ATI/PPT vital signs CH 27 Flashcards
What constitutes vital signs?
- temp
- pulse
- respirations
- BP
- pain O2 sat is supposed to be 95 or above
Why is it important to monitor vital signs?
- direct reflection of health status
- important to detect variations from normal/baseline to determine disease exacerbation
Evidence Based Finding
1-early recognition/timely tx
2-iD pts at risk for adverse events
3-use pre-planned/structural assessment of physiological parameters {protocol}
4-eliminate barriers to emergency assistance when pt’s status is deteriorating
Temperature
1-heat produced vs. heat lost
2-surface body temps are lower than core(axillary v. Rectal)
3-thermoregulation=hypothalamus
How is heat produced?
1-metabolism,2-hormones,3-exercise,4-shivering
How is heat lost?
1-skin,2-sweat evaporation,3-breathing,4-urine/feces
Heat Production
Results from increases in basal metabolic rate,muscle activity,thyroxine output,testosterone & sympathetic stimulation
Heat loss
1-radiation=transfer of heat from one object to another without contact between them;2-convection=dispersion of heat by air currents/movement;3-evaporation=dispersion of heat through water vapor;4-conduction=transfer from body directly to another surface
Visible perspiration on skin
Diaphoresis
Factors affecting temp
1-circadian rhythm,2-age,3-gender,4-stress,5-environmental temps
Core temp measurement sites
1-rectum,2-tympanic membrane,3-temporal artery,4-pulmonary artery,5-esophagus & 6-urinary bladder
Surface temp measurement sites
1-skin,2-mouth,3-axillae
Expected temp ranges
1-oral=(96.8-100.4) avg is 98.6
2-rectal=(.9 degrees higher than oral/tympanic)
3-axillary=(.9 degrees lower)
4-temporal=close to rectal,but (1 degree higher than oral,2 degree higher than axillary)
Increased body temp causes/what to look for
1-tissue injury like MI,PE,cancer,trauma or surgery/infections/inflammatory processes
2-know if its gradual or sudden onset
3-hyperthermia vs. Neurogenic fever vs. fever of unknown origin
4-ovulation/menses
5-exercise,dehydration,activity
Pt presentation with w/ increased temp(assessment)
1-decreased appetite,2-headache,3-dry skin,4-thirst,5-achy muscles,6-increased pulse/respirations
Considerations to temp-newborns & elderly
Newborns=lose heat rapidly;(97.7-99.5)
Elderly=loss of subcu fat;harder to get a reading since body struggles trying to regulate
How to reduce fever
1-provide antibiotics/Tylenol or Motrin(antipyretics)*don’t give to children/adolescents w/ fever or chicken pox because of Reyes
2-sponge baths,3-cooling blankets,4-cool packs
Assessing temp
1-thermometers,2-sites,3-age group,4-contraindicated
Nursing interventions for temp variations
1-frequent monitoring 2-monitoring I/O 3-monitor for seizures 4-med administration 5-IV fluid administration 6-use cooling/warming devices
Nursing dx
1-hypothermia as evidenced by…
2-hyperthermia related to..
3-risk for unbalanced body temp(elderly/newborn)
4-ineffective thermoregulation(elderly/preemies)
Oral temp
4 years of age & older
**Do NOT use for pts who are mouth breathers or have experienced trauma to face/mouth
Rectal temp
- *DO NOT use on pts with diarrhea,bleeding precautions such as those with low platelets, or have rectal disorders
- *3 months old and younger should NOT use this site due to rectal perforation
- more accurate than axillary
Tympanic temp
- ear up & back for adults,down & back for child under 3
- readings can be inaccurate for children under 3 mo
Pulse
1-autonomicNS=controls HR 2-parasympatheticNS=lowers HR 3-sympatheticNS=raises HR -can be palpated or auscultated -result of ventricular contraction
What is the pulse made of?
