanometer
• Blood supply to artery is occluded, then allowed to
return slowly
• Two ways pressure is measured:
– When heart beats (systolic pressure)
– Between heart beats (diastolic pressure)
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Blood Pressure Maintenance
• Depends on:
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Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
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Blood Pressure Terms
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Systolic pressure
Diastolic pressure
Pulse pressure
Hypertension
Hypotension
Orthostatic hypotension
Postural blood pressures (orthostatic)
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Influencing Factors
Age
Stress
Ethnicity
Gender
Diurnal variation
Medications
Cold environment
Hot showers
Site and position
Eating, socializing
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Blood Pressure Measurement
Equipment—Manual and automatic
Auscultated
Palpated
Sites
Children
Self-measurement
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Guidelines for Assessment
Appropriate size cuff
Sitting or lying; arm at heart level;
manometer at eye level
Place cuff securely 1 inch above antecubital
space
Palpate artery and pump to absence of pulse
Release air; wait 30 seconds
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Guidelines cont’d
• Place stethoscope over artery; inflate within 7
seconds to 30 mm over absence of pulse
• Deflate slowly (2-3 mm/sec)
• Note Korotkoff sounds (536)
• Wait 30 seconds if need to recheck
• Do not take BP at site of mastectomy or
atriovenous fistula used for hemodialysis
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Additional Nursing Interventions
• Compare to previous readings, if available
• Client teaching
• Reporting and recording
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Common Mistakes
• See p. 537, Table 24-10
• In addition:
– Taking BP over clothing can make it difficult to
hear correct BP
– Sleeve rolled up too tight can cause abnormally
high reading
– Improper placement of earpieces
– Stethoscope diaphragm turned to wrong side
– Environmental noise
– Tubing rubbing together
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