vital sign lecture

Views:
 
Category: Education
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

Vital Signs:

Vital Signs Nursing 101 Readings: Chapter 24 in Taylor CD- ROM : Module 1 Mrs.Chardeen Spring 2011

Objectives: The student will be able to::

Objectives: The student will be able to: Define the key terms used in describing the observation skills used in the measurement of vital signs. Identify the assessment techniques for the 5 Vital Signs State normal vital sign values for adults, children and infants Define the dynamics of thermoregulation. Discuss the factors that cause variations in temperature, pulse, respiration and blood pressure. Understand the nurse’s responsibility and accountability in the taking, reporting and recording of vial signs. List occasions when it is appropriate to delegate vital sign measurement to unlicensed assistive personnel.

Introduction to Vital Sign Measurement:

Introduction to Vital Sign Measurement Cardinal Signs When to Take Vital Signs Responsibility and Accountability Delegation of Vital Signs Baseline measurements

When to take VS: :

When to take VS: Admission Routine schedule once admitted (unit specific) Before and after surgery Before and after invasive procedures Before and after blood transfusions As indicated with medications which affect cardiovascular, respiratory, and thermoregulation functions

When to take VS::

When to take VS: When there is a change in client’s physical condition, LOC, or increased pain Before and after nursing interventions which influence vital signs- i.e.. OOB for first time When a client reports nonspecific symptoms of physical distress- i.e.. Feels funny, strange When the nurse feels it is needed

When to take VS::

When to take VS: It is the nurse’s responsibility to be proficient in the measurement of VS and be able to interpret the results. RN’s may delegate the taking of VS to unlicensed personnel but is always the one who must analyze the results and interpret the significance. The RN also needs to intervene when appropriate, and need to consider the correlation between VS and the client’s health status. Needs to communicate significant changes in VS All clients need baseline measurements and the nurse assigned to care for the client must know what these are as reported in the chart/computer .

Temperature:

Temperature Definition: The difference between the amount of heat produced by body processes and the amount of heat lost to the environment.

Body Temperature:

Body Temperature Norms= 36.5-37.5 C or 98.6-100.4 F (avg. 37 C or 98.6 F) Core body temperature Temperature Regulation (Thermoregulation) Heat production Heat loss Factors affecting temperature

Fever- Pyrexia:

Fever- Pyrexia Fever Patterns Pyrexia- fever above 38 C or 100.4 F Hyperpyrexia- above 41 C or 105.8 F Hypothermia- very low temp down to 34 C or 93.2 F Sustained fever Intermittent fever Remittent fever Relapsing fever

Assessment sites and methods:

Assessment sites and methods Mouth/Oral Tympanic Axilla Rectum Are noninvasive chemically prepared thermometer patches that can be applied to the skin

Thermometer types:

Thermometer types Mercury in glass- most familiar, but not used too frequently, not used due to potential of exposure to mercury (hazardous) if break-call the agency’s environmental services oral temp taken for 2-5 minutes (or according to policy), Axillary- 2-3 minutes, rectal 5 minutes, each line on F thermometer=0.2 degrees C=0.1 deg.

Thermometer types:

Thermometer types Electronic- uses a pencil like probe usually resulting in a reading in 20-50 seconds beep sounds and thermometer is removed, oral/axillary probe and a rectal probe are available so be certain which probe you are using

Documentation:

Documentation Site Time of day Temperature and unit of measurement

Pulse:

Pulse blood flows in a continuous circuit electrical impulses from the SA node of the heart travel through heart muscle to stimulate cardiac contraction approx. 60-70 ml of blood enters the aorta with each contraction

Measurement Techniques:

Measurement Techniques Palpation- using fingers to feel the pulse--- NO THUMB Auscultation- using stethoscope to listen to pulse- apical

Normal ranges:

Normal ranges Infants 120-160 Toddlers- 90-140 Preschoolers- 80-110 School Age- 75-100 Adolescent- 60-90 Adult- 60-100

Pulse characteristics :

Pulse characteristics palpable bounding in relation to blood flow in a peripheral artery feels like a tap when palpating an artery lightly against underlying bone or muscle number of pulsing sensations in one minute is the pulse rate provides data regarding CV system and overall health status

Pulse Variations :

Pulse Variations Bradycardia- abnormally low heart rate usually below 60 for adults Tachycardia- abnormally high heart rate usually above 100 for adults Dysrhythmia- irregular rhythm in heart rate

Sites for Assessing Pulse by Palpation:

Sites for Assessing Pulse by Palpation

Parts of a stethoscope :

Parts of a stethoscope Earpieces- should fit snugly and follow the natural curve of the ear canal, point toward the face when it is in place Tubing- 12-18 inches long, longer tubing decreases the transmission of sound waves

Chest piece of Stethoscope:

