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79 Cards in this Set
- Front
- Back
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Frequency of VS Assessment
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• On admissionto any health care facility or institution
• Based onfacility or institutional policy and procedures • Any timethere is a change in the patient's condition • Any timethere is a loss of consciousness • Before andafter any surgical or invasive diagnostic procedure• Before andafter activity that may increase risk, such as ambulation after surgery• Beforeadministering medications that affect cardiovascular and respiratory function |
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Vital Signs
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Temperature (T)
Pulse (P) Respiration (R) Blood pressure (BP) Pain (often included as fifth sign) |
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Preparing for the General Survey
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• Agree on a time for the assessment.•The time should not interfere with meals, dailyroutines, or visiting hours.• Make sure patient is as free of pain as possible.• Prepare the examination room or space.• Provide privacy for the patient.• Gather the supplies and instruments needed. • Provide a curtain or screen if the area is open toothers.
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General Survey
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Appearance
Behavior Vital Signs,pain Height andWeight WaistCircumference BMI ifindicated |
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Components of a Health History
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§ BiographicalData §name, DOB,gender, address, billing, race/ethnicity/occupation, etc. § Reason forseeking health care/Chief Complaint (CC)§use exactwords, usually in quotations§ Hx of presenthealth illness (HPI) §patientdescription/explanation of symptoms§ Past HealthHx §Illnesses/diseases,treatments, surgeries, hospitalizations, vaccinations, etc.§ Family Hx § Psychosocialand Lifestyle Factors§ADLs,smoking/ETOH, support network, exposure risks, intimate partner violence, etc. § Review ofSystems (ROS)§Pertinentquestions about all body systems
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Subjective Data
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What the patient tells you (the patient’s verbal report) about their health.
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Objective Data
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Measurable or observed through physical exam.
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Purposes of the Health Assessment
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Ø Establish thenurse–patient relationship.§ The patientis the primary source of data Ø Gather dataabout the patient’s generalhealth status.Ø Identifypatient strengths.Ø Identifyactual and potential health problems.Ø Establish abase for the nursing process.
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Health Assessment is a Process
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•Gather information about health status
•Evaluate and synthesize data •Plan interventions based on data •Evaluate outcomes to deliver care
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VS as Part ofa Health Assessment
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Health History
Physical assessment Comprehensive health assessment Ongoing partial health assessment Focused health assessment Emergency health assessment |
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Nurse’sResponsibility When Assessing Vital Signs
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Ensure theaccuracy of the data.
Interpretvital sign findings. Reportabnormal findings. Followprinciples of delegation. Validateabnormal findings and further assess the patient. |
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Normal Ranges for Healthy Adults
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Oral temperature—37.0°C, 98.6°F
Pulse rate—60 to 100 (80 average) Respirations—12 to 20 breaths/min Blood pressure—120/80 |
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Newborn (axillary) |
T- 35.9-36.9 C 96.7-98.5 F P- 70-190 R- 30-35 BP- 73/55 |
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Infant (temporal) |
T- 37.1-38.1 C 98.7-100.5 F P- 80-150 R- 20-40 BP- 85/37 |
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Child (tympanic) |
T- 36.8-37.8 C 98.2-100 F P- 70-115 R- 20-25 BP- 95/57 |
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Adult (oral) |
T- 35.8-37.5 C 96.4-99.5 F P- 60-100 R- 12-20 BP- 120/80 |
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Older Adult |
vitals? |
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Temperature
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•Differencebetween the amount of heat produced, and the amount of heat lost to theenvironment
•Coretemperature is higher than surface temperature •Temperaturevaries based on age, gender, activity, health, environmentaltemperatures/conditions, time of day |
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Normal Temperatures for HealthyAdults
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•Oral:37.0°C, 98.6°F
•Rectal:37.5°C, 99.5°F •Axillary:36.5°C, 97.7°F •Tympanic:37.5ºC, 99.5°F •Forehead:34.4°C, 94.0°F |
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Fever
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•Pyrexia
•“febrile” •Immune and inflammatory response •Fevers can be beneficial to cleardisease-causing microorganisms •Too high >106F (41C) can cause braindamage•Mustbe cooled rapidly |
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Types of Fever
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Intermittent
Remittent Sustainedor continuous Relapsingor recurrent
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Intermittent
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temperature returns to normal at least once
every 24 hours |
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Remittent
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temperaturedoes not return to normal and fluctuates a few degrees up and down
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Sustainedor continuous
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temperatureremains above normal with minimal variations
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Relapsingor recurrent
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temperaturereturns to normal for one or more days with one or more episodes of fever, eachaslong asseveral days
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Equipment for AssessingTemperature
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•Electronic and digital thermometers
•Tympanic membrane thermometers•Disposable single-use thermometers •Temporal artery thermometers •Automated monitoring devices |
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Selecting the Appropriate Site
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Policiesand procedures may specify siteRNmust choose an appropriate site using the correct equipment according to thepatient’s condition
•Oral •Tympanic•Temporal Artery•Axillary •Rectal |
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Pulse
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Pulserate = number of contractions over a peripheral artery in 1 minute
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Characteristicsof Pulse
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•Rate
•Amplitudeand quality •Rhythm •Volume |
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Rate
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Normal, tachycardia, bradycardia
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Amplitude and quality
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strong or weak?
