Foundations of Nursing 6th ed. (Exam 7) Ch.4 - Vital Signs

Guidelines for obtaining/measuring vital signs

-measure vital signs correctly -understand and interpret the values -Communicated findings appropriately -begin interventions as needed -nurse who cares for the patient is ideally the one to assess vital signs -make sure equipment is in proper working condition -use standard precautions & make sure equipment is clean -beware of patient's normal range of vital signs -know patient's medical history, therapies & medications prescribed -keep environmental factors that have potential to affect vital signs to minimum -approach the patient in calm, caring manner while demonstrating proficiency in handling supplies -use organized, systemic approach -nurse & physician decide the frequency of vital sign measurement -evaluate the results of vital sign measurement -verify & communicate significant changes in vital sign -nurse or health care personnel measure vital signs before primary provider examine the patient -report abnormalities in vital signs to the physician

Vital Signs

Indication of basic body function -Temperature -Pulse -Respirations -Blood Pressure -Pain

FLACC scale

used for infants -face -legs -activity -crying -consolability

Wong-baker scale

Used for children Pain rating scale. Face scale

Factors affecting body temperature

Normal range: 97F - 99.6F -Age (state of health, varies among neonate, infancy, puberty, and older adults) -Exercise (activity level) -Hormonal influences (hormonal changes during ovulation, menstrual cycle & menopause cause body temperature fluctuations) -Diurnal influences (change throughout the day, lowest between 1am-4am, peaks around 4pm-6pm) -Stress: physical/emotional (raises body temperature) -Environment (can raise/lower body temp, the changes depend on the extent of exposure, air humidity, and the presence of convection currents) -Ingestion of hot/cold liquids (cause variations in oral temperature readings) -Smoking cigarettes/cigar (alters body temperature measurement) (BOX 4-4, p.62)

Temperature extremes

Can't go below 93.2 or above 105

Core temperature

Temperature of the deep tissue of the body; it remains relative constant unless a person is expose to severe extremes in environmental temperature

Surface Temperature

Temperature of the skin; it often varies in response to the environment

How to record vital signs?

Location of temperature reading (must be documented with each temperature reading!) -Oral = O with a circle around it (98.6F) -Tympanic = T with a circle around it (98.6F) -Axillary = A or Ax with a circle around it (97.6F) -Rectal = R with a circle around it (99.5F) BP reading -final /O may be added (120/80/0) if the beat is clearly heart until the end -ap = apical pulse Report -report any abnormal findings to the nurse manager or physician -record the nurses' notes for any accompanying or precipitating signs & symptoms -document any interventions initiated

Colors for thermometer

Red = Rectal (insert 1.5 inches) child (no more than 1 inch) Blue = Oral

Tempa-DOT

Disposable single use thermometer strip

How to manipulate the ear when taking a tympanic temperature

Pull Pinna Up and back for adults Down and back for children

Only $35.99/year

Classification of Fevers

-Constant - remains elevated consistently, fluctuate very little -Intermittent- rises and falls -Remittent - temp never returns to normal until the patient becomes well

Signs and symptoms of elevated body temperature

-Thirst -Anorexia -Flushed, warm skin -Irritability -Glassy eyes/photophobia (sensitivity to light) -Headache -elevated pulse and respiratory rates -Restlessness of excessive sleepiness -Increased perspiration -Disorientation, progressing to convulsions in infants and children

Auscultating using the stethoscope

-when assessing the apical heart rate, the nurse uses a stethoscope Major Parts of the stethoscope -earpieces: Should fit snugly and comfortably in the nurses ears. The binaurals will be angled and strong enough that the earpieces stay firmly in the nurse's ears -polyvinyl tubing: 12-18in long, the tubing is thick-walled & moderately rigid to eliminate transmission of environment noise -chestpiece: consists of a bell (transmits low-pitched sounds created by low-velocity movement; used for heart & vascular sound) or diaphragm (transmits the high-pitched sounds created by the high-velocity movement of air & blood)

