Vital signs PDF

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Vital signs...

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● fVital signs ○ Used to get a baseline ○ Body temp, pulse, respiration, bp, pain and pulse oximetry ○ Pain is the 5th vital sign ○ Monitor the functions of the body ○ ALWAYS ask the patient about their pain ○ Pulse ox ■ Measure O2 in the blood ○ Once you do the pulse ox, you get the O2 in the blood and the pulse rate ○ Do vital signs ON ADMISSION ● Assessment of vital signs ○ A patient shouldnt come in or go home without doing vital signs ○ A doctor cant send a patient home without a vital sign ○ Ex: Vaccines can cause a slight fever, so ○ Take vital signs according to the hospital vital signs ■ Some say take it every 4 hrs for a stable patient ■ If the vital signs are abnormal, you can do more frequent vital signs ○ Nurses don't always have to follow the doctor's order for vital signs ○ When there is a change in patient status ■ Take them more frequently ○ Do them before and after surgery ■ If they have abnormal ones before surgery, let the doctor know ■ If the surgery is life saving, they still do the surgery even with abnormal ones ■ Do them after to see if there are any abnormalities after surgery ○ Administration of meds ■ If there is a drug to give ppl with heart conditions, take heart rate before giving meds to see if you have to give the medication ■ If a patient has bp meds ordered, check the patients blood pressure to see if you have to give it ■ If a patient had blood sugar meds ordered, don't give a hypoglycemic before giving blood sugar ■ Nurses can hold meds if the patient parameters are below normal ■ Assess vital signs after giving meds to see if the drug is therapeutic ○ Efebrile=no fever, febrile=fever ○ Patients believe the hospital rooms are cold ○ You have to see if its a real fever or an environmental fever (from putting the temp up and making them warm) ○ The Nursing process ■ Anything over 100.4 is a fever

● 97.4-100.3 is normal ranges ● If an order indicates that the vital signs should be taken once a shift. In planning care for the client, what would be a appropriate nursing measure ○ Take them more frequently until it stabilizes ○ If a patient just drank cold water ■ You can wait 15-30 mins or use the armpit (if they drank water or something cold or hot you can wait) ● Rectal temp is the best one ○ But we don't take them unless you have an order ○ But for adults do a oral or armpit ■ Pulse physiology ● How is the pulse regulated ● Variations ○ Bradycardia= Lower than 60 bpm ○ Tachycardia= Higher than 100 ● Pulse characteristics ○ Take pulse rate by a machine or palpate the pulse ■ When the nurse does an assessment, you palpate for the RATE and RHYTHM ● The pulse rate needs to be normal (regular rhythm ● Irregular rhythm= gets faster and abormal ○ Also check for pulse volume ■ Check for the strength of the pulse ● Some people have a weak (thready) pulse or a forceful one (forceful is called a bounding pulse) ● If hypovolemic or has tachycardia ○ Expect a high pulse rate ■ Check if pulse is equal ● Check at same time to do bilateral equality ○ Don't do the carotid together ● Pulse-factors that can affect the pulse ○ Expect a high pulse rate if dehydrated ○ If a fever, expect a higher pulse ○ If you assess a patient and they have a temp=100.4 and has a pulse of 118 ■ Prioritize the heart rate because the body is compensating ● Take care of the fever to get the heart rate

down unless they have a cardiac problem (in that case, its causing the heart rate to go up) ■ Pulse sites ● Carotid, apical (the heart for one full minute), radial (we do brachial when you take bp), only do femoral if you need to assess it, popliteal not regularly, dorsalis pedis (yes, its easy to find), Posterior tibial (not regularly) ○ You only assess the apical pulse if all the other places are irregular ■ If you say you cannot palpate the dorsalis pedis, don't go to another one if they have peripheral vascular disease because they need pulses there ● So use a doppler ■ Measuring apical pulse rate ● If you have an irregular pulse, the rhythm is irregular or unavailable ○ If you can't feel a pulse, use a doppler ■ SO don't say the patient doesn't have a pulse, if they are diabetic and have peripheral vascular disease and you cant feel it (like if you cant feel a dorsalis pedis pulse) ● If you are uncertain, ask ■ If you use a doppler, document it and let the doctor know ■ Seen in CV, pulmonary, renal disease ○ Done prior to giving meds that affect the heart rate ○ Also for newborns (only do apical for one min), infants, children ■ A nurse will asses more than the rate ● See if they are breathing properly (look at rise and fall of chest) ● If a person has respiratory problems, you will see a diff pattern of breathing (nurses check the ENTIRE respiratory system) ○ They might breathe a little harder, use more effort, if their head is moving they have problems ○ Tips of nose will flare (nasal flaring) ○ Have chest exposed to see retraction (costal or diaphragmatic) ■ If its problem, costal area will be pulled in ■ Diaphragmatic, abdomen will be pulled back ○ Look at rate, quality, depth, rhythm ○ When doing head to toe, palpate the pulse, you can tell if its irregular or not