1-rate(BPM),2-quality,(strong vs. weak)3-rhythm,4-volume,5-equality
Rate
Number of times per minute you feel/hear the pulse
Rhythm
Regularity of impulses
Strength(amplitude) or stroke volume
- Volume of blood ejected against arterial wall w/ each heart contraction & condition of arterial vascular system
- strength of impulse should stay same from beat to beat
- strength is 0-4(0=absent,unable to palpate,1=diminished/weaker than expected,2=brisk,expected,3=increased,strong,4=full volume,bounding
Equality
- peripheral pulse impulses should be symmetrical in quality & quantity from right side of body to left
- assess strength/equality to evaluate adequacy of vascular system
- inequality or absence of pulse on one side can indicate a disease state such as thrombus or aortic dissection
Cardiac output
Amount of blood per minute
CO=SV x HR
Pulse deficit
Difference in apical/radial pulse
-must be done by 2 nurses
Dysrhythmia
Irregular heart rhythm, generally with an irregular radial pulse
Expected HR range
Adults=60-100/minat rest
Infants=120-160/min
Adolescent=80-90/min
Tachycardia
Rate greater than expected range, or 100/min
Factors that lead to tachycardia
1-exercise,2-fever/heat exposure,3-meds,4-changing position from lying down to sitting/standing,5-acute pain,6-hyperthyroidism,7-anemia,hypoxemia,8-stress/anxiety/fear,9-hypovolemia,shock,heart failure,hemorrhage
Meds that cause tachycardia
- epinephrine
- levothyroxine
- beta2-adrenergic agonists(albuterol)
Bradycardia
Rate less than expected range or slower than 60/min
Factors leading to bradycardia
1-long term physical fitness,2-hypothermia,3-meds,4-changing position from standing/sitting to lying down,5-chronic,severe pain,6-hypothyroidism,7-relaxation
Nurse interventions, monitor for…
1-pain,2-anxiety,3-fatigue,4-shock,5-insomnia,6-medication side effects(know expected outcomes)
Meds that cause bradycardia
- digoxin
- beta blockers(propranolol)
- calcium channel blockers(verapamil)
Peripheral pulse points
1-carotid 2-brachial 3-femoral 4-radial 5-dorsalis pedis 6-posterior tibial
Two types of pulses
Peripheral(felt or palpated) and apical(auscultated)
Apical pulse
Auscultated(listened to) over the apex of the heart;lub-dub
Nursing dx
- decreased cardiac output due to blood loss
- ineffective peripheral tissue perfusion(disease)
- deficient fluid volume
- acute pain
Respiration definition
- Chemoreceptors in carotid arteries & aorta primarily monitor carbon dioxide levels of the blood.
- rising CO2 triggers respiratory center of brain to increase RR
- increased RR rids body of CO2
Process of Respiration
1-ventilation,2-diffusion,3-perfusion
Ventilation
- Exchange of oxygen&carbon dioxide in the lungs
- measure w/ the RR,rhythm,&depth
Diffusion
- exchange of oxygen&carbon dioxide between alveoli & red blood cells
- Measure w/ pulse oximetry
Perfusion
- flow of red blood cells to and from the pulmonary capillaries
- measure w/ pulse oximetry
Rate
- number of full inspirations/expirations in 1 min
- determined by observing number of times pts chest rises/falls
- expected reference range is 12 to 20/min
Depth
- amount of chest wall expansion that occurs w/ each breath
- altered depths are deep or shallow
Rhythm
- observation of breathing intervals
- expect a regular rhythm(eupnea) w/ an occasional sigh
Pulse Oximetry
- noninvasive, indirect measurement of oxygen saturation of the blood
- percent of hemoglobin that is bound w/ oxygen in arteries is the percent of saturation of hemoglobin
- reference range is 95% to 100%
- acceptable levels for some is 91% to 100%
Factors affecting respirations
1-Age=rate decreases w/ age(newborns=35-40/min;school aged=20-30/min)
2-Sex=men/children=diaphragmatic breathers/abdominal movements more noticeable;women=thoracic muscles,chest more pronounced
3-Pain=can decrease respirations;increases at first then stabilizes
4-Anxiety=increases rate&depth
5-Acid base balance=illnesses, COPD,emphysema
6-meds
7-Neurological injury=brain stem decreases rate&rhythm
8-Anemia=low oxygen;increases in RR & alterations in rhythm to compensate
Tachypnea
Increased respirations
