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85 Cards in this Set
- Front
- Back
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Vital Signs to Assess
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Body temperature
Pulse Respirations Blood Pressure Pulse Oximetry Pain – to be discussed at a later date. |
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When to assess Vital Signs
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On admission to a health care agency to obtain baseline data
When a client has a change in health status or reports onset of new symptoms such as chest pain or feeling hot/faint Before and after surgery or an invasive procedure Before and/or after the administration of medication that could affect the respiratory or cardiovascular systems Before and after any nursing intervention that could affect the vital signs (ambulating a patient who has been on bedrest. |
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Delegation of Vital Signs
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Nurse must first assess individual and determine that client is medically stable
Determine if the vital sign measurement is considered routine for client Then the UAP may measure, record and report vital signs Interpretation of measurement rests with nurse |
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What is Respiration?
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The exchange of oxygen and carbon dioxide within the body’s tissues (the act of breathing)
Inspiration or Inhalation – intake of air into the lungs. Expiration or Exhalation – breathing out the gases from the lungs Ventilation – movement of air in and out of lungs |
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Costal (thoracic) breathing
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Uses external intercostal muscles and other accessory muscles (sternocleidomastoid)
Observed by the movement of the chest upward and outward |
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Diaphragmatic (abdominal) breathing
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Involves contraction and relaxation of the diaphragm
Observed by movement of the abdomen |
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Respiratory Rates for Age Groups
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Newborn 30-60
1 year 20-40 5-8 years 15-25 10 years 15-25 Teen 15-20 Adult 12-20 Older Adults 15-20 |
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Breathing Assessment
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Nurse should be aware of:
Client’s normal breathing pattern. The influence of the client’s health problems on respirations. Any medications or therapies that might affect respirations. The relationship of the client’s respiration to cardiovascular function. |
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Counting Respirations
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Do not inform patient you will be counting their respirations
After taking pulse leave fingers on wrist and observe abdomen or chest Count for 30 seconds and multiply X2 Note depth, rhythm, and character Count for 60 seconds if irregular or if infant or small child Document findings |
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Eupnea
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normal rate and depth of breathing
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Tachypnea
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abnormally rapid rate of breathing, >20/min in adults
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Bradypnea
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abnormally slow respirations,
< 12/min in adults |
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Apnea
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cessation of breathing
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Hyperpnea
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Exaggerated deep, rapid, or labored breathing. (Like after exercise.) Deeper breaths than Tachypnea.
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Depth of Respirations
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Normal
Deep - Hyperventilation Shallow - Hypoventilation |
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Cheyne-Stokes
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Abnormal rhythm – Cheyne-Stokes breathing
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Rhythm of Respirations
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Normally, respirations are evenly spaced
Described as irregular/uneven or regular/even |
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Quality of Respirations
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Effort used to breathe:
Non-labored breathing: Effortless Labored breathing: Dyspnea Orthopnea May experience retractions. Sound of breathing Stridor Stertor Wheeze Bubbling |
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Effectiveness of Respirations
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Measured by…
the uptake of O2 from the air into the blood AND the release of CO2 from blood into expired air. Pulse Oximetry |
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Factors Affecting Respirations
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Body positioning
Acute pain Hemoglobin Function Exercise Stress Environmental temperature fluctuations Lowered oxygen concentration at increased altitudes Certain medications Increased intracranial pressure |
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Respirations
What to report to HCP |
A respiratory rate significantly above or below the normal range and any notable change in respirations from previous assessment
Irregular respiratory rhythm Inadequate respiratory depth Abnormal character of breathing: Orthopnea Wheezing Stridor Bubbling Any reports of dyspnea |
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Respirations
Lifespan Considerations-Infants |
Infants
Crying affects respirations Most NBs are nose breathers NBs may exhibit “periodic breathing” Respiratory rate and effort increase with resp. infections |
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Respirations
Lifespan Considerations-Children |
Children
Diaphragmatic breathers Count respirations prior to invasive procedures |
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Respirations
Lifespan Considerations-Older Adults |
Older Adults
Count respirations after pulse Anatomic and physiological changes |
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CORE TEMPERATURE:
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Temperature of the deep tissues of the body
Remains relatively constant Controlled by the hypothalamus in our brain Sites: rectal and tympanic membrane Normal Core Body Temperature Range: ~96.8-99.8 degrees Fahrenheit |
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SURFACE TEMPERATURE:
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Temperature of the skin, the subcutaneous tissue, and fat of the body
Rises and falls in response to environment Sites: skin, oral, axillae Normal Surface Body Temperature Range: ~96.8-99.0 degrees Fahrenheit |
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Factors affecting body’s heat production.
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Basal metabolic rate
Muscle Activity Thyroxine output Epinephrine, norepinephrine and sympathetic stimulation/stress response Fever |
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Conduction
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The process of losing body heat through physical contact with another object.