■ Factors affecting respirations ● If they are having problems, they have increased or decreased respirations, difficulty or labored breathing, nose flaring, irritability (late sign, can be signs of hypoxia), the skin color changes (cyanotic=blue), in darker skinned people they look ashy ● If the nail bed is cyanotic in a darker skinned person, it will be dark ● Look at the conjunctivitis ○ If its pink its normal, if its blue the person is cyanotic ● First find out O2 concentration in the blood to get a baseline ■ Assessment ● Inspection ● Auscultation ● Monitor ABGs (arterial blood gas) to get accurate readings if someone has a respiratory probelm ● Normal O2 saturation= 97-99% ● Normal Sp02 ○ In cardiac history, they will have something around 85-87, normal is 95-100%, below 70% is life threatening ■ Blood pressure ● Contraction of ventricles ● Various variations of the norm ■ Factors affecting BP ● Know when to assess a patient ○ If a patient walks around the unit,don't take the vital signs right away ■ Have the patient relax and then take the vital signs ● Find out what happened to the patient if you see high bp and they have a normal baseline ■ Hypotension (Orthostatic) ● Bp drops when you stand or sit ○ In that case, someone feels dizzy when they move from standing to sitting ○ Don't take the patient out of bed if they feel dizzy ○ Take bp standing, sitting, laying down ○ If a person is dizzy you can suspect orthostatic hypotension and take the bp standing, sitting, laying down with you next to them so you can take it and see if its true, then you don't get them out of bed again since they are dizzy ■ If its already on the chart, still do it because you want to confirm everything

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● Use different bp cuffs The nursing process ■ 68 year old male example ● Diaphoretic=sweating ● Subjective= headache, nausea, vomiting, father/mother disease, dizzy ■ Objective: Sweating, bp, Age (age is objective because it comes with the report, if you asks and tells you then its subjective) , time of bp taken ■ If the patient tells you a symptom, that's subjective ● If a patient says they have pain, you go by what the patient says and put subjective ● If the patient says hes a smoker for 25 years, that's subjective Nurse’s role: Vital signs ■ What should be documented ● Everything ● Should be documented in the chart ● Alter the HCP if its abnormal ○ If a pulse is 50-100 for a normal person, if someones is 102 then its not significant ○ Look at other things like stress and such Vital signs ■ Indicators of physiologic functioning and reflect the health status of a person. Vital signs include a person’s temperature, pulse, respiration, and blood pressure ● Pain assessment is included ■ Pulse oximetry (noninvasive measurement of arterial oxyhemoglobin sat) is included ■ Best times to do vital signs ● Screenings at health fairs ● Home ● Upon admission to a health care setting ● When meds are given that affect cardiac rate and rhythm, before and after surgical procedures ● Emergencies ■ Frequency depends on medical diagnosis, comorbidities, types of treatments, patients level of acuity (keenness) ■ Best indicators of cardiopulmonary arrest, ICU admission, unexpected death ● O2 sat and vital signs For example, vital signs are assessed at least every 4 hours in hospitalized patients with elevated temperatures, with high or low blood pressures, with

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changes in pulse rate or rhythm, or with respiratory difficulty. When to assess vital signs ○ On admission to any health care facility or institution ○ Based on facility or institutional policy and procedures ○ Any time there is a change in the patient’s condition ○ Any time there is a loss of consciousness ○ Before and after any surgical or invasive diagnostic procedure ○ Before and after activity that may increase risk, such as ambulation after surgery ○ Before administering medications that affect cardiovascular and respiratory function Temperature ○ Difference between amount of heat produced by the body and the amount of heat lost to the environment measured in degrees ○ Core body temp (intracranial, intrathoracic, and intraabdominal) is higher than surface body temp ○ Normal temp is 35.9-38 (96.7-100.5) ■ Body temp is lowest in the early morning and highest in the late afternoon The core body temperature of a healthy person is maintained within a fairly constant range by the thermoregulatory set point of the thermoregulatory center in the hypothalamus Primary source of body heat is metabolism (heat is a byproduct of metabolic activities tha generate energy) ○ Hormones, exercise, SNS, thyroid hormone , shivering (results in muscle tremors causing heat making) ■ Shivering also makes pilomotor muscles erect (goose bumps) Skin is the primary site of heat loss The circulating blood brings heat to the small connections between the arterioles and the venules, which lie directly below the skin’s surface. These connections, called arteriovenous shunts, may remain open to allow heat to dissipate ○ The sympathetic nervous system controls the opening and closing of the shunts in response to changes in core body temperature and in environmental temperature Factors affecting body temp ○ Circadian rhythm ■ Peak elevation of temp is between 4-8 pm ○ Body temperature varies among people, with a range of 0.3° to 0.6°C (0.5° to 1.0°F) Intermittent: The body temperature returns to normal at least once every 24 hours. Remittent: The body temperature does not return to normal and fluctuates a few degrees up or down. Sustained or Continuous: The body temperature remains above normal with minimal variations.

