Science In Nursing: Vital Signs

Front 1

Role of the Nurse

Back 1

• -PATIENT AND FAMILY CARE
• 1. Nurse=ADVOCATE for patients and families
• 2. Nurse Practitioner=correctly diagnose, treat, prescribe AND advocate for patients and families
o put family on the team→need family to ensure quality care outside hospital
• Goal-ask the right question

Front 2

Therapeutic Communication

Back 2

• Process:
o 1. Absorb what is being said (regardless of if you agree)
o 2. Distill the meaning from the person’s perspective
o 3. Try to engage in a conversation from the OTHER PERSONS POINT OF VIEW
• the reality is THEIR reality NOT your reality

Front 3

Maslow’s Hierarchy of Needs

Back 3

Bottom-up
People Softly Lubricate Erection Sites
Physiological needs
• breathing, food, water, sex, sleep, homeostasis, excretion
Safety
• Security of body, employment, resources, morality, the family, health, property
Love/Belonging
• Friendship, family, sexual intimacy
Esteem
• Self-esteem, confidence, achievement, respect of others, respect by others
Self-actualization
• Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts

Front 4

How often to Monitor Vital Signs

Back 4

-at bottom of pyramid
• Hospital: Every 4-8 hours
o At admission
o Before, during, after surgery
o Whenever patients condition changes
• Home health setting: each visit
• Clinic: each visit
• Skilled nursing faciities (SNF): weekly to monthly

Front 5

The Main Vital Signs

Back 5

-Puppies Rarely Bark To People
• Pulse
• Respirations
• Blood Pressuee
• Temp
• Pain

Front 6

The Nursing Process

Back 6

• Assessment
• Action
• Re-Assessment

Front 7

Pulse

Back 7

• Number of times your heart beats reported in one minute
o w/ attention to regularity
o measures blood flow
o can do it 30 sec x 2
o on the radial side on arm near wrist
o Normal-60-100 beats/min
• Avg 70-80
o Pulse changes are symptoms NOT problems
• →need other symptoms to be present for diagnosis

Front 8

Stroke Volume

Back 8

quantity of blood forced out by each contraction of the left ventricle
o Avg 70 mL

Front 9

Cardiac Output

Back 9

total quantity of blood pumped/min
=stroke volume x pulse

Front 10

Reporting Pulse

Back 10

o Rate and regularity, quality (pulse volume and bilateral equality)
• Boundy (intense) vs thready (weak/faint)

Front 11

Assessments of pulse

Back 11

o Palpatation (feeling)
o Auscultation (listening w/ a stethascope)
o One series of LUB and DUB sounds

Front 12

Pulses in Body

Back 12

temporal artery, facial artery, carotid artery, apical pulse, distal

Front 13

Apical pulse

Back 13

• Around 5th intercostal space at midclavicular line
• Use when
 Radial pulse weak or irregular
 Rate <60 beats/min or >100 beats/min
 Patient takes cardiac meds
 Infants up to 3 years

Front 14

Distal pulse

Back 14

farther out/away from center
• Can tell if an artery is being compressed by checking pulses below that artery→if getting enough blood
• Femoral, popliteal, posterior tibial, dorsalis pedis
• Brachial, radial
• Can check capillary refill
 Nail beds→time to refill blood

Front 15

Factors that Influence Pulse Rate

Back 15

• Developmental level:
 Newborns-rapid pulse rate
 Stabilizes in childhood
 Slows in old age
• Sex:
 Adult women have slightly more rapid pulse rate
• Exercise:
 Muscle activity increases pulse rate
 Well-conditioned hearts return to normal pulse rate faster
 Well-conditioned hearts have lower baseline rate
• Food
 Ingestion→increase HR
• Fever
 For each degree F elevated in temp→HR increases 10 beats/min
• Disease
 Heart disease→increase HR
 Hyperthyroid→increase
• Blood-loss
• Position changes
• Medication

Front 16

Tachycardia

Back 16

• Fast HR
 >100bpm
• Factors:
 Pain
 Bleeding
 Scared, anxiety, stress
 Febrile (infection)
 Conduction-electrical impulses→faster impulses→HR faster than norm
 Hypoxia-oxygen deprivation
 Allergic reactions, anafilaxis
 Heat
 Graves/Hyperthyroid