Chest piece of Stethoscope Diaphragm= circular, flat surface- transmits high pitched sounds created by the high velocity movement of air and blood, Bowel/lung/heart sounds best ausculated with the diaphragm, best when nurse presses firmly to make a tight seal against the client’s skin Bell= bowl shaped- transmits low pitched sounds created by the low velocity movement of blood- heart and vascular sound are ausculated by the bell

Procedures for assessing the pulse :

Procedures for assessing the pulse Apical- assessed by a stethoscope, heart located behind and to the left of the sternum, point of maximal impulse is located at the apex of the heart usually found at the 5th intercostal space and to the left of the mid clavicular line Palpation- gently touching the pulse site with the index and second finger to feel pulse

Counting the pulse:

Counting the pulse Count Peripheral pulse for 30 seconds and multiply by 2 for any peripheral pulses Count Apical pulse for 1 minute, will hear two sounds which make up the heart beat (lub-dub), lub=S1 (slower and lower), dub=S2 (higher pitched and shorter)

Respirations:

Respirations Intro: The mechanisms the body uses to exchange gases between the atmosphere and blood/cells involve three processes:

Mechanism of Respiration:

Mechanism of Respiration Ventilation- mechanical movement of gases into and out of the lungs, regulated by levels of oxygen and CO2 Diffusion- movement of oxygen and carbon dioxide between the alveoli and the red blood cells Perfusion- distribution of red blood cells to and from the pulmonary capillaries

Normal Ranges :

Normal Ranges Newborn- 35-40 Infant- 30-50 Toddler- 25-32 Child- 20-30 Adolescent- 16-19 Adult- 12-20

Respiratory Variations:

Respiratory Variations Bradypnea- rate less than acceptable level Tachypnea- rate over acceptable limits Apnea- no respirations Eupnea- normal respirations

Factors affecting respiration:

Factors affecting respiration two part process- breathing in and out known as inhalation and exhalation increase in CO2 will increase respirations sudden change in character of respirations may be clinically significant

Factors affecting Respiration:

Factors affecting Respiration Exercise Pain Anxiety- result of sympathetic stimulation Smoking Body position- straight, erect is best, promotes full chest expansion, stooped/slumped/lying flat prevents full chest expansion Medications- i.e.. Narcotics Neurological injury Hemoglobin function Anemia- reduces the # of RBC’s to carry O2- increases rate

Assessing respiratory rate:

Assessing respiratory rate Characteristics of respiration- Adults normally breathe in a smooth, uninterrupted pattern of 12-20 per minute, need to assess rhythm and depth of respirations, not just the rate Techniques to measure respiration- observe a full inspiration and expiration, count for 30 sec. and multiply by 2

Blood Pressure:

Blood Pressure It is the lateral force on the walls of an artery created by the pulsing blood under pressure from the heart blood flows throughout the circulatory system because of pressure changes moving from an area of high pressure to low pressure

Blood Pressure:

Blood Pressure standard unit of measurement if millimeters of mercury (mmHG) has to do with the height to which blood pressure can elevate a column of mercury recorded as a ratio with the systolic before the diastolic Physiology of arterial blood pressure- including cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and arterial elasticity

Measurement :

Measurement Systole- heart contraction ejects blood under high pressure into the aorta, peak of maximum pressure when ejection occurs is the systolic blood pressure Diastole- when heart relaxes the blood in the remaining arteries exerts a minimum or diastolic blood pressure Korotokoff sounds

Variations :

Variations Hypotension- blood pressure below acceptable limits Hypertension- blood pressure above acceptable limits

Factors affecting Blood Pressure :

Factors affecting Blood Pressure Age Stress Gender (after puberty men have higher BP), Race Daily variations Meds Activity

Normal ranges for BP readings for age:

Normal ranges for BP readings for age Newborn- 40 (mean) 1 month- 85/54 1 year- 95/65 6 years- 105/65 10-13 years- 110-65 14-17- 120/75 Adult- Follow American Heart Association Guidelines

American Heart Association Blood Pressure Guidelines:

American Heart Association Blood Pressure Guidelines Blood Pressure Category Systolic (mmHg) Diastolic (mmHg) Normal Less than 120 And Less than 80 Prehypertension 120-139 Or 80-89 Hypertension- Stage 1 140-159 Or 90-99 Hypertension- Stage 2 160 or higher Or 100 or higher

Procedures to measure BP through auscultation :

Procedures to measure BP through auscultation Equipment needed: Stethoscope, Sphygmomanometer or electric device like a dynamap

Parts of a Sphygmomanometer – 3 Sizes of Cuffs:

Parts of a Sphygmomanometer – 3 Sizes of Cuffs

Pain:

Pain Definition of Pain How to assess for Pain Verbal Non-Verbal Pain scales What do I need to do with the data? PQRST

Recording vital sign data:

Recording vital sign data Temperature Documentation Pulse documentation Respiration documentation Blood pressure documentation

Conclusion:

Conclusion Questions/Comments/Concerns

authorStream Live Help