Lesson 2 - Vital Signs Flashcards
Importance of Measuring Vital Signs
-measurement of health status
-component of patient assessment
-reflects functioning of “vital” body systems
-base for clinical decision-making
-reflects changes in physiological status
The 5 Vital Signs
-temperature
-pulse
-respiratory rate
-blood pressure
-oxygen saturation
The 6th vital sign
Pain-considered another vital sign
When to assess Vitals
-during home care visit
-upon admission
-according to order or facility practice standards
-before, during, after surgery, invasive diagnostic procedure, administration of some meds/blood products
Vital Order Shortcuts
ie q8h means every (q) eight hours (h)
How often to check vitals
-depends on: provider orders, situation, or your own judgement
Someone who has had surgery
hourly
Older adult in extended care facility
monthly
Very ill patient in ICU
constantly
stable patient waiting for long term care
weekly
patient who says she is feeling faint
every 15 mins
patient in hospital with pneumonia
once per shift
Thermoregulation
-controlled by the hypothalamus
-the balance between heat protection and heat loss
Core temperature
-temp of structures deep within the body
-relatively constant
-taken rectally (red thermometer), tympanic (ear)
Surface temperature
-temperature on the surface of the body
-fluctuates
-normal is 36-38 degrees celsius
-taken orally (blue thermometer), axillary (armpit), temporal (forehead)
Core Mean Temp
36.5-37.5
Oral Mean Temp
37.0 (35.5-37.5)
Tympanic Mean Temp
36.5 (35.5-38.0)
Rectal Mean Temp
37.5 (36.6-38.0)
Axillary Mean Temp
36.0 (34.7-37.3)
Temporal Mean Temp
35.0
Mean Temp
-expected findings/average
Temperature Feedback Mechanism
-warm and cold temp sensors in the body send message to hypothalamus and hypothalamus responds
When the body is too hot…
-vasodilation
-brings blood closer to the skin to expel heat
-sweating
When the body is too cold…
-vasoconstriction
-brings blood away from skin to retain heat
-shivering
What to do when patient is feeling cold
-warm blankets
-warm drinks
Heat production
-by product of body metabolism
-food is the fuel for metabolism
Basal Metabolic Rate (BMR)
-number of calories you burn as your body performs life sustaining functions
-based on surface area and thyroid function
-higher in men
-increases with exercise
Why don’t newborns shiver?
-chubby so they stay warmer
-underdeveloped temp regulation system
Relationship between temp and demographic
-reasons behind alterations and temp
-older adults have lower average temp
-babies and young kids are sensitive to change
-exercise increases temp temporarily
-women: temp falls before ovulation and increases before menopause
Circadian Rhythm and Temp
-body is cooler in the morning and warmer in the evening
Convection
body heat lost to surrounding air which is cycled and cooled off
Radiation
body heat lost to near objects without touching them
Evaporation
perspiration
Conduction
body heat lost to near objects through physical touch
Clinical Temp Alterations
-infection
-inflammatory response
-deteriorating status
-thermoregulatory disorders (spinal cord injuries)
Hyperpyrexia
-extremely high temps associated with severe infection
-41-44 degrees celsius
Pyrexia
-raised body temp, fever
-38-40 degrees celsius
Normal temp
36-37 degrees celsius
Hypothermia
-extremely cold temp
-34-35 degrees celsius
-blankets, warm fluids, remove wet clothing, check room temp
Heat Stroke
-prolonged exposure to high temp
-delirium, confusion, muscle cramps, hot dry skin
Heat Exhaustion
-body can’t cool off
-excessive sweating, high heart rate
Objective data (temp)
-temp reading
-skin colour
-goose bumps
-sweating
-rubbing arms
-panting
Subjective data (temp)
-patient says they feel hot/cold
Considerations when assessing temp
-choose appropriate equipment
-consider temp influencing factors
-assess in relation to schedule, symptoms
Purpose of breathing
-bring oxygen to blood and remove carbon dioxide
Ventilation
movement of gas in/out of lungs
Diffusion
movement of gas from high to low concentration in alveoli
Perfusion
distribution of RBCs to organs/tissues
Inhalation/inspiration
-breathe in
-active process
Exhalation/expiration
-breathe out
-passive process
Respiration Regulation
-voluntary and involuntary control
Medulla Oblongata
regulates breathing rate
What drives respirations?
-carbon dioxide levels in the blood drive the increase/decrease in respirations
Which nerve controls respirations?
-phrenic nerve
-sends signals from brain to diaphragm
Tidal volume
-inhalation volume is usually 500mL of air
How are respirations measured
in breaths per minute
Newborn (expected findings)
30-60 breaths/min
Infant (expected findings)
30-50 breaths/min
Toddler (expected findings)
25-32 breaths/min
Child (expected findings)
15-25 breaths/min
Teens (expected findings)
16-19 breaths/min
Adults (expected findings)
12-20 breaths/min
Patterns in respirations?
