4 vital signs

Vital Signs N200/200L Spring 2012 11/12/16 Guidelines for Measuring Vital Signs O Establish a baseline O Understand and interpret values O Appropriately delegate O Communicate findings O Ensure equipment is in working order O Accurately document findings 11/12/16 Vital Signs O Cardinal signs O Body Temperature O Pulse O Respirations O Blood pressure O Pulse Oximeter O Pain (considered a vital sign) 11/12/16 Vital Signs How often should you assess vital signs? O Change in client’s health status O Client reports symptoms (baseline changes) O Pre and post procedures O Pre and post medication administration that may affect CV system O Pre and post nursing intervention that may vital signs O Routine according to agency O According to specific orders 11/12/16 Body Temperature O Body temperature = balance between heat produced and heat lost from body Measured in degrees O Temperature range: O 98.6°F to 100.4°F or 36°C to 38°C O Temperature sites: O Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery 11/12/16 Body Temperature O Two kinds of body temperature: O Core temperature O Temperature of DEEP tissues of body, such as abdominal cavity O Surface temperature O Temperature of skin, subcutaneous tissue and fat Not as constant as core temperature rises and falls in response to the temperature 11/12/16 Body Temperature Regulation Neural and vascular control Heat production Heat loss Skin temperature regulation Behavioral control Thermoregulation 11/12/16 Body Temperature O Heat Production O Basal Metabolic Rate (BMR) O O O Rate of energy utilization to maintain essential physiological activities such as breathing Rates decrease with age Muscle Activity Thyroxine output (Thyroid Gland) O Increases cellular metabolic rates Chemical thermogenesis 11/12/16 Body Temperature O Heat Production O Epinephrine, Norepinephrine, and sympathic stimulation O O All three increase the rate of metabolism in many body tissues Fever O Increases cellular metabolic rate, thus increasing body temperature (infectious process) 11/12/16 Factors Affecting Body Temperature O Diurnal variations O (circadian rhythms) O Age O Exercise O Hormones O Stress O Environment 11/12/16 Assessment of Ventilation O Easy to assess O Respiratory rate O Ventilatory depth O Ventilatory rhythm O Diffusion and perfusion O Arterial oxygen saturation 11/12/16 Components of Vent/Resp Assessment O Rate O Breaths per minute O Eupnea O Bradypnea O Tachypnea O Depth O Normal O Deep O Shallow O Rhythm O Regular O Irregular O Quality O Effort O Sounds O Effectiveness O Uptake and transport of O2 O Transport and elimination of CO2 11/12/16 Respirations O Recognizing Inadequate Breathing O Labored breathing O Use of accessory muscles O Pale or blue skin O Cool, clammy skin O Irregular respirations O Abnormal lung sounds 11/12/16 Pulse Oximetry O Noninvasive O Estimates arterial blood oxygen saturation (SpO2) O Normal SpO2 85-100%; < 70% life threatening O Detects hypoxemia before clinical signs and symptoms O Sensor, photodetector, pulse oximeter unit 11/12/16 Pulse Oximetry O Factors that affect accuracy include: O Hemoglobin level O Circulation O Activity O Carbon monoxide poisoning 11/12/16 Systolic and Diastolic Blood Pressure O Systolic O Contraction of the ventricles O Diastolic O Ventricles are at rest O Lower pressure present at all times O Measured in mm Hg O Recorded as a fraction, e.g 120/80 O Systolic = 120 and Diastolic = 80 O Pulse Pressure = difference between systolic and diastolic pressures 11/12/16 Diastole Systole 11/12/16 Arterial Blood Pressure and Physiology O Force exerted on walls of an artery O Systolic and diastolic O Cardiac output O Peripheral resistance O Blood volume O Viscosity O Elasticity 11/12/16 Factors Influencing Blood Pressure O Age O Stress O Ethnicity O Gender O Daily Variation O Medications O Activity, weight O Smoking O Assessment of blood pressure and pulse evaluates the general state of PERFUSION and cardiovascular health 11/12/16 Korotkoff’s Sounds 11/12/16 Hypertension and Hypotension  Hypertension      More common than hypotension Thickening of walls Loss of elasticity Family history Risk factors  Hypotension 90 mm Hg  Dilation of arteries  Loss of blood volume  Decrease of blood flow to vital organs  Orthostatic/postural  11/12/16 Measurement of Blood Pressure O Equipment O Auscultation O Children O Ultrasonic stethoscope O Palpation O Lower extremity O Electronic blood pressure 11/12/16 Important Concepts O Hypertension O Hypotension O Orthostatic hypotension O Narrow/wide pulse pressures 11/12/16 Delegation of Measurement of Vital Signs O General considerations prior to delegation O Nurse assesses to determine stability of client O Measurement is considered to be routine O Interpretation rests with the nurse O T, P, R & B/P O Routine measurement may be delegated to UAP O UAP reports abnormal temperatures O Nurse interprets abnormal temperature and determines response 11/12/16 Oxygen Saturation Delegation O Application of the pulse oximeter sensor and recording the Sp02 may be delegated to UAP O Nurse interprets oxygen saturation value and determines response 11/12/16 [...]... disposable O Infrared (tympanic) O Temperature-sensitive tape O Glass mercury O Scanning infrared (temporal artery) 11/12/16 Nursing Care for Fever O O O O O Monitor vital signs Assess skin color and temperature Monitor laboratory results for signs of dehydration or infection Remove excess blankets when the client feels warm Provide adequate nutrition and fluid O Measure intake and output O Reduce physical... respirations O Abnormal lung sounds 11/12/16 Pulse Oximetry O Noninvasive O Estimates arterial blood oxygen saturation (SpO2) O Normal SpO2 85-100%; < 70% life threatening O Detects hypoxemia before clinical signs and symptoms O Sensor, photodetector, pulse oximeter unit 11/12/16 Pulse Oximetry O Factors that affect accuracy include: O Hemoglobin level O Circulation O Activity O Carbon monoxide poisoning 11/12/16...     More common than hypotension Thickening of walls Loss of elasticity Family history Risk factors  Hypotension 90 mm Hg  Dilation of arteries  Loss of blood volume  Decrease of blood flow to vital organs  Orthostatic/postural  11/12/16 Measurement of Blood Pressure O Equipment O Auscultation O Children O Ultrasonic stethoscope O Palpation O Lower extremity O Electronic blood pressure 11/12/16