Download NEO 111 Lab #2 Powerpoint Presentation Vital Signs

NEO 111
Vital Signs
Melanie Jorgenson, RN, BSN
Vital Signs include…
▫ Blood Pressure (B/P)
▫ Pulse (P or HR)—Radial or Apical
▫ Respirations (RR)
▫ Temperature—Oral, Rectal (R), Axillary (Ax),
▫ Tympanic (Tymp), Temporal Artery
▫ Pain Assessment Pulse Oximetry
Vital Signs – When?
• On admission
• Based on policy and procedure
• When there is a change in patient
condition
• Before and after surgery or a procedure
• Before and after activity that may increase
risk
• Prior to medication administration that
may affect CV or respiratory function
Pain “The 5th Vital Sign”
 Pain is subjective—what ever the patient says it is
 WILDA or HILDA assessment
 Word/How does your pain feel (description)
 Intensity (pain scales)
 Location (new or chronic?)
 Duration (constant or intermittent?)
 Aggravating and Alleviating Factors (what makes
the pain worse/better, what interventions have
been tried?)
Pain “The 5th Vital Sign”
 Nonverbal indicators of pain
 Grimacing
 Guarding
 Decreased activity/mobility
 Increased pulse & B/P (acute pain only)
 Shallow respiration
 Regular ongoing re-evaluation & re-evaluation
after an intervention to determine effectiveness
Blood Pressure
• Blood pressure is the force of blood against
arterial walls
• Systolic pressure is the highest pressure and
correlates with ventricular contraction (systole)
• Diastolic pressure is the lowest pressure and
correlates with ventricular relaxation (diastole)
• Blood pressure is written as Systolic/Diastolic
Blood Pressure
• Blood pressure should be taken with the proper size
cuff
▫ Index line within the range on the cuff or
▫ The cuff height should be approx 40% of the
circumference of the limb used
▫ Too small cuff results in a false high reading
▫ Too large cuff results in a false low reading
• Exercise, Caffeine & Nicotine may alter B/P and
pulse
• Avoid BP on extremity that has AV fistula,
Peripheral or central IV or side that has had
mastectomy and/or axillary node dissection
Blood Pressure
• Line up the artery line indicator with the artery
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(position the tubes on either side of the artery—tubes always located
distal)
Estimate your patient’s systolic B/P
1st Korotkoff sound = systolic pressure
Cessation of sound = diastolic pressure
B/P is read and recorded to the nearest even
number
• Important to know patient’s baseline blood
pressure for comparison as well as “normal
blood pressure” values
Reading a Sphygmomanometer
Normal & Abnormal Blood Pressure
Values
• Normal <120 mm Hg systolic*; <80 mm Hg diastolic
• Always consider what is “normal” for your particular
patient. (medications, age, etc…)
• Pulse pressure is the difference between the systolic
and diastolic reading
▫ An increased or widening pulse pressure (>60 mm Hg)
is concerning for cardiac disease (stiffening of arteries,
atherosclerosis or other medical condition)
Orthostatic Hypotension (postural
hypotension)
 How are Orthostatic B/P readings performed?
 Have pt lay down for 3-5 mins take BP and pulse, sit for 2
min take BP and Pulse, stand for 2 min take BP and pulse
 What indicates positive orthostatic hypotension?
 Drop in systolic BP of 25 mm Hg (text) 20 mm Hg (practice)
or a drop in diastolic by 10 mmg Hg when changing from a
lying to sitting or sitting to standing position
 Increase in pulse by 20 beats per minute when changing
form a lying to sitting or sitting to standing position
 Teach pt to rise slowly, raise HOB, dangle on side, slowly
stand, return to a sitting or lying position if symptomatic.
Pulse
 Record rate, rhythm and amplitude/quality
 Normal pulse rate for an adult is 60-100 bmp
 Normal pulse rate for a child (6-8 year old) is 75-110
 Normal pulse rate for an infant is 80-180 (newborn);
80-140 (1-3 year old)
More about pulses
• Name Peripheral pulse sites….
• Pulse volume variations: 0, 1+, 2+,
3+, 4+
Palpating the radial pulse
Apical Pulse
• Where do you place the stethoscope to listen to
the apical pulse?
• How long do you listen to apical pulse?
Apical Pulse
Respirations
 Observe at the sternal notch
 Assess rate, rhythm, effort, depth ( if applicable)
 An increase in carbon dioxide is the most
powerful respiratory stimulant
 Pulse oximeter
Questions….
 What is a “normal” respiratory rate in an adult?
 12-20 breaths per minute
 What is a “normal” respiratory rate in an child?
 15-25 (6-8 year olds)
 What is a “normal” respiratory rate in an infant?
 30-60 (newborn); 20-40 (1-3 year old)
Abnormal Respirations
• Hyperventilation, Hypoventilation
• Apnea—apnea that lasts longer than 4-6 minutes
may lead to brain damage and death
• Dyspnea, grunting, nasal flaring, retractions
• Orthopnea, Tachypnea, Bradypnea
Oxygen saturation
• Measures arterial oxyhemoglobin saturation
(SaO2 or SpO2)
• Often need to remove artificial nails and nail
polish
• Alternative sites-toe, earlobe, bridge of nose
Questions
• What is considered a “normal SaO2 range?
▫ 95%-100%
• When is less than 95% an expected finding?
• Know pt’s Hgb level…why?
Temperature
• Surface & Core Temperatures
▫ Surface—Temperature of skin—Oral & Axillary
▫ Core—Deep tissue—Rectal, Temporal Artery &
Tympanic
 Temps are lowest in early morning and highest
in late afternoon
 Normal Value Relative to Site
 Oral used as a baseline 98.6°F or 37.0°C
Oral Temperature
• Patient should not drink, smoke, eat, chew gum
for 15-30 minutes prior
• You should avoid and oral temp:
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disease of mouth
surgery of nose/mouth,
receiving oxygen by mask
unable to close mouth
Axillary Temperature
• Often used for newborns
• If axilla just washed wait 15-30 mins
• Watch placement
Correct placement for axillary thermometer
Rectal Temperature
• Most accurate
• When should you avoid a rectal temperature
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Newborns
small children
pt who had rectal surgery
diarrhea or disease of rectum
people with certain heart diseases (vagus nerve)
neutropenic pt
some neurologic disorders
Tympanic Temperature
 Need good seal
 Point probe toward opposite eye/jaw
 When should you avoid taking a tympanic
temperature?
 Drainage from ear, scars on tympanic membrane,
infection, radiation, narrow ear canal, hat
 The pinna should be positioned up and back
for an adult and down and back for a child
Documentation
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Pt’s age, gender, race
Vital Signs:
T Ax, Tympanic, Rectal, O (assumed)
P Rate, Rhythm, Amplitude
R Rate, Rhythm, Effort (Depth if needed)
BP result, extremity used, pt position
SpO2 receiving O2 or RA, where assessed
Pain Assessment
Documentation
• October 2, 2009
• 0730 34 yr old Caucasian male VS: T 98.2°F
L Tympanic R 16 regular, shallow, unlabored,
P 86 L radial, regular, 2+, BP 126/86 L arm
sitting. SpO2 96% on 2L NC L index finger.
Pt states pain in left leg 1 on 1-10 scale.
Patient in bed watching TV. Call bell in
reach.----------------M Jorgenson, RN
References
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Images from:
• Lynn, Pamela RN, MSN Taylor's Clinical Nursing Skills A Nursing Process Approach, 2nd
Edition. Lippincott,
Hutson, Janice & Constantino, Sheri, Use of Powerpoint material. 2010