Front 17

Bradycardia

Back 17

• Slow HR
 <60 bpm
• Factors:
 Conduction/Heart Attack (myocardial infarction)
 Medications/narcotics
 The dying process
 Vagus nerve stimulation (vasovagal)
 Alcohol
 Anorexia/Malnutrition
 High athletic status
 Hypothermia
 Sleep
 Respiratory alkylosis
 Position changes (lying→sitting->standing)
 Hypothyroid
 High potassium levels

Front 18

Inadequate Circulation

Back 18

• Pallor-paleness of skin
• Cyanosis-bluish/gray discoloration of skin due to excessive carbon dioxide and deficient oxygen in blood
• If distal body part (like feet) are cool and pulse weak/thready→check higher up pulses to see if lower extremities are getting enough circulation

Front 19

Respirations

Back 19

• Breathing
• Measure by counting patient breathing for 30 seconds
o Unknowing count=count so that the patient does not know you are doing it
• Normal=12-20
o if abnormal→can be the first indication that something is wrong

Front 20

Mechanical movement of breathing

Back 20

o Pulmonary ventilation-movement of air in and out of the resp. system
o Inspiration-drawing air into the lungs
• Involves ribs and diaphragm conraction
• →create negative pressure→air into lungs→lungs expand
o Expiration-relaxation of thoracic muscles and diaphragm
• Lungs recoil→Air expels from the lungs

Front 21

Chemical movement of respiration

Back 21

o External resp-gas exchange btw alveoli and blood supply
o Internal respration-exchange of gasses btw capillaries and body tissue cells

Front 22

Hyperventilation/Tachypnea

Back 22

o Higher than normal breathing rate
o Rapid and deep breathing
• Prolonged Rapid Respirations
o Alyklosis
• →can cause metabolic imbalance b/c losing CO2 too quickly
 Seizures, lethargy/confusion, nausea, rapid breathing, etc

Front 23

Factors Causing Hyperventilation

Back 23

• Low oxygen states
• Fear/anxiety
• Exertion
• Diseases (pulmonary emboli)
• Acid base imbalance→acidosis
• Carbon monoxide poisoning
• Smoking
• Pulmonary edema (fluid in lungs)
• Orthopnea (breathing becomes worse when lying flat)
 b/c fluid in lungs from heart failure

Front 24

Hypoventilation/bradypnea

Back 24

o Too few respirations
o Rapid, shallow respirations
o Hypoxia-O2 deprivation

o Continued Hypoventilation
• Acidosis
 CO2 retained
 Muscle weakness, headache, drowsiness, dizziness, etc

Front 25

Factors Causing Hypoventilation

Back 25

• Medications/narcotics
• Brain stem injury/increased intracranial pressure
 Bleeding or inflamed/enlarged brain
• Acid base imbalance

Front 26

Factors that influence Respiration

Back 26

o Developmental level
• Newborns resp 40-90
• Children-gradually decreases
• Adults-12-20
o Exercise-increase in rate and depth
o Pain-increase in rate and depth
o Hemoglobin-increase in rate and depth
o Stress
o Smoking-increases rate
o Fever-increases rate
o Disease-increase or decrease depending on disease
o Meds:
• CNS depresants→slower and deeper
• Caffine→shallow and fast
o Position

Front 27

Tools to Assess Oxygenation

Back 27

o Arterial blood gases (ABGs)
• Directly measures the partial prssures of oxygen, CO2, blood pH
o Pulse oximetry
• Noninvasive method
• Uses external device that measures oxygen saturation
 Saturation of red blood cells
• BUT RBCs can be saturated w/ other things
o CO
 Normal reading 98-99

Front 28

Assessment of Respiration

Back 28

o Rate
• Apnea, bradypnea, tachypnea
o Description
• Deep, shallow, etc
o Rhythm
• Pattern
• Abnormal-cheyne-stokes
o Sound
• Wheeze-high-pitched continuous musical sounds
 Usually heard on expiration
• Rhonchi-low-pitched continuous sounds caused by secretions in the large airways
• Crackles-discontinuous sounds usually heard on inspiration
 May be high-pitched popping sounds or low-pitched bubbling sounds
• Stridor-a piercing, high-pitched sound heard primarily during inspiration
 Upper-airway obstruction
 Do not hear w/ stethoscope

o Effort
• Dyspnea-labored breathing
• Orthopnea-inability to breath when horizontal