•Absent= 0 •Diminished= +1 •Brisk= +2 (expected) •Bounding= +3 |
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Rhythm
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regular or irregular |
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Volume
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of blood ejected with each heartbeat (stroke volume) |
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Factors Affecting Pulse
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•Age/Biology
•Womenhigher than men, decreases with age•Physical Activity •Fever, Stress •Medications •Mayincrease or decrease rate •Disease |
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Assessing Pulse
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Peripheral pulses are usually palpated
Apical pulse is auscultated -Whengiving medications that alter heart rate and rhythm -Youngerthan 2 years old Doppler ultrasound |
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Respirations
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•Ventilation
•Diffusion •Perfusion |
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Ventilation
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movement of air in and out of lungs
•Inhalation: breathing in •Exhalation: breathing out |
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Diffusion
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Exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood
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Perfusion
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Exchange of oxygen and carbon dioxide between circulating blood and tissue cells
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Rate and Depth of Breathing
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•Changesin response to tissue demands
•Controlled by respiratory centers in the medulla and pons •Activated by impulses from chemoreceptors •Increase in carbon dioxide is the most powerful respiratory stimulant |
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Respiratory Rates
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Eupnea
Tachypnea Bradypnea Apnea Dyspnea Orthopnea |
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Eupnea
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normal, unlabored respiration; one respiration to four heartbeats
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Tachypnea
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increased respiratory rate; may occur in
response to an increased metabolic rate |
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Bradypnea
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decreased respiratory rate; occurs in some pathologic conditions
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Apnea
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periods when no breathing occurs
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Dyspnea
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difficult or labored breathing
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Orthopnea
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changes in breathing when sitting or standing
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Tachypnea |
-Respiratory rate above the expected reference range(greater than 20 breaths per minute). --- Possible causes
◦Physical activity ◦Anxiety◦Pain◦Health conditions (e.g., asthma) -Common symptoms ◦DizzinessTingling inthe hands |
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Bradypnea
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Respiratoryrate that is below the expected reference range (less than 12 breaths perminute).
-Possiblecauses◦Healthconditions◦Medications:opioids, sedatives -Commonsymptoms◦Dizziness◦Fatigue ◦Weakness◦Confusion◦Impairedcoordination |
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Blood Pressure
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•Forceof the blood against arterial walls •Controlledby a variety of mechanisms to maintain adequate tissue perfusion
•Pressurerises as ventricle contracts and falls as heart relaxes •Highestpressure is systolic •Lowestpressure is diastolic |
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Assessing Blood Pressure
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•Listeningfor Korotkoff sounds with stethoscope
•Firstsound is systolic pressure. •Changeor cessation of sounds occurs—diastolic pressure.• Thebrachial, radial, and popliteal arteries are commonly used. |
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FalseHigh
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Cuff too small
Releasing valve too slow Reinflating bladder during auscultation |
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Falselow
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Noisy environment
Cuff too big Earpieces fitting incorrectly Improper bladder pumping |
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Major Classifications ofHypertension
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primary secondary |
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Primary(essential) Hypertension
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Characterized by an increase above normal in both systolic and diastolic pressures No known cause
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Secondary Hypertension
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•Caused by another disease conditions •Common causes include kidney disease, adrenal cortex disorders, and aorta disorders
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Categories of AntihypertensiveMedications
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Diuretics
Beta-adrenergic blockers Vasodilators and calcium channelblockers ACE inhibitors
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Oxygen Saturation
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• Oxygenationsaturation is the estimated amount of oxygen bound to the hemoglobin. •Expressed as a percentage
•Direct reflection of a client’s respiratory status • Expectedreference range is 95% to 100%. |
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Alterations in Oxygenation
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Decreased oxygen saturation is a level below 95%.