Bradypnea
Decreased respirations
Apnea
Absence of respirations
Dyspnea
Difficulty w/ respirations
Orthopnea
Difficulty w/ respirations while lying flat
Respiratory patterns
1-Cheyne-stokes=near death breathing pattern;stop-go
2-tachypnea=fast
3-bradypnea=slow
4-biots=irregular
Nursing dx
- ineffective breathing pattern
- impaired gas exchange
- risk for activity intolerance
Blood Pressure-definition and formula
-How stretchy your arteries are
-Cardiac output & Systemic (peripheral) vascular resistance
BP=CO x SVR
Systole
Top reading of BP, highest amount of pressure on artery
Diastole
Bottom reading of BP; lowest amount of pressure on artery
Cardiac output is determined by
1-HR
2-Contractility
3-Blood volume
4-Venous return
-increases in any of these increase CO and BP
-decreases in any of these decrease CO and BP
Systemic Vascular Resistance(SVR) reflects
The amount of constriction or dilation of the arteries, & diameter of blood vessels
- increases in SVR increase BP
- decreases in SVR decrease BP
Classifications of BP: normal
Systolic=less than 120 AND
Diastolic=less than 80
Classifications of BP: prehypertension
Systolic=120-139 OR
Diastolic=80-89
Classifications of BP: stage 1 hypertension
Systolic=140-159 OR
Diastolic=90-99
Classifications of BP: stage 2 hypertension
Systolic=greater than 160 OR
Diastolic=greater than 100
Classification: How to classify
- base classification on highest reading
- pt who has 124/92 has stage 1 instead of prehypertension because DBP places pt in that category
- If pt has SBP over 140 and DBP over 90 that are avgs of 2 or more readings, pt must come back for 2 or more visits for additional readings
- if readings are elevated on 3 separate occasions over several weeks,pt has hypertension
Orthostatic(postural) Hypotension definition
- BP that decreases when pt changes position from lying to sitting or standing
- it can result from various causes(peripheral vasodilation,med adverse effects,fluid depletion,anemia,prolonged bed rest)
- **see chart on p. 598
Orthostatic Hypotension: how to assess
1-take pts BP and HR in supine position
2-have pt change to sitting or standing, wait 1-3 min and reassess BP and HR
3-pt has OH if the SBP decreases more than 20 and/or DBP decreases more than 10 w/ a 10-20% increase in HR
**Do NOT delegate this procedure to an assistive personnel
Factors affecting BP
1-age 2-circadian rhythms 3-stress 4-ethnicity 5-sex 6-meds 7-exercise 8-obesity 9-family hx
Factors affecting BP: Age
- infants=have lower BP that increases w/ age
- older children/adolescents=varying BP based on body size;larger kids have higher BP
- adults=can increase w/ age
- older adults=can have a slightly elevated systolic pressure due to decreased elasticity of blood vessels
Factors affecting BP: Circadian rhythm
- BP lowest in early morning
- peaks during later part of afternoon/evening
Factors affecting BP: Stress
Associated w/ fear,emotional strain, and acute pain; increases BP
Factors affecting BP: ethnicity
AA have a higher incidence of hypertension in general and at earlier ages
Factors affecting BP: Sex
- Adolescent to middle-aged men have higher BP than female counterparts
- Postmenopausal women have higher BP then their male counterparts
Factors affecting BP: Meds
- lower BP=opiates,antihypertensives,cardiac meds
- raise BP=cocaine,nicotine,cold medications,oral contraceptives,alcohol and antidepressants
Factors affecting BP: exercise
- During=increases SBP
- After=Can cause a decrease in BP for several hrs after
Factors affecting BP: obesity
Contributes to hypertension
Factors affecting BP: Diet
- Diets high in sodium increase risk of hypertension
- BP increases after eating food
Factors affecting BP: family hx
Family hx of hypertension can increase the risk, this is an example of a nonmodifiable factor
Hypotension definition
- BP below the expected reference range(SBP less than 100/DBP below 60) & can be a result of fluid depletion,heart failure,or vasodilation
- seen in athletes,blood loss or ineffective pump
Pulse pressure definition
Difference between the SBP and DBP readings