Front 29

Temperature

Back 29

• Degree of heat maintained by the body
• Heat produced minus heat lost
• No number considered normal b/c metabolism varies amongst ind. and age

Front 30

Sites to measure temperature

Back 30

o Temporal-most accurate representation of core temp
• Fast, safe, accurate
o Oral-common means
• Do NOT use oral if:
 Patient does not breathe well (or need mouth to breathe)
 Patient has eaten/drank something recently (hot and cold can alter temp reading
 Patient prone to seizures
 Babies
o Rectal-best option
• EXCEPT when patient has
 Low HR
 Neutrapenic-few white blood cells
• On chemo, steroids, fragile mucous tissue→ has high risk for infection
• Generally higher temp than core
• Axillary-not very accurate
 Lower than normal temp

Front 31

What is Normal Core Temperature?

Back 31

o 97-99 F
o 36.1-38.2C

Front 32

Thermoregulation

Back 32

o Temp regulation
o To decrease body temp:
• Heat sensors stimulated→impulses to reduce body temp→vasodilation→diversion core-warm blood to surface→sweating→inhibition of heat production
o To increase body temp:
• Hypothalamus sensors detect cold→impulses to increase heat production→shivering and releas of epinephrine→increases metabolism→reduce heat loss→blood vessel constriction→diversion of blood from surface to core to be warmed

Front 33

F to C

Back 33

(F-32)x5/9=C

Front 34

C to F

Back 34

(Cx9/5) +32=F

Front 35

Abnormal Temperature

Back 35

o Febrile (fever)
o Hyperthermia-above 100F or 37.8C core
• Heat Stroke
o Hypothermia-below 95F or 35C
• Associated w/ extended exposure to cold
o Hyperpyrexia-fever above 105.8F

Front 36

Factors in Temperature

Back 36

o Developmental level
• Infants and adults more susceptible to temp change
 Infants-ost 30% heat through head
 Adults-slower metabolism
o Environment
o Sex
• Women body temp varies w/ menstrual cycle and pregnancy
• Temp lower when progesterone levels low
o Emotions and Stress
• Stimulate nervous system→increase metabolic rate→increase temp
o Exercise
o Circadian rhythm
• Cyclical repition of certain physiological processes
 →changes in temp and blood pressure

Front 37

3 Phases of Fever (Pyrexia)

Back 37

o Initial Phase (febrile episode or onset)
• Body temp is rising but not yet reached a new set point
• Can be gradual or sudden
• Patient feels chilly and uncomfortable
o Second Phase (course)
• Body temp reaches max (set point) and remains fairly constant
• Patient feels flushed, warm, dry
• Few days-few weeks
o Third Phase (defervescence or crisis)
• Temp returns to normal
• Patient feels warm and is flushed in response to vasodilation
• Diaphoresis occurs→fever “breaks”

Front 38

4 Types of Fever

Back 38

o Intermittent-temp alternates regularly btw periods of fever and periods of normal/below normal temp
• w/out pharmological intervention
• OR temp returns to norm at least once every 24 hours
o Remittent-substantial fluctuations in temp above normal during 24 hour period
o Constant (sustained) fever-temp slightly fluctuates but ALWAYS above normal
o Relapsing (recurrent) fever-short periods of fever alternating w/ periods of normal temps
• Lasting 1-2 days

Front 39

What to expect w/ Patients
o Client w/ infection
o Infant w/ fever
o Client who experienced heat stroke
o Client w/ head injury
o Client on chemo
o Client w/ AIDS

Back 39

• Infection-will have fever
 Do not need to treat ALL fevers
 Infection is sign that the body is fighting an infection
 If the fever is rising→would want to get help w/ fever control and antibiotics
• Infant w/ fever-older infant can wait a little bit
 Newborn baby-fever is a sign of sepsis
• Get treated right away
• Client w/ heat stroke-watch for fever→still bad!
• Client w/ head injury-Bad! Maybe look at first
• A client on chemo-immunosupressed
• A client w/ AIDS-immunosuppressed
• →need to monitor fever very closely

