Class 1 Vital Signs Flashcards
Elder speak
conveys a message of incompetence of the receiver and dominance of the speaker over the elder
-resistance to care in older adults with dementia (resistant, combative, aggressive)
-disrupts nursing care
-increases cost of care by 30%
Vital Signs
Temperature
Pulse
Respiration
Blood Pressure
Pain
Pulse Oximetry SpO2 and FIO2
When assess vital signs?
admission; institutional policy; change in patient’s condition; before & after surgical or invasive diagnostic procedures; before and/or after certain medications; before and/or after activity in certain cases
Baseline
Nursing Process
ADPIE
-assessment
-diagnosis or interpretation of assessment findings
-planning
-implementation
-evaluation
Independent Nursing Actions:
assessment of VS requires you to make judgements about the means of measurement, equipment, & frequency
Normal Ranges for VS for healthy adults
Oral temp: 35.8-37.5 C
Pulse rate: 60-100 beats per minute
Respirations: 12-20 breaths per minute
Blood pressure lower than 120/80
Temperature
difference in heat you generate and heat you lose (heat produced-heat loss)
Factors that affect temp:
-circadian rhythms (lower in am; higher in pm)
-age (woman are higher; elderly are lower)
-physical activity
-environmental temperature
Temperature physiology
Regulation by hypothalamus
-heat production:
-primary source is metabolism**
-hormones, muscle movements, & exercise increase metabolism
-heat loss:
-skin (primary source; mostly head)
-evaporation of sweat
-warming & humidifying inspired air
-eliminating urine & feces
Temperature Sites (Core)
internal body temp; temp at deep tissue
-rectal (no rectal if heart problems (vagus nerve –>decreased heart rate), low WBC neutropenic (can perforate lead to infection), low platelets)
-tympanic
-temporal artery
-pulmonary artery, bladder, esophagus
Temperature Sites (surface)
oral
axilla
skin surface chemical strips
you take the measurement of surface body temp to obtain a representative average temp of core body tissues
Thermometers
red is rectal
blue is oral & axilla
afebrile
without fever (temp)
febrile
fever
pyrexia
fever
Physical effects of Fever
decreased appetite
headache
hot skin
flushed face
thirst
muscle aches
fatigue
fever blisters
elderly may have periods of confusion/altered level of consciousness**
Interventions for patients with a fever
maximize heat loss:
-remove heavy blankets
-keep clothing & linens dry (otherwise chills/shivering causes increased metabolism)
-cool compresses
-ice packs
-cooling blanket
minimize heat production:
-limit physical activity
Pulse physiology
-the palpable bounding of the blood flow in a peripheral artery
-regulated by the cardiac sinoatrial node
-normal rate is 60-100 bpm
-count for 30 seconds X 2 or 15 seconds X 4
-lub/dub=a count of 1
-apical pulse take for 1 minute
characteristics of a peripheral pulse (3)
- rate
- rhythm (regular/irregular)
- Amplitude EPIC 4-point scale (how strong)
4+=bounding
3+=strong
2+=moderate
1+=weak
0=absent
Sites for detecting pulse
temporal (temple)
carotid (neck)
brachial (elbow)
radial (wrist)
femoral (groin)
popliteal (behind knee)
posterior tibial (inner above heel)
dorsalis pedis (top of food outer ankle)
Methods for Assessing a Pulse
-palpating peripheral arteries
-auscultating apical pulse with stethoscope
-5th intercostal space/mid-clavicular line=PMI
-doppler of peripheral arteries (if cannot find pulse)
Why don’t take pulse with thumb?
can hear your own pulse when using thumb
Tachycardia
over 100 bpm
Bradycardia
less than 60 bpm
Pulse Deficit
difference in apical & radial pulses
-requires 2 people
-1 takes apical other takes radial
apical is always higher than peripheral
shows blood flow to extremities
Assessing Respirations
Inspection
-rate (bpm)
-depth (normal; deep; shallow)
-rhythm (regular; kushmal)
-work of breathing
-symmetry (2 lungs)
auscultation (listen to sounds)
-breath sounds
Hypoventilation
shallow depth & low rate
Hyperventilation
fast rate & depth
Dyspnea
difficult breathing
Tachypnea
fast breathing (increased rate)
Orthopnea
difficult breathing laying down; easier breathing standing
Apnea
without breathing
Blood Pressure
-Force of blood against arterial walls
-highest pressure on arterial walls is systolic (ventricle is pumping)
-contraction of the ventricles
-lowest pressure on arterial walls is diastolic
-ventricles at rest
AHA Blood Pressure Guidelines
Normal: less than 120/80
Elevated: systolic between 120-129 AND diastolic less than 80
**Stage 1: Systolic 130-139 OR diastolic 80-89 mm Hg
-lifestyle changes should begin at 130/80 mm Hg (monitor; lose weight; less salt)
-medication if patient is at risk for CV event
**Stage 2: Systolic at least 140 OR diastolic at least 90
**Hypertensive Crisis: Systolic over 180 AND/OR diastolic over 120
Factors Affecting Blood Pressure
-age (older)
-race (AA hypertensive)
-circadian rhythm (lower in am)
-food intake (salt & fat in food)
-exercise
-weight (increased weight=increased BP)
-emotional state
-body position (lowest supine=flat)
-drugs/medications
-disease processes
-cigarette smoking (CO2 causes vasoconstriction-more force for narrow vessel)
DID YOU KNOW THAT…
reducing salt or sodium intake to less than 2300 mg per day could reduce cases of high bp by 11 million and save $18 billion health care dollars every year
Equipment for assessing blood pressure
-stethoscope & sphygmomanometer (BP cuff)
-doppler ultrasound
-electronic or automated devices
**2 step process is for auscultatory gap
How to assess a manual BP
2 step method
-auscultatory gap
positioning (sitting up; arm level at heart)
Assessing Blood Pressure
Listening for Korotkoff sounds with stethoscope
-first sound is systolic pressure
-the diastolic dilemma
-AHA: the point at which all sounds disappear
-5th Korotkoff sound
The brachial artery is most commonly used
Clinical Decisions
-Where to obtain a BP reading
-Where not to obtain a BP reading (mastectomy; AV fistula; lymphoma; amputee; IV; dialysis ports)
-Size of the cuff
-What do I do in an isolation room? (clean cart when done)
-What do I do if the reading indicates hypertension of hypotension?