Pulse Volume Variations

Pulse volume - the amount of blood pushing against the artery wall with each beat 0 Absent (none felt) 1+ Thready (difficult to feel, not palpate when only slight pressure applied) 2+ Weak Pulse (somewhat stronger than thready pulse but not palpable when light pressure applied) 3+ Normal Pulse (easily felt but not palpate when moderate pressure applied) 4+ Bounding Pulse (feels full & springlike even under moderate pressure)

PMI (Point of Maximum Impulse)

-Apical pulse (5th intercostal space); is over apex of heart

Factors that affect pulse rates

-Age - pulse rate decreases from infant-adulthood; increases in older adults b/c of weakened heart muscle or medication -Exercise - short-term (increases pulse rate); long-term (strengthen heart muscle, cause lower-than-normal rate at rest, quicker return ti resting rate after exercise) -Fever, Heat (increase the pulse rate b/c of increased metabolic rate; hypothermia will decrease pulse rate) -Acute pain, Anxiety (increase pulse rate b/c sympathetic stimulation) -Unrelieved severe pain, Chronic pain (decrease pulse rate b/c of parasympathetic stimulation) -Medications (alter pulse rate) -Hemorrhage (increases pulse rate b/c sympathetic stimulation) -Postural Changes (lying down decreases the pulse rate; standing/sitting increases pulse rate) -Metabolism -Pulmonary conditions (increase pulse rate b/c cause poor oxgygeneration) BOX 4-9, p.70

Respirations

The taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing

Internal Respirations

-the exchange of gas at the tissue level caused by the process of cellular oxidation (any process in which the oxygen content of a compound is increased) & alveolar level (gas exchange that occurs in the alveoli of the lungs) -normal level 12 - 20 breaths per minute

External Respirations

Breathing movements that can be observed by the nurse; inspiration (taking in O2) & expiration (giving off CO2); rate of respiration is controlled by the medulla oblongata; normal respiratory rate for adult is between 12-20 respiration/min

Factors influencing respirations

-Disease/Illness (chronic lung disease, reduced RBC levels, chest pain, kidney disease, febrile disease, disease of heart can alter the normal stimulus for ventilation, rate & depth of respiration) -Stress (anxious/fearful cause cause hyperventilation, increases in rate & depth of respiratory) -Fever/Hyperpyrexia (greatly elevated temperature; cause abnormal rapid rate of breathing) -Age (infancy-adulthood = respiratory rate declines due to lung's capacity increases, older adult = respiratory rate increases due to lung capacity & depth of respiration decrease) -Sex (men have greater lung capacity) -Body position (slumped/stooped positions = ventilation impairs, decrease depth of respirations; straight erect posture = promotes full chest expansion; lying flat = full chest expansion is limited) -Medications (increase/decrease the rate & depth of respirations and affect the rhythm) -Exercise (increase rate/depth of respiration) -Acute pain (increases rate & depth of respirations due to sympathetic stimulation, breathing is shallow) -Smoking (changes lungs' airways, increase respiratory rate) -Brainstem injury (impairs respiratory center & inhibit respiratory rate & rhythm) -Hemoglobin function (its reduction = increasing in respiratory rate & depth) (BOX 4-11, p.76)

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Respiration Assessment

Includes the rate, depth, rhythm, and quality -the rhythm of respiration should be regular and uninterrupted

Dyspnea

Breathing with difficulty

Bradypnea

Slow respiratory rate, below 10 per minute

Tachypnea

Rapid respiratory rate (can be caused by fever or exercise)

Cheyne-Stokes respiration

Abnormal pattern of respiration characterized by alternating periods of apnea and deep, rapid breathing; usually appear in critically or terminal ill patient.

