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NURSING INTERVENTIONS VITAL SIGN MEASUREMENT VITAL SIGNS Vital signs are indicators of the body's: Physiological status Response to Physical stressors Environmental stressors Psychological stressors SJ/LAC FFP YEAR ONE - VITAL SIGNS 2 VITAL SIGNS Temperature, Pulse Blood Pressure & respiration rate can REVEAL the patients ability to: Maintain body temperature regulation Maintain local & systemic blood flow Maintain oxygenation of the tissues SJ/LAC FFP YEAR ONE - VITAL SIGNS 3 VITAL SIGNS Any difference between a clients NORMAL EXPECTED baseline measurement and the ACTUAL PRESENT vital sign is an indication for the nurse to PURSUE APPROPRIATE necessary care and INITIATE nursing action/therapies. SJ/LAC FFP YEAR ONE - VITAL SIGNS 4 VITAL SIGNS Temperature & Respiration Vital sign changes may reveal sudden changes as well as progressive changes raised temperature may indicate an infection; raised pulse - ?bleeding; lowered blood pressure - ?bleeding SJ/LAC FFP YEAR ONE - VITAL SIGNS 5 CONSIDERATIONS OF VITAL SIGN MEASUREMENT From a nursing viewpoint Measurement provides information used to determine a patient / clients baseline data & response to medical ./ nursing therapy Vital sign recording is a quick, efficient way of monitoring a condition or identifying problems. Can be used as a basis for clinical problem solving Vital sign measurement is incorporated into Practice for assessment & determining the need for intervention(s), Viewed as routine care measures SJ/LAC FFP YEAR ONE - VITAL SIGNS 6 TEMPERATURE In health, tissues & cells function best within a relatively narrow range of temperature controlled by the hypothalamus. Body Core temperature is maintained within + or 0.6 of a degree Celsius / centigrade. Surface body temperature fluctuates according to environmental changes. Skin temperature can range between 20o - 40oC without causing tissue damage. SJ/LAC FFP YEAR ONE - VITAL SIGNS 7 TEMPERATURE Temperature range is balanced & regulated to allow for changes that result from Exercise, Activity and Rest. Temperature regulatory mechanisms include: Vasodilatation, Vasoconstriction, Sweating & avoiding environmental extremes hot/cold. For body temperature to stay constant HEAT PRODUCED must equal HEAT LOST to the environment. When internal control mechanisms fail the nurse may initiate measures to CONTROL the immediate environments REMOVE or ADD coverings GIVE MEDICATIONS - antipyretics SJ/LAC FFP YEAR ONE - VITAL SIGNS 8 Monitoring temperatures Types of thermometers Glass with a mercury column; Electronic; Disposable; Tympanic Thermometry. SJ/LAC FFP YEAR ONE - VITAL SIGNS 9 Factors influencing / affecting temperature General age; exercise; hormones; stress; environment; medications; daily fluctuation / time / gender Specific diagnosed infections; burns / open wounds; Low white cell count <5,000; High WBC > 12,000; immunosuppresive drug therapy; post operative state; hyperthermic therapy; hypothermic therapy; injury to the hypothalamus; infusion of blood products Nurses asses for Fever or Hypothermia SJ/LAC FFP YEAR ONE - VITAL SIGNS 10 Show Video on Genius thermometers SJ/LAC FFP YEAR ONE - VITAL SIGNS 11 RESPIRATIONS Human survival depends on the ability for Oxygen to reach the body cells and Carbon Dioxide to be removed from the cells. Factors affecting character of respirations Exercise; acute pain; anxiety; smoking; anaemia; body position; medications; brain stem injury. SJ/LAC FFP YEAR ONE - VITAL SIGNS 12 ASSESSMENT OF RESPIRATIONS Easiest of all vital signs to measure but most often haphazardly recorded. NEVER estimate a respiratory rate Accurate measurement of the chest wall rising and falling is required. Any change may be important Respiration is tied to the function of numerous body systems, therefore the nurse must consider all variables when change occurs. SJ/LAC FFP YEAR ONE - VITAL SIGNS 13 MEASUREMENT RATE - determined by a full inspiration and expiration, will vary with age DEPTH - assessed by observing the degree of movement in the chest wall and is usually considered to be deep, normal or shallow. RHYTHM - regular occurrence of respiration will depict a normal range. During assessment the nurse estimates the time interval; after each respiration cycle. Respiration is then either regular or irregular in rhythm SJ/LAC FFP YEAR ONE - VITAL SIGNS 14 ALTERATIONS IN BREATHING PATTERN Bradypnoea rate regular, but abnormally slow < 12 b/min rate regular, but abnormally fast > 20 b/min Tachypnoea Hyperpnoea Biots resp. abnormally shallow for 2-3 breaths, followed by irregular periods of apnoea laboured respirations, increased depth, increased rate > 20 breaths / minute Hyperventilation rate & depth increased Hypoventilation rate & depth abnormally low Cheyne-Stoke rate & depth irregular, alternating periods of apnoea and hyperventilation Kussmaul resp. abnormally deep, regular but increased in rate SJ/LAC FFP YEAR ONE - VITAL SIGNS 15 WHEN TO RECORD VITAL SIGNS On clients admission to a health care facility In hospital, on routine or schedule according to physicians order or hospital policy During clients visit to clinic or physicians office Before & after any surgical procedure Before & after any invasive diagnostic procedure Before & after administration of medications that affect cardiovascular, respiratory & temperature control function SJ/LAC FFP YEAR ONE - VITAL SIGNS 16 WHEN TO RECORD VITAL SIGNS When the clients general physical condition changes e.g. loss of consciousness or increased intensity of pain Before & after nursing interventions influencing any one of the vital signs e.g. before ambulating client previously on bed rest or before client performs range of movement exercises Whenever client reports to nurse any non- specific symptoms of physical distress e.g. "feeling funny or different" SJ/LAC FFP YEAR ONE - VITAL SIGNS 17 Patient at risk score. PAR Research completed in Swansea NHS trust. Reduced observation of Respiratory recording. Aim = Early indications of deteriation. SJ/LAC FFP YEAR ONE - VITAL SIGNS 18 SJ/LAC FFP YEAR ONE - VITAL SIGNS 19 SJ/LAC FFP YEAR ONE - VITAL SIGNS 20 References: Potter,A. Perry,A. (1997) Fundamentals of Nursing, Concepts, Process & Practice St Louis: Mosby Ch 32 p 594 Taylor,C. Lillis,C. LeMonde,P. (1997) Fundamentals of Nursing - The Art & Science of Nursing Care. Philadelphia: Lippincott Ch25 p432 SJ/LAC FFP YEAR ONE - VITAL SIGNS 21