Possible causes ◦Health condition (e.g., pneumonia, chronic lungdisease, pulmonary edema, poor cardiac output). Common symptoms ◦Decrease in mental alertness◦Confusion |
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Sources of Pain
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Nociceptive
Cutaneous Somatic Visceral Neuropathic
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Nociceptive
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Damaged/inflamed tissue other than that of the peripheral and central nervous systems i.e., cutaneous, somatic and visceral pain
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Cutaneous
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in the skin or subcutaneous tissue
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Somatic
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in the bones, joints, muscles, skin or connective tissue
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Visceral
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•ininternal organs
•i.e.,stomach, intestine. It can causereferred pain in other body locations separate from the stimulus. |
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Neuropathic
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•Arisesfrom abnormal or damaged pain nerves
•i.e.,phantom limb pain; diabetic neuropathy•Painis usually intense, shooting, burning or described as “pins and needles” |
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Origin of Pain
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•Physical:cause of pain can be identified
•Psychogenic:cause of pain cannot be identified •Referred:pain is perceived in an area distant from its point of origin |
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Common Responses to Pain
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•Physiologic•Behavioral•Affective
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Acute Pain
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-Rapid in onset, varies in intensity and duration -Protective in nature
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Chronic Pain
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May be limited, intermittent, or persistent --Lasts beyond the normal healing period
Periods of remission or exacerbation are common |
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Factors Affecting Pain Experience
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Culture
Ethnicvariables Family,sex, gender, and age variables Religiousbeliefs Environmentand support people Anxietyand other stressors Pastpain experience |
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Pain Assessment
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-The nurse uses subjectiveindicators to assess the client’s pain by asking questions about thecharacteristics of the pain.
*Location *Duration *Quantity *Quality *Chronology *AggravatingFactors *Relieving Factors *AssociatedPhenomenon |
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Pain Assessment – “OLD CART”
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O - ONSET
L - LOCATION D - DURATION C - CHARACTERISTICS A - GGREVATING FACTORS R - RELIEAVING FACTORS T - TREATMENT |
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Objective Indicators of Pain
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•Vital signs initially showing anelevation in blood pressure, heart rate, and respiration•Muscle tension or rigidity •Pallor•When pain becomes more severe,there is a decrease in blood pressure and heart rate•Nauseaand vomiting •Fainting•Withdrawal to pain•Grimacing•Restlessness•Guarding the area of pain
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Perform a Comprehensive Pain Assessment
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•Use a reliable and valid tool todetermine pain intensity.
•Accept the client’s report of pain. •Assist the client in establishing acomfort-function goal. •Apply the Hierarchy of Pain Measures inclients who are unable to report their pain. |
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Numeric Pain Scale
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•The numeric scale involves a pain rating from 0- 10.
•The client is asked to rate the pain on a scale of 0-10. •Slight pain = 1and 3. •Moderate pain = 4and 7. •Severe pain = 8and 10. |
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Visual Pain Rating Scale -
Wong-Baker FACES |
- The scale is rated “0” with a smiling face and no hurt, “2” hurts alittle bit, “4” hurts a little more, “6” hurts even more, “8” hurts a wholelot, and “10” is a crying face and hurts worst.
-6 faces |
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Manipulating Pain ExperienceFactors
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•Removeor alter cause of pain.
•Alterfactors affecting pain tolerance. •Initiatenonpharmacologic relief measures. |
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Nonpharmacologic Pain ReliefMeasures #1
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*Distraction *Humor *Music *Imagery *Relaxation *Cutaneousstimulation *Acupuncture *Hypnosis *Biofeedback *Therapeutictouch *Animal-facilitatedtherapy
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Pharmacologic Pain ReliefMeasures
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*Analgesicadministration *Nonopioidanalgesics *Opioidsor narcotic analgesics *Adjuvantdrugs *Patient-controlledanalgesia *Epiduralanalgesia *Localanesthesia
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