Blood Pressure

-the pressure exerted by the circulating volume of blood on the arterial walls, veins, and chambers of the heart; it's measure in millimeters of mercury (mm Hg) -it reflects cardiac output, quality of arteries, blood volume, blood viscosity -increased volume = increased BP -artery's lumens (channels w/in arteries) narrow & less flexible = increased BP -increased blood viscosity (thickess) = slower flow of blood in capillaries & backup pressure in large vessels. Reading & Follow-up checkup -Optimal = less than 120/80 mm Hg (recheck in 2yr) -Prehypertension = 120-139/80-89 mm Hg (recheck in 1yr) -Hypertension = 140/90 mm Hg (recheck from 1 week - 2 months depend on the severity)

Pulse pressure

Difference between the systolic and diastolic

Apical pulse

heartbeat as measured with the bell or disk of the stethoscope placed over the apex of the heart where the 5th intercostal is located, represents actual beating of the heart. Most authentic of all pulses

Diastolic Pressure

The second & lower number of BP reading, represent the pressure within the artery between beats (between contractions of atria or ventricles; when blood enters the relaxed chambers from the systemic circulation and the lungs) Normal - 80 PreHTN - 80 - 89

Dysrhythmia

Any disturbance or abnormality in a normal rhythmic pattern, specifically irregularity in the normal rhythm of the heart

Febrile

-Body temperature above normal -Fever is a body defense; elevated body temperature destroys bacteria -105F+ can damage normal body cells

Hypertension

-consistent readings of 140/90 or more Risk factors -family history of hypertension -obesity -smoking -heavy alcohol consumption -elevated blood cholesterol -continued exposure to stress

Hyperthermia

Condition of abnormally high body temperature

Hypotension

Occurs when the blood pressure is below normal

Hypothermia

Condition of abnormally low body temperature

Korotkoff sounds

-pulsating sounds heard while measuring BP when using a sphygmomanometer 5 Phases: 1.sharp thump (130-140) 2.blowing/whooshing sound (120-129) 3.softer thump than phase 1 (101-119) 4.softer blowing sound that fades (90-100) 5.silence (80-89)

Orthostatic Hypotension

-sudden drop in BP with positional change -a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when moving from lying to sitting position

Pulse

Rhythmic beating or vibrating movement; regular current expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts; each pulse beat corresponds to a contraction of the heart (normal adult pulse rate = 60-100 beats/min, ave.= 80 beats/min)

Pulse deficit

A condition that exists when the radial pulse rate is less than the ventricular rate as auscultated at the apex of the heart

Sphygmomanometer

Blood pressure cuff, used to measure arterial BP

Stethoscope

Instrument placed against a patient's body to hear heart, lung and bowel sounds.

Systolic pressure

The higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries; 1st sound heard on auscultation Normal - 120 PreHT - 120 - 139

Temperature

Relative pressure of sensible heat or cold

Tympanic

Membranous eardrum

Conditions that cause alterations in BP

-Hemorrhage (lowers) - decreased blood volume -Increased Intracranial Pressure (raises) - disturbance of cardiovascular control mechanism in brainstem resulting form pressure exerted on the medulla oblongata -Acute Pain (raises) - increased vasomotor tone and peripheral vascular resistance as a result of sympathetic stimulation -End-stage renal disease (raises) - increased blood volume resulting form increased retention of sodium ad water; release of renin (a vasopressure that increases peripheral vascular resistance) -Primary essential hypertension (raises) - increased peripheral vascular resistance resulting from progressive thickening of arterial walls -General anesthesia (lowers) - decreased vasomotor tone resulting from depression of vasomotor center in brain-stem -Exercise (raises) - increased cardiac output -postural change (lowers) - decreased blood volume as person moves from ling to setting or standing position -Smoking (raises) - increased vasoconstriction

Normal Blood pressure

120/80 or less

Height and weight

-Helps assess normal growth and development -Aids in proper drug dosage calculation -May be used to assess the effectiveness of drug therapy, such as diuretics -Significant loss of weight may be a sign of an underlying disease

When vital signs are assessed?