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Convection
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The process of losing body heat through the movement of air.
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Radiation
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The transfer of body heat to another object without contact.
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Vaporization
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The loss of body heat through the conversion of water to gas. (Sweating, Breathing)
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Role of Skin in Temperature Regulation
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When skin becomes chilled…
Shivering increases heat production. Sweating is inhibited to reduce heat loss. Vasoconstriction reduces heat loss. Release epinephrine to increase cellular metabolism and heat production. When skin becomes warm… Sweating increases heat loss. Peripheral vasodilatation increases heat loss. |
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Factors Affecting Body Temerature
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Age
Circadian Rhythms Exercise Hormone Levels Stress Environment |
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Pyrexia
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fever - febrile
Above usual range. |
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Hyperpyrexia
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Extremely High Fever
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Hypothermia
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Below usual body temperature.
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Intermittent fever
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Goes from fever to normal in intervals.
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Remittent fever
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Wide fluctuations - all above normal.
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Relapsing fever
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Short periods of a few days with fever, then break a few days.
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Constant fever
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Remains above normal.
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Fever spike
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Rise to fever very rapidly.
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When is an elevated temperature not a fever?
Heat exhaustion |
Paleness
Dizziness and/or fainting Nausea and/or vomiting Moderately increased temperature (101 – 102 degrees F) |
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When is an elevated temperature not a fever?
Heat stroke |
Warm, flush skin (often do not sweat)
Delirious, unconscious and/or having seizures A temperature of 106 degrees F or higher. |
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Clinical Manifestations of Fever - Onset
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cold or chill phase
Increased heart rate Increased respiratory rate and depth Shivering Pallid, cold skin Complaints of feeling cold Cyanotic nail beds “Goosebump” appearance of the skin Cessation of sweating |
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Clinical Manifestations of Fever - Course
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plateau phase
Absence of chills Skin that feels warm Photosensitivity Glassy-eyed appearance Increased pulse and respiratory rates Increased thirst Mild to severe dehydration Drowsiness, restlessness, delirium, or convulsion Herpetic lesions of the mouth Loss of appetite Malaise, weakness and aching muscles |
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Clinical Manifestations of Fever - Defervescence
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fever abatement/flush phase
Skin that appears flushed and feels warm Sweating Decreased shivering Possible dehydration |
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Nursing interventions for febrile clients
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Monitor vital signs
Assess skin color and temperature Monitor laboratory reports for indications of infection or dehydration Provide adequate nutrition and fluids (2,500-3,500 mL) Remove excess blankets when warm, and provide extra warmth when chilled. Measure I & O Reduce physical activity Administer antipyretics as ordered Provide oral hygiene Provide tepid sponge bath Provide dry clothing and bed linens |
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Clinical Manifestations of Hypothermia
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Decreased body temperature, pulse and resp.
Severe shivering (initially) Feelings of cold and chills Pale, cool, waxy skin Frostbite (discolored, blistered nose, fingers and toes) Hypotension Decreased urinary output Lack of muscle coordination Disorientation Drowsiness progressing to coma |
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Nursing interventions for clients with hypothermia
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Provide a warm environment
Provide dry clothing Apply warm blankets Keep limbs close to body Cover the scalp with a cap or turban Supply warm oral or intravenous fluids Apply warming pads. |
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Common sites for measuring body temperature
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Oral
Rectal Axillary Tympanic membrane Skin/temporal artery |
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Oxygen Saturation
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evaluates the respiratory processes of diffusion and perfusion
percent of all hemoglobin binding sites that are occupied by O2. measured by pulse oximeter |
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Pulse Oximeter Assessment Sites
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Fingers
Toes Earlobe Forehead Bridge of nose Sole of foot (infant) |
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Pulse Oximetry - Acceptable
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90% - 100% - acceptable
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Pulse Oximetry - May be accepteble for certain diseases.
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85% - 89% - may be acceptable for certain chronic diseases
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Pulse Oximetry - Abnormal
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<85% - abnormal
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Pulse Oximetry- Life Threatening
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<70% - life threatening
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Factors that affect accurate SpO2
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Light transmission
Hemoglobin Impaired Circulation Activity Carbon Monoxide Poisoning |
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What is a Pulse?
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A wave of blood created by contraction of the left ventricle of the heart.
Palpated where an artery passes along or over a bone It is an indicator of the heart’s rate and rhythm or circulatory status Pulse is expressed in beats per minute: bpm Peripheral pulse: located away from heart Apical pulse: central pulse located at apex of the heart |
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Factors Influencing Pulse Rates
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Age
Sex Exercise Fever Emotions/Stress Medications Hemorrhage/Hypovolemia/Dehydration Postural changes Pulmonary conditions/Pathology |
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Sites used to assess pulse
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Temporal
Carotid Apical Brachial Radial Femoral Popliteal Posterior Tibial Pedal pulse (dorsalis pedis) |
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Allen’s Test
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Performed to check collateral circulation
Have patient make a fist and compress ulnar and radial arteries simultaneously Have patient open and close their hand repeatedly, hand should blanch Release pressure from the ulnar artery while compressing the radial artery Hand of patient should turn pink within 6 seconds if ulnar artery is patent |
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Assessing the Pulse
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Client should be in a comfortable position.