Front 40

Skin Descriptions

Back 40

o Hot/dry, hot/wet, dry, cool, clammy, cyanotic(blue), rubor (red)
• Diaphoretic-very sweaty
• diaphoretic slime-type of sweat when a patient is having a heart attack
 body pushing fluid out
 wipe sweat off→immidiately new fluid arises
• tenting-dry→pink skin
 dead skin rises up

Front 41

Metabolism

Back 41

• Sum of all physical and chemical processes and changes that take place in the body
• Basal Metabolic Rate (BMR)-amount of energy required to maintain body at rest
o Influenced by: body size, muscle mass, hormones
• Nonshivering thermogenesis-metabolism of brown fat to produce heat
o Produced by infants b/c can’t produce heat through shivering

Front 42

Blood Pressure

Back 42

• Pressure of the blood as it is forced against arterial walls during cardiac contraction
• Systolic Pressure
o Peak pressure exerted against arterial walls as the ventricles contract and eject blood
o When the heart is squeezing
• Diastolic Pressure
o Minimum pressure exerted against arterial walls btw cardiac contractions when the heart is at rest
o When the heart is resting

Front 43

Measurement of Blood Pressure

Back 43

o In mmHg
o Essentially the amount of peripheral vascular resistance
o Recorded as systolic over diastolic
o Pulse pressure-difference btw systolic and diastolic pressures

Front 44

Normal Ranges of Blood Pressure

Back 44

o Systolic <120
o Diastolic<80
• >100 Bad!
 →Worse to have high diastolic (high resting pressure)

Front 45

Blood Pressure Regulation

Back 45

o Influenced by 3 factors
• Cardiac function
• Peripheral vascular resistance
• Blood volume
o Adjusts arterial pressure to regulate blood supply to body tissues by capillary beds

Front 46

Non-invasive Blood Pressure Measurement

Back 46

o Most common
o Sphygmomanometer
• Cuff, pressure bulb w/ regulating valve, manometer
o Stethascope
• Used to auscultate the pressures

Front 47

Process of Blood Pressure Measuring

Back 47

• Place stethascope over artery
• Inflate cuff
 Artery is occluded as pressure of cuff exceeds pressure in artery
• Deflate cuff
 Blood begins to flow rapidly through partially open artery
• Heatrturbulent flow through stethoscope
• Record this as SYSTOLIC BP
 Hear different Korotkoff sounds
 Hear silence
• Record this as DIASTOLIC BP

Front 48

Korotkoff’s Sounds

Back 48

o As you deflate the cuff…
o 1. Turbulent sound→systole
o 2. Soft swishing sound
o 3. Begins midway through BP
• sharp, rhythmic tapping sound
o 4. Sharp and rhythmic tapping but softer and fading
o 5. Silence→diastolic BP

Front 49

Direct method of measuring Blood Pressure

Back 49

o Catheter threaded into artery
o Monitors pressure electronically in wave form
o In-client setting only

Front 50

Hypotension

Back 50

o Systolic BP <100mmHg
o Orthostatic/Postural hypotension-sudden drop in BP on moving from lying to sitting or standing position

Front 51

Hypertension

Back 51

o Pre-hypertension
• Systolic 120-130
• Diastolic 80-89
o BP persistently higher than normal
• Systolic>140
• Diastolic >90
• High measurement on 2 or more separate occasions
o Major cause of illness and death
• Increases stress on heart and blood vessels
• Severity directly related to degree of elevation
o Primary or Essential Hypertension
• No known cause for increase
• 90% of cases
o Secondary Hypertension
• Has a cause
• Often renal-related

Front 52

Assessment: When BP is decreasing and HR is increasing

Back 52

o Body is sensing that its not getting enough oxygen
o HR increases to get more oxygen but it is not working
o →circulation is being compromised
o →internally bleeding!
o Can show agitation, confusion, low conscious

Front 53

Pain

Back 53

• Should be assessed for pain
• Assessed by scale 1-10 or w/ frown-smile
• Treatment for pain
o Start w/ non-opioids
• Ex. Motrin

Front 54

Cohn's Vital Sign of the Future

Back 54

• Social Determinants of Health
o Genetic and zip code can determine vital health
o Education, housing, employment