-temperature, pulse, respiration, and blood pressure are usually assessed at the same time at set intervals -a set of vital signs is taken when the patient is admitted to the facility and then as prescribed by the physician or as policy dictates -the more ill the patient, the more frequent nurse will take vital signs -it is important to recognize the age-related differences in vital signs (TABLE 4-1, p.60) BOX 4-2, p.59 -during admission & discharge to a health care facility -on routine determined by physician/agency policy -before/after surgical procedures, invasive diagnostic procedures, administering certain medications, and certain nursing interventions -when patient's general condition changes -when patient reports nonspecific symptoms of physical distress -routinely as part of a procedure -when assessing patient during home health visit -paint (5th): must be evaluated & documented each time other ital signs are taken

Things never to do!

-Never use thumb to palpate a pulse -Never use oral route to assess infants temp -Never take oral route temp after patient has had hot or cold drinks within 15 min -Never take oral route for temp for unconscious patient -Never take carotid pulse on both sides simultaneously -Never take BP in arm with IV -Never take BP on mastectomy surgical site -Never force a rectal temp -Never make up readings for ANY of the vital signs

What are some cultural factors that are needed to be considered in several cultures?

-some Italians, Greeks, and Native Americans believe that garlic or onions eaten raw or worn on the body will prevent an illness such as high blood pressure -provide privacy when taking the apical pulse of female patients for Asian, Middle East, Hispanic, and African cultures & their elders -use same sex provider to take rectal temperature & touch the patient's chest -consult the physician and the family decision maker regarding giving info to the patient about the abnormal vital signs -determine the patient's understanding of new procedures being performed -use and interpreter if needed, and demonstrate the procedure to promote patient's understanding

Auscultate

Listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones

Tachycardia

Pulse is faster than 100 beats per minute (can be caused by: shock, hemorrhage, exercise, fever, medication, substance abuse, acute pain)

Bradycardia

Pulse is slower than 60 beats per minute (caused by unrelieved severe pain b/c pain stimulates the parasympathetic nervous system)

Vital signs readings are interrelated

-a rise in temperature has potential to cause an increase in pulse rate -respiratory rate & BP readings increase with the rise in temperature -when BP falls because of hemorrhage , the pulse and respiration increase & temperature usually decreases

What are the factors needed to be aware when taking vital signs in older adults? (p.60)

-at 75+ yrs old: -core temperature averages 97.2F (36C) -environment temperature plays a significant role, may contribute to hypothermia & hyperthermia -occlusive amounts of cerumen (ear wax) may affect tympanic temperature reading -pulse irregularities are common (should take apical pulse) -pulse can be easily occluded -depth of respiration decreases & rate of respiration increases -lost upper arm mass (standard adult cuff might be too large) -skin is more fragile & susceptible to cuff pressure -accurate measurement of BP & closely monitoring is essential for those receiving antihypertensive & vasodilators for orthostatic hyptension -orthostatic hypotension is common in inactive older adult -have baseline temperature that is not typical of the adult patient -infection is often afebrile (w/o fever) -manifestation of delayed or diminished febrile response to infection are subtle & variable and very difficult to assess -decreased heart rate at rest -pulse rate takes longer to return to normal resting rate once elevated -stethoscope placed at fifth intercostal space (ICS) or the lower edge of the breast -heart sounds are often muffled or difficult & increase in air space in the lungs -BP elevates with age -increase in systolic pressure related to decreased vessel elasticity & diastolic pressure remains the same, resulting in wider pulse pressure -need to change position slowly to avoid postural hypotension & prevent injuries -decreased efficiency of respiratory muscles results in breathlessness at low exercise level -responses to hypoxia are reduced 50% -difficult to identify and acceptable pulse oximeter probe site (peripheral vascular disease, decreased cardiac output, cold induced vasoconstriction, anemia

Regulators of body temperature

Hypothalamus -regulator of body temperature -helps maintain balance between heat lost and heat produced by the body Metabolism -increase with exercise & digestion -primary mechanism for the body to generate heat Constriction of peripheral vessels prevents loss of heat through the skin surface & helps conserve heat