expected respiration rates decrease with age
Bradypnea
-abnormally slow breathing
-less than 10 breaths/min
-breath sounds are regular
Tachypnea
-abnormally rapid breathing
-more than 24 breaths/min
-breath sounds are shallow
Hyperpnea
-laboured breathing
-increased in depth and rate
-more than 20 breaths/min
-occurs normally during exercise
Apnea
-breathing temporally stops and then starts up again
Hypoventilation
slow and shallow breathing
Hyperventilation/kussmaul
fast and deep breathing
Cheyne-Stokes Respiration
alternating periods of apnea and increasingly deep, rapid breathing
Dyspnea
difficulty breathing
Orthopnea
requiring a certain body position for comfortable breathing
Sleep Apnea
breathing stops several times during sleep
Nursing Considerations for assessing respirations
-patient status (active vs rest)
-underlying conditions
-rate, rhythm, depth, pattern
-breathing effort, flared nares, accessory muscles
-patient stance
Counting Respirations
-count for 30 seconds
-be discrete so voluntary control doesn’t take over
Oxygen Status
-evaluates gas exchange and perfusions
-measured as a percentage
-aka Pulse oximetry, pulse ox, oxygen saturation, O2 saturation, O2 sat, sats, SpO2
Expected O2 Sat findings
-92-100% depending on patient condition and regardless of age
COPD
-chronic obstructive pulmonary disease
-88-92%
ABG
-arterial blood gas test
-more accurate
-more painful
-more costly
Hypoxia
not enough oxygen in the blood
Cyanosis
-objective evidence of decreased oxygen in the blood
-below 85%
Central Cyanosis
-blue around lips and tongue
Peripheral Cyanosis
-blue on extremities
-legs, eyes, fingers
Abnormal pulse ox reading
-if low result found but patient seems ok… consider positioning, positioning of probe, encourage deep breathing, medical history, assess the trend, consider supplementary o2, report to buddy nurse
Low pulse ox results (get help when…)
-if also symptomatic with difficulty breathing, uncontrolled coughing, wheezing, cyanosis, losing consciousness
Pulse
-the effect of the beating of the heart on the bodies arteries
-forcing blood into vessels stretches them
-muscular & elastic arteries stretch and contract
Stroke Volume
amount of blood pumped from the left ventricle per beat
Cardiac Output
-heart rate x stroke volume
Control of the heartbeat
electrical impulsed through SA and AV node
Role of Sympathetic Nervous System
-increases the activity of the SA node
-responds to increased oxygen demands
Role of Parasympathetic Nervous System
-decreases activity of SA node to maintain homeostasis
-rest mode
Strong hearts
-fewer bpm needed to circulate blood
-athletes
-lower pulse
Weak hearts
-more bpm needed to circulate blood
-higher pulse
Bradycardia
-less than 60 bpm in adults
-too slow
Tachycardia
-more than 100 bpm in adults
-too fast
Disrhythmia
abnormal heart/pulse rates
Assessing pulse rate
-rate, rhythm, strength, equality
-physiological conditions can alter heart
Newborn (expected pulse rate)
120-160 bpm
1-3 years old (expected pulse rate)
90-140 bpm
6-8 years old (expected pulse rate)
75-110 bpm
10-12 years old (expected pulse rate)
75-110 bpm
Teen (expected pulse rate)
60-90 bpm
Adult (expected pulse rate)
60-100 bpm
Pulse Amplitude
the strength at which the pulse beats are felt
0 - non-palpable or absent
-cannot feel pulse
1+ - diminished, weak, barely palpable
easy to lose, not strong
2+ - strong
lost with slight pressure
3+ - full, increased
lost with moderate pressure
4+ - bounding
strong, unable to/significant pressure needed to obliterate
Assessing Pulse - Regular Rhythm
-assess for at least 30 seconds
-peripheral pulse ie. neck/carotid, wrist/radial, groin/femoral, foot
Assessing Pulse - Irregular Rhythm
-assess for at lease 60 seconds
-apical pulse; stethoscope placed on heart
Which artery is used for measuring BP?
brachial
Systolic Blood Pressure
-arterial pressure during systole/heart contraction
-top number
Diastolic Blood Pressure
-lowest pressure in arteries during diastole/relaxation
-bottom number
Determinants of Blood Pressure
-cardiac output
-peripheral resistance
-blood volume
-blood viscosity
-artery wall elasticity
Influences on Blood Pressure
-age
-medications
-stress
-ethnicity (asian, indigenous, african have higher BP)
-gender (boys after puberty and post menopausal women have higher BP)
-activity, weight, smoking
-daily variations
Hypertension
-chronically high BP
-“silent killer”
-serious health complications
-mostly related to lifestyle
Optimal BP
<120/<80
Normal BP
<130/<85
High normal BP
130-139/85-89
Grade 1 Hypertension (HTN)
140-159/90-99
Grade 2 HTN
160-179/100-109
Grade 3 HTN
> 179/>109
Unit of BP
mmHg (millimeters of mercury)
Hypotension
-chronically low BP
-seriousness depends on cause ie. internal bleeding
Orthostatic Hypotension
-results from postural change ie. laying down to standing
Manual BP Assessment
-more difficult to learn
-time consuming
-more reliable if done well
Machine BP Assessment
-not as reliable
-convenient
-if you get an abnormal reading complete a manual assessment
-avoid over-reliance on technology
Cuff placement
-upper arm
-lower arm
-thigh
Korotkoff Sounds
-heard to detect systolic and diastolic BP
Abnormal BP Measurement
-ask patient how they are feeling
-consider body size, race, recent activity, health status, medications
-report and document
If BP is low…
be present when patient moves/get up to prevent falls
If any vital signs are abnormal…
1) check again to be sure
2) assess patient - how are they feeling?
3) look if this abnormality is a trend or new
4) document
5) report
6) reassess in 15 mins
Explaining Results
-be able to provide the patient with the results of their vitals and inform them if they are normal/abnormal and what this means