● Relapsing or Recurrent: The body temperature returns to normal for one or more days with one or more episodes of fever, each as long as several days. ● Patients with fever may experience loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase ● Factors affecting body temp ○ Age ■ Older adults lose thermoregulatory control with aging ■ Body temps in older adults may be lower than the average adult temp ■ Old and very young are at risk ● Older adults have impaired responses, infants and kids change more rapidly to hot and cold air temps ○ Diurnal Variations (Circadian Rhythms) ■ Some events in humans recur at 24 hr intervals ■ Predictable fluctuations in measurements of body temp and bp are examples of functions that have a circadian rhythm ● Like how body temp is 0.6 C (1.0-2.0 F) lower in the morning that in the late afternoon and early evening ○ Exercise ■ Exercising increases body temp ■ Increased metabolism resulting from muscle activity creates hear ■ Consider if the patient did any physical activity ○ Hormones ■ Women experience more fluctuations because of hormone changes ■ Increase in progesterone secretion at ovulation increases body temperature as much as 0.3° to 0.6°C (0.5° to 1.0°F). ○ Stress ○ State of health ■ Disease can affect temp ○ Environment ■ When one is exposed to cold temps without warm clothing, heat loss may be increased to hypothermia ■ If someone is exposed to too much heat, hyperthermia may result ● A normal person is afebrile ● Increased body temp ○ Fever or pyrexia is an increase above normal in body temp ○ A feverish person is febrile ○ Fever occurs in response to a displacement (upwards) of the thermoregulatory set point in the hypothalamus, caused by pyrogens (substances that cause fever) ■ Substances can be bacteria, viruses, chemicals made from tissue injury (like from MI, pulmonary emboli, cancer, trauma, surgery) ○ Most fevers arent harmful

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■ Some can destroy microorganisms, increase the susceptibility of diseasecausing organisms to anti-infective agents, and enhanced response by the immune system ■ BUt a fever equal or greater than 41 C (106) ○ When the thermostatic set point is too high, the hypothalamus initiates temp rising mechanisms ■ Shivering, piloerection, vasoconstriction, and increased metabolism ■ After the body temp rises to the new set point, heat losing mechanism (sweating, vasodilation, increased respirations) keep the body temp from rising too high ■ Onset of fever is rapid in kids ● Mild elevation in temp can indicate a serious infection in infants younger than 3 months because they don't have well developed temp control ● Older adults have a lower baseline body temp ■ Fever might be one of the later signs of illness with slight elevations above normal in a infection (even if its serious) ● Look for the baseline norm for body temp Hyperthermia vs fever ○ Hyperthermia’s hypothalamic set point isnt changed, but in situations of extreme heat or excessive heat production Neurogenic fever ○ Result of damage to the hypothalamus from intracranial trauma, bleeding, or pressure ○ Doesnt respond to antipyrics Fever of 38.3 C (101 F) or higher that lasts for 3 weeks or longer without a cause is FUO Physical effects of fever ○ Patients with fever may experience loss of appetite; headache; hot, dry skin; flushed face; thirst; muscle aches; and fatigue. Respirations and pulse rate increase. ○ Younng kids may have seizures, older adults may have periods of confusion and delirium ○ Fever blisters may come as fever actives the type 1 herpes simplex virus ○ Fluid, electrolyte, and acid–base imbalances are potentially dangerous complications of fever. Treatment of fever ○ If the fever is caused from a bacterial infection, give antipyretics ■ Aspirin, ibuprofen, acetaminophen ○ You can use cool sponge baths, cool packs, hypothermia (cooling blankets) ○ Oral fluids are increased to maintain celllar and intravascular status and prevent dehydration