Nursing interventions for the patient with an abnormal body temperature

BOX 4-6, p.62

Hypothyroidism

-produce a subnormal temperature, can cause a slowing of pulse rate

Obtaining temperature measurements

Peripheral temperature -gives a good estimate of core temperature -is used when a patient has a normal body temperature -if the patient's temperature is rising or falling rapidly, the body's thermoregulatory system will affect peripheral sites, and temperatures can lag behind true core temperature Heat sensitive patches -used to obtain an actual reading of surface temperature

Assessing tympanic temperature accurately

BOX 4-7, p.64

Elimination of mercury-containing devices

-1714 - Fahrenheit invented the constant reference point thermometer using mercury in glass -1868 - Wunderlich established the normal range of body temperature in humans (97.2-99.5F) -1g Hg can contaminate 20 acres lake -DONOT touch spilled Hg droplets; rinse affected area for 15 min

American Academic of Pediatrics

Addresses the hazards of mercury and discusses possible measures for pediatricians to reduce children's exposure

How to measure temperature with an electronic thermometer?

Oral -insert probe into the posterior sublingual pocket -require patient's cooperation -DONOT use in: patients with surgery fracture, comatose/disoriented patient, in small infats Rectal (normally 1F higher than oral) -put patient in Sim's position with upper leg flexed; expose only the rectal area -lubricate 1in of tip -adults: insert thermometer probe 1.5in children: insert the thermometer probe no more than 1in -can't use for patient's with recent rectal surgery or certain conditions of the perineum Axillary (normally 1F lower than oral) -insert probe into center of axilla, lower arm over thermometer; placing patient's arm across their chest -least accurate Tympanic -gently tug ear pinna upward and back for an adult; down & back for a child Temporal artery

Tympanic temperature

-more accurate than traditional thermometer because measurement is from and enclosed cavity un affected by the environment temperature -tympanic membrane shares its blood supply with the hypothalamus; thus, it is a good source for obtaining core-term perature readings Benefits: -suitable for patients of all ages (except infants) -eliminate the risk of cross-contamination -cost effective

Oral measurement

-most accessible site; comfortable for patient; necessitates NO position change -DONOT USE for: infants, children, disoriented or unconscious patients; those with oral surgery, trauma (face, mouth), oral pain, breathe only with mouth open, history of convulsions, shaking chill

Rectal measurement

DONOT USE for: patients after rectal surgery, rectal disorder (tumor, hemorrhoids), who can't positioned for proper thermometer displacement

Axilla measurement

-safe, non invasive -least accurate

Temporal measurement

-provides core temperature; rapid, non invasive method; tolerated well by children

Hypovolemia

Abnormally low circulating blood volume

Major pulses

-look for rate, rhythm, volume, strength -includes: temporal, facial, carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis

Angle of Louis

Located just below suprasternal notch at point where horizontal ridge is felt along body of sternum.

Metabolism

The aggregate of all chemical processes that take place in living organisms resulting in growth, generation of energy, elimination of wastes, and other bodily functions as they relate to the destruction of nutrients in the body after digestion

Depth of respiration

-determined by the amount of air taken in with inhalation -normally 500mL of air is inspired with each breath

Diaphragm

-a dome-shaped musculofibrous partition that separates the thoracic and abdominal cavities -aids respirations by moving down during inspiration and moving up during expiration.

Alveoli

air cell of lungs where gases are exchanged in respiration, it aerates when during sighing

Assessment of respiration

-ASSESS: rate, depth, quality, rhythm, patterns of breathing -movements of diaphragm & intercostal muscles allows nurse to judge the depth of respiration -shallow respiration makes ventilation difficult to observe & only small amount of air is exchanged in the lungs -best time to assess respiration is when counting radial or apical pulse

Costal retraction

The visible sinking-in of the soft tissues of the chest between & around the firmer tissues of the cartilaginous and body ribs, as occurs with increased inspiration effort

Apnea

Lack of spontaneous respiration

Hyperventilation

-occurs when the rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases, such as during emotional trauma -volume & depth of respiration increase

Hypoventilation

-occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs, such as after open cholecystectomy is performed -respiratory rate is below normal, and depth of ventilation is depressed