AV Fistula’s
pulse on it=thrill (feels pulse)
hear sound=bruit (whooshing sound)
bruit over fistula is normal; connects artery to vein
Hypertension
over 120/80
Hypotension
90/60 WITH symptoms
Orthostatic Hypotension
Start supine; sit up
drop 20 mm Hg in systolic or 10 mmHg in diastolic when changing position means you have orthostatic hypotension
Primary hypertension
Secondary hypertension
due to other disease
Always record BP in even numbers
Automatic BP machines
advantages:
-ease of use
-efficient when repeated measurements are indicated
-do not need a stethoscope
limitations:
-expensive equipment
-requires electricity & space
-sensitive to outside motion
-vulnerable to error in..
-arrhythmias
-obese extremity
-hypotension
MAP
need a mean arterial pressure of 60mm Hg or greater to perfuse vital organs
normal: 70-100
minimum: 60
MAP=2 x diastolic + systolic/3
Pain is subjective & is always what the patient says it is!
Intensity-Scales
-Mild (1-3) Moderate (4-6) Severe (7-10)
-FLACC scale: face, legs, arms, cry, consolability
-PAINAD: for dementia (grimacing; withdrawal @ touch)
**see pain handout sheet
-onset
-location (where)
-functional limitations (stopping you from doing something)
-pain interventions (meds; massage; reposition)
-patient’s functional goal (chronic pain 10/10 to get to 3/10)
reassess in 4 hours or sooner
Why do we under treat pain?
personal biases
hcp incorrectly believe: pain is normal part of aging (it is NOT); pain relief may lead to respiratory depression or addiction
insufficient education for nurses on how to pain assessment
older adults fear they will become addicted
cognitive or communication impairments in older adults
Pulse Oximetry SpO2
**measures the amount of hemoglobin saturated with oxygen in arterial blood (not venous because oxygenated)
-measures oxygenation NOT ventilation (for both do ABG)
-Normal healthy adult >95%
-Most adults with disease we accept >92%
-<92% may indicate that O2 to the tissues is inadequate
-in patients >80 yo and with lung disease (accept lower number)
-85%-89% SpO2 levels may be their acceptable norm
-less than 85% is abnormal in everyone!!
hypoxemia kills
**amount of O2 breathed need fiO2
88% on room air is way different than 88% on O2
What to do if O2 reads 89%?
reposition (sit up/raise head) & take a deep breath
Factors affecting pulse oximetry readings
interference with light transmission:
-outside light sources
-carbon monoxide (could also reflect light like O2)
-patient motion
-jaundice
^^estimate low
-skin pigmentation may result in signal loss or over estimation of saturation (false high)
interference with arterial pulsations:
-peripheral vascular disease
-hypothermia at assessment site
-low cardiac output..not good perfusion
-hypotension..not good perfusion
-peripheral edema..not good perfusion
-tight probe
-arrhythmias
-edema
Criteria for Rapid Response Team (why we measure vitals)
-heart rate over 140/ min or less than 40/min
-respiratory rate over 28/min or less than 8/min
-systolic blood pressure greater than 180 mm Hg or less than 90 mm Hg
-oxygen saturation less than 90% despite supplementation
-acute change in mental status
Differences in books normal vital signs
Taylor for fundamentals:
T: 35.8-37.5
P: 60-100
R: 12-20
SpO2: 95%-100% be aware of Hgb..what is acceptable may change in patients with COPD, COVID, and other circumstances
Jarvis for health assessment:
T: 35.8-37.3
P: 60-100
R: 10-20
SpO2: 97%-99% on RA or 95% clinically acceptable with normal Hgb