Be aware of medications the client could be on that would affect the heart rate. Client must be at rest from physical activity for 10 to 15 minutes. Know the baseline rate for the client. |
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Tachycardia
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abnormal elevated heart rate
Greater than 100bpm in an adult |
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Bradycardia
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slow heart rate
Less than 60 bpm in an adult |
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Pulse Rhythm
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The interval between each beat. Indicates the “pattern” of the beats.
Regular Rhythm = equal time between beats (normal pulse) Irregular Rhythm = random beats which may be consistent or unpredictable ( dysrhythmia or arrhythmia) |
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Pulse Volume or Strength
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Force of blood with each beat
Usually the same with each beat Scale Description 0 Absent, not palpable 1+ Pulse diminished, barely palpable 2+ Expected/normal, easily palpable 3+ Full pulse, increased 4+ Strong and bounding pulse |
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Pulse Equality
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Bilaterally equal
Determine if right and left pulses are the same Assess adequacy of blood flow (perfusion) to a particular area of the body |
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Variations in Pulse
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Newborns 130 (80-180 bpm)
1 year 120 (80-140 bpm) 5-8 years 100 (75-120 bpm) 10 years 70 (50-90 bpm) Teen 75 (50-90 bpm) Adult 80 (60-100 bpm) Older adult 70 (60-100 bpm) |
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Pulse Deficit
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Apical rate will be the same as radial rate or could be higher. The apical rate is never lower than the radial pulse.
Pulse deficit: any discrepancy between 2 pulse rates Pulse Deficit Causes The thrust of blood from the heart is too weak for the wave to be felt at the peripheral pulse site That vascular disease is preventing impulses from being transmitted |
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What is blood pressure?
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the pressure exerted by the blood as it flows through the arteries.
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Determinants of Blood Pressure
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Pumping Action of the Heart
Peripheral Vascular Resistance Blood Volume Blood Viscosity |
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Factors affecting Blood Pressure
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Age
Exercise Stress Race Gender Medications Obesity Diurnal variations Disease Process Temperature |
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Hypertension
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Blood pressure that is persistently above normal
Diagnosed with at least an elevate blood pressure at two different times. Often asymptomatic |
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Hypotension
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A blood pressure that is below normal
Systolic reading consistently between 85 and 110 mm Hg in an adult |
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Orthostatic hypotension
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a blood pressure that falls when the client sits or stands.
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Assessing Orthostatic Hypotension
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Place client in a supine position for 10 minutes.
Record the client’s pulse and BP. Assist the client to slowly sit or stand. Support client in case of faintness. Immediately recheck pulse and BP in the same site as previously. Repeat the pulse and BP after 3 minutes. Record results. |
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Ideal Cuff Size
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The cuff bladder should have a:
Width 40% of the arm circumference. Length- 2/3 of limb circumference. |
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Ideal Bladder Cuff Size
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The bladder enclosed by the cuff should encircle:
80% of adult arm 100% of child |
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Blood Pressure Assessment Sites
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Upper Arm – brachial
Thigh - popliteal Lower Leg – dorsalis pedis |
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Blood Pressure Assessment Sites
Do Not Use Extremity When: |
An IV
Trauma or injury Surgical removal of breast or lymph nodes Renal Dialysis Shunt (fistula) Paralysis Cast or bandage on any part of limb |
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Korotkoff Phases
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Phase 1: A sharp tapping. (Systolic)
Phase 2: A swishing or whooshing sound. Phase 3: A thump softer than the tapping in phase one. Phase 4: A softer blowing muffled sound that fades. Phase 5: Silence (Diastolic) |
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Blood Pressure
What to Report to HCP |
Systolic (of an adult)
greater than 140mmHg less than 100mmHg Diastolic (of an adult) greater than 90mmHg |
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Blood Pressure
Lifespan Considerations - Infants |
Lower edge of bp cuff can be closer to antecubital space of an infant
Arm & thigh pressures are equivalent in children under 1 year of age NB SBP range= 50-80mmHg NB DBP range= 25-55mmHg |
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Blood Pressure
Lifespan Considerations - Children |
Explain each step and demonstrate on a doll
Take bp prior to uncomfortable procedures Thigh pressure is about 10mmHg higher than in arm Quick Reference for normal SBP Normal SBP = 80 + (2 x child’s age in years) |
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Blood Pressure
Lifespan Considerations - Older Adults |
Fragile skin
Antihypertensive Meds Arm contractures |