Nursing interventions for patient with abnormal pulse

BOX 4-10, p.74

Cardiac output

The amount of blood discharged from the left or right ventricle per minute

Factors influence blood pressure

-Age - BP increases with age -Anxiety, fear, pain, emotional stress - increase BP b/c increased heart rate & peripheral vascular resistance -Medications - can either lower or increase BP -Hormones - alteration of hormones in pregnancy can increase BP -Diurnal (happening daily) - morning (lower BP), BP rising throughout the day, late afternoon/evening (BP peaking), night (lower BP) -Race - high in urban Blacks due to genetic or environmental -Sex - males tend to have higher BP after puberty; females have higher BP after menopause

Auscultatory gap

-temporary disappearance of sound heard over the brachial artery -occurs b/t first & second Korokoff sounds -the gap in sound sometimes covers a range of 40 mm Hg thus has the potential to cause an underestimation of systolic pressure or overestimation of diastolic pressure

Doppler ultrasonic stethoscope

This stethoscope allows yo to hear low frequency sounds and is commonly used with adults who have very weak blood pressure and with infants and children

How to ensure that blood pressure reading is accurate?

-the environment is quiet, warm & comfort -equipment is in good working order -cuff fits correctly on the arm & at the level of heart; cuff should be approximately 40% of the circumference of the extremity on which the cuff is to be used -have the gauge in plain view, not of to the side of the arm -have patient lying down or sitting position with both feet flat on the floor (legs NOT crossed) -cuff should be 1-2in above the antecubital space & is centered over the brachial artery

In what condition the cuff should not be applied to the arm?

-catheter is in antecubital fossa & fluids are infusing -arteriovenous shunt is in place -breast or axillary surgery has been performed on that side -an arm or hand has been traumatized or is diseased -lower arm cast or bulky bandage is in place

Nursing interventions for the patient with abnormal blood pressure reading

BOX 4-15, p.84

Assessing blood pressure in both arm

BOX 4-16, p.84

Assessment of BP in lower extremities

-it helps to compare BP in the upper extremities when there are circulatory abnormalities -placing the patient in prone position or flex the knee slightly for easier assess to the popliteal artery -systolic pressure in lower extremities is usually higher by 10-40 mm Hg -diastolic pressure is the same

automatic measurement device

Advantages -ease of use and efficiency when repeated or when frequent measurements are indicated -useful for home use if patient or caregiver has hearing difficulties -the ability to use a stethoscope is not required Disadvantages -more sensitive o outside interference and are susceptible to errors -patient movements, vibration, outside noise have the potential to interfere with the microphone or the sensor signal -most are unable to process sounds or vibrations of low BP -the range of device sophistication sometimes makes it difficult to compare BP measurements

What are the two common types of devices for self measurement that are used by the general public?

-portable home devices (aneroid sphymomanometer & electronic digital readout devices): easily become inaccurate & require recalibration more than once a year, improper cuff placement or movement of the arm gives incorrect readings -stationary automated machines (BP values vary by 5-10 mm Hg)

How to coordinate vital signs?

The skill of vital signs measurement can be delegated to assistant personnel (AP). However, the nurse is RESPONSIBLE for assessing the effect of changes in the body's vital signs (p.86)

Patient conditions that make use of electronic blood pressure measurements inappropriate

Irregular hear rate Peripheral vascular obstruction Arrhythmias Shivering Seizures Excessive tremors Unable to cooperate to minimize arm motions Older adults Obese extremity

Weight & Height

-helps assess normal growth & development -aids in proper drug dosage calculation -used to assess the effectiveness of drug therapy

Height

-vertical measurement of a structure, organ or other object form bottom to top when it is placed or projected in an upright position

Weight

-force exerted on a body by the gravity of the earth; normal weight depends on the frame of the individual -give the physician info for prescribing medication dosages & determine nutritional status & water balance -1L of fluid = 1 kg (2.2 lb) -weigh the patient at the same time of day, on same scale, and in same type or amount of clothing to allow an objective comparison -ideal time to weight patient is 6 AM, after voiding & before breakfast