Chapter 30 Vital Signs - Beerbower, M. PDF

Preview

Summary

Beerbower, M....

Description

Chapter 30: Vital Signs Vital Signs: indicators of health status, measure the effectiveness of circulatory, respiratory, neural, and endocrine functions Guidelines for Measuring Vital Signs - Measuring vital signs is your responsibility, you may delegate it however it is your job to review the vital sign data - Assess equipment to make sure it is working correctly - Select equipment on the basis of the patient’s condition + characteristics - Know the patient’s usual range of vital signs, can differ from acceptable range for that age or physical state. These serve as baseline for comparison with later findings - Know patient’s medical history, therapies, and medications - Control or minimize environmental factors that affect vital signs - Use organized, systemic approach when taking vital signs - Collaborate with healthcare providers to decide the frequency of vital sign assessment, you are responsible for judging whether more frequent assessments are needed - Use vital signs to determine indications for medication administration - Analyze results of vital sign measurement on basis of patient’s condition and past medical history - Verify and communicate significant changes - Instruct the patient/family in vital sign assessment and the significance of findings NORMAL VITAL SIGNS TEMPERATURE: 96.8 - 100.4 F (36 - 38 C) - AVERAGE ORAL/TYMPANIC: 98.6 F (37 C) - AVERAGE RECTAL 99.5 F (37 C) - AXILLARY 97.7 F (36.5 C) PULSE - 60 - 100 BPM, STRONG AND REGULAR PULSE OX - NORMAL SpO2 > 95% RESPIRATIONS - 12 - 20 BPM. DEEP AND REGULAR BLOOD PRESSURE - 90 diastolic is hypertension - Prehypertension is when adults average 2 or more readings in the last 2 subsequent visits between 120 - 139mmHg systolic and 80-89 diastolic Normal BP recommends FU in 2 years

-

-

-

-

Prehypertension recommends FU in 1 year Stage I hypertension recommends FU in 1 mo Stage II hypertension recommends FU in 1 mo, or 1 week depending on how high it is Hypotension: present when systolic BP falls < 90mmHg - Possible for some people to naturally have low BP - Occurs because of dilation of arteries, loss of substantial blood volume, or failure of heart to pump adequately - Associated with pallor, skin mottling, clamminess, confusion, increased HR, decreased urine output Orthostatic hypotension: occurs when normotensive person develops symptoms and a drop in systolic BP by at least 20 mmHg within 3 min of rising to an upright position - Patient who are dehydrated, anemic, or have experienced prolonged bed rest are at risk for this - Assessing for measurements at this time includes obtaining BP and pulse with patient supine, sitting, and then standing (often 3 min after patient changes position) Sphygmomanometer: blood pressure cuff - Width of cuff is 40% circumference of arm or 20% wider than the diameter - Inflatable bladder encircles at least 80% of upper arm adult and completely on a child - Cuff too wide = false low reading - Cuff too narrow = false high reading - Cuff wrapped too loose = false high reading - Deflating cuff too slowly - false high diastolic reading - Deflating cuff too fast = false low systolic and false high diastolic - Arm below heart level = false high reading - Arm above heart level = false low reading - Arm non supported = false high reading - Stethoscope fits poorly or impairment of examiner’s hearing causes muffled noise = false low systolic and false high diastolic - Inflating too slow = false high diastolic - Stethoscope applied to firmly = false low diastolic - Repeating assessments to fast = false high diastolic - Inadequate inflation level = false low systolic - Multiple examiners using different sounds for diastolic reading = false high systolic and false low diastolic Best environment for readings are in quiet room at comfortable temp, sitting is preferred Position must be the same if you need to repeatedly get the measurements and for them to be accurate Before obtaining BP attempt to control factors responsible for artificially high readings such as stress or pain During initial assessment obtain and record BP in both arms, normally there is a 5-10 mmHg difference

-

-

-

-

-

-

Ask patient to state usual BP, if they don’t know, let them know after recording it Kortoff sounds: - Phase 1: sharp thump (systolic pressure) - Phase 2: blowing or whooshing sound - Phase 3: crisp, intense tapping - Phase 4: softer blowing sound that fades (diastolic pressure in infants and children) - Phase 5: silence (diastolic pressure in adults) Children between ages of 3 through adolescence need to have BP checked at least annually Measurement of BP in infants and children is difficult because: - Different arm size requires careful and appropriate cuff selection, don’t choose cuff size based on name because it is possible it is still too large or small - Readings are difficult to get because they are restless and anxious - Placing stethoscope too firmly causes errors in auscultation When you can’t auscultate sounds because of a weakened arterial pulse you use and ultrasonic stethoscope, which allows you to hear low-frequency systolic sounds Indirect measurement of BP by palpation is useful for those whose arterial pulsations are to weak to create sounds - Such as in severe blood loss and decreased heart contractility - This skill cannot be delegated to an assistant Auscultatory Gap: in some patients with hypertension, the sounds usually heard over the brachial artery when cuff pressure is high disappears and then reappear at a lower level - Typically occur during first and second sounds - Covers range of 40mmHg - Examiner needs to be certain to inflate cuff high enough to hear systolic pressure before gap Systolic pressure in the lower extremity is usually 10-40 mmHg higher than in upper extremity, the diastolic is the same Obtaining electronic BP is a skill that can be done by a NAP but the nurse first has to make sure that the patient is stable and does not need to be monitored closely - Conditions where electronic BP is not appropriate: - Irregular HR - Peripheral vascular obstruction - Shivering - Seizures - Excessive tremors - Inability to cooperate - BP less than 90mmHg systolic The self measuring BP machines at stores have a difference of 5-10 mmHg than those of a manual BP Some people who do self measurements become very self conscious and then try adjusting their medications or they are not using the devices correctly so they are not getting accurate information

Health Promotion and Vital Signs - Importance of diet, exercise, remaining tobacco free - Risk of hypothermia, frostbite, heat stroke - Demonstrate self-assessment of HR using carotid (for those who are using medications that affect it) - Demonstrate how to obtain BP at home appropriately and making sure that it is taken at the same time everyday -...