○ Give them simple carbs to prevent tissue breakdown from hypermetabolic activity ● Decreased Body temp ○ Hypothermia ■ Body temp below lower limit of normal ■ occurs when the compensatory physiologic responses meant to produce and retain heat are overwhelmed by unprotected exposure to cold environments. ■ Chronic conditions (alcoholism, malnutrion, hypothyroidism) increase risk ■ Patients in the perioperative (surgical) period and newborns are at risk ■ Death occurs under 35 C (95 F) ■ Therapeutic hypothermia (purposeful lowering of core body temp) ● Helps after cardiac arrest by reducing metabolic rate and O2 demand of the body to improve survival and neurologic outcomes ○ Physical effects of hypothermia ■ Poor coordination, slurred speech, poor judgment, amnesia, hallucinations, and stupor. ● Respirations decrease and the pulse becomes weak and irregular with lowering blood pressure ○ Treatment of hypothermia ■ Rewarm the patient with clothing, blankets, pads, warmers, warm fluids ● Assessing temp ○ Can be delegated to the UAP ■ But nurse must assess fundings, assess effect of changes in body temp ■ Teach patient about measurement, normal values, and the need to report abnormal findings ○ Equipment ■ Body temperature, measured in degrees, may be assessed with a variety of devices—electronic and digital thermometers, tympanic membrane thermometers, disposable single-use thermometers, temporal artery thermometers, and automated monitoring devices. ■ Electronic and digital ● Electronic and digital thermometers measure oral, rectal, or axillary body temperature over a time period from a few seconds to 30 seconds ■ Tympanic membrane thermometers ● Use infrared sensors to detect heat given off by the tympanic membrane, reflecting the temperature of the blood flowing in the carotid artery ■ Temporal artery thermomters ● Measure body temp by capturing the heat emitted by the skin over the temporal artery

● Can be accurate, but it must be clean and must be used right ■ Disposable single-use thermometers ● Nonbreakable ● Eliminates danger of cross-infection and used for patients with transmission-based precaution ● Temp sensitive patches or tape are applied to the abdomen or forehead and change color at diff temp ranges ● Usually used for a toddler or young child at home ● Used to reassess the temp if the color on the tape or patch indicates that the temp is out of normal range ■ Automated monitoring devices ● Require less time ○ Sites and methods of assessing body temp ■ Factors affecting site selection include the patient’s age, state of consciousness, amount of pain, and other care or treatments (such as oxygen administration) being provided ■ If its other than oral, document the site ■ If theres no site listed on the chart, its assumed to be oral ■ Oral (sublingual), tympanic, temporal artery, rectal, and axillary ■ Temporal artery ones are swiped over the skin covering the temporal ■ Don't use oral temps for kids under 5 or kids with developmental problems, patients who cant follow directions, or confused and comatose patients ■ If a patient has been smoking or chewed gum, wait 15-30 mins to get oral tissues back to normal temp ■ Don't use oral temps in ppl with oral cavity disease, has nose or mouth surgery, or if they are on seizure precautions ■ Oral temps shouldnt be assesed in ppl getting O2 by mask ● Because the time it takes to get a reading can lower the blood O2 ■ Normal oral temp readings are 36.5° to 37.5°C (97.7° to 99.5°F) ○ Tympanic membrane temp ■ Thermometer doesnt touch the tympanic membrane ■ Temp readings arent significantly altered by cerumen (earwax) or otitis media (middle ear infection) ■ Normal tympanic temperature readings range from 36.8° to 37.8°C (98.2° to 100°F) ■ If a patient has drainage from the ear, ear pain, ear infection, or scarring on the tympanic membrane on one side, then the opposite ear may be used to measure the tympanic temperature. ○ Assessing a temporal artery temp ■ Assess for head coverings, anything covering the area

● Hat, hair, wig, bandage ■ If a patient is lying on their side, only measure the head exposed ■ Don't measure over scar tissue, open lesions, or abrasions ■ Temporal are more accurate than axillary ■ Move thermometer across forehead slowly ■ Normal temporal artery temperature readings range from 37.1° to 38.1°C (98.7° to 100.5°F) ○ Assessing an axillary temp ■ Used when both oral and rectal sites are contraindicted or when they are inaccessible ■ Should not be used if you need accurate temps ■ Best used for neonates ■ Affected by ambient temp, local blood flow, placement, closure of axillary cavity ■ Place the probe in the center of the axilla; hold the patient’s arm by the patient’s side until the measurement is complete. ● Normal axillary temperature readings range from 35.9° to 36.9°C (96.7° to 98.5°F) ○ Assessing a rectal temp ■ Most accurate, but most are embarrased to do it ■ Don't use with newborns, kids with diarrhea, patients with rectal surgery or rectum disease ■ Insertion can slow heart rate by activating vagus nerve ● So don't give it with people with heart disease or people who had cardiac surgery ■ Don't give it to neutropenic patients (low wbc like leukemia) and in patients with neurological issues (Spinal cord injuries) ■ Don'...