vital signs (1).ppt

8/10/2019 Vital Signs (1).ppt

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Metro Community CollegeNursing Program

Nancy Pares, RN, MSN


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Objective data that contributes to all othernursing and medical information

Baseline values establish the norm againstwhich subsequent measures are compared

Accurate information is essential

Information must be obtained and recordedaccurately.


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One of the most frequent assessments madeas a nurse

Nurse is Responsible for measuring, interpreting

significance and making decisions about care

Knowing normal ranges

Knowing history and other therapies that may affectVS


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Nurse must Know environmental factors that affect vital signs

Exercise, stress, etc.

Use a systematic, organized approach

Verify and communicate changes in vital signs Monitor VS regularly

Frequency determined by

MD order; nursing judgement, client condition and

facility standards


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Hospital: Every 4-8 hours

Home health: each visit

Clinic: Each visit

Skilled facility

Daily and as needed


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Degree of heat maintained by the body

Heat produced minus heat lost equals body

temperature

Organs have receptors that monitor corebody temperature


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Core temperature Normal

96.2 degrees F to 100.4 degrees F

36.2 degrees C to 38 degrees C

Surface temperature Lower than core temperature

Use oral and axillary method


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Neural control Hypothalmus acts as thermostat

Vascular control Vasoconstriction ---hypothalmus directs the body

to decrease heat loss and increase heat production

If cold, vasoconstriction will conserve heatshivering will occur


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Vasodilation If body temp is above normal, the hypothalmus will

direct the body to decrease heat production;

Perspiration and increased respiratory rate

Body heat production Bodys cells produce heat from foodreleasing

energy.

Kilocalorie= energy value;

BMR= rate of energy used in the body to maintainessential activities


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If metabolism increases, more heat isproduced

More muscle= greater metabolism

Shivering is an early response forthermoregulation that increases heat

production.


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Conduction Transfer of heat from a warm to cool surface by

direct contact

Convection Transfer of heat through currents of air or water

Radiation Loss of heat through electromagnetic waves from

surfaces that are warmer than the surrounding air

Evaporation Water to vapor lost from skin or breathing


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Age Exercise

Hormones

Circadian cycle Stress

Ingestion of food

smoking


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Fever (pyrexia) Abnormally high body temperature (>100.4 F)

Occurs in response to pyrogens (bacteria)

Pyrogens induce secretion of prostoglandins that

reset the hypothalmic thermostat to a highertemperature

Hyperpyrexia Fever > 105.8


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Temp increases: Immune system stimulates hypothalmus to new set

point

Chills, shivers

Feels cold even though temp increasing When body temp is reset, chills subside


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Metabolism increases O2 consumption increases

HR and RR increase

Energy stores are used Dehydration and confusion

When cause is removed, set point drops


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Vasodilation Warm flushed skin and diaphoresis

Benefits Activates the immune system

Interleukin 1 stimulates antibody production

Fights viruses by stimulating interleukin

Serves as a diagnostic tool


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Chill stage: Temp every 1-4 hours

Reduce activity

Warm blankets

Throughout course Fluids, tepid baths, limit activity, keep dry

Provide oral hygiene

Provide air circulation


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Heat stroke Prolonged exposure to heat

Depression of hypothalmus

Emergency

S/S: hot, dry skin, confusion, delirium

Hypothermia Below 95 degrees

Uncontrolled shivering, loss of memory,LOCdecreases

Limits: 77-109 degrees F


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Oral Most accessible and accurate Do not use if unconscious, confused recent oral or

facial OR

Rectal 99 F Avoid with MI and after lower GI

Axillary 97 Fleast accurate, most safe

Tympanic 98 Favoid with infection, after exercise, w

hearing aid


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The wave begins when the left ventriclecontracts and ends when the ventricle relaxes

Indirect measure of cardiac output


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Each contraction forces blood into the alreadyfilled aorta, causing increased pressure withinthe arterial system

Systole: Peak of the wave; contraction of the heart

Diastole Resting phase of the heart


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Rate Measured in beats per minute (bpm)

Normal

60-100 bpm

Females slightly higher Average

70-80 bpm


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Apical is most accurate Use a standard stethescope to auscultate the

number of heartbeats at the apex of the heart

A heartbeat is one series of the LUB and DUBsounds


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Apical: at the apex of the heart Carotid: between midline and side of neck Brachial: medially in the antecubital space Radial: laterally on the anterior wrist Femoral: in the groin fold Popliteal: behind the knee Post tibial

Dorsalis pedis ulnar


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Bradycardia: rate < 60 bpm Tachycardia: rate> 100 bpm Is the rate regular? What is the quality?

Bounding? Thready?

Dysrhythmia (arrhythmia) Pulse deficit

Difference between radial and apical


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Exercise Body temperature

Anxiety

position

Emotions Medications

Hemorrhage

Pulmonarycondition


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Stroke volume The quantity of blood pumped out by each

contraction of the left ventricle

Cardiac output Stroke volume x pulse (heart) rate


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Pallor Paleness of skin when compared with another part

of the body

Cyanosis Bluish-grayish discoloration of the skin due to

excessive carbon dioxide and deficient oxygen inthe blood


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The exchange of oxygen and carbon dioxidein the body

Two separate process Mechanical

chemical


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Mechanical Pulmonary ventilation; breathing

Ventilation:

Active movement of air in and out of the respiratory

system Conduction

Movement through the airways of the lung


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Chemical Exchange of oxygen and carbon dioxide

Diffusion

Movement of oxygen and CO2 between alveoli and RBC

Perfusion Distribution of blood through the pulmonary

capillaries


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Inspiration Drawing air into the lung

Involves the ribs, diaphragm

Creates negative pressure-allows air into lung

Expiration Relaxation of the thoracic muscles and diaphragm

causing air to be expelled


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Rate: regulated by blood levels of O2, CO2and ph

Chemial receptors detect changes and signalCNS (medulla)

Normal: 12-20 breaths per minute Apnea: no breathing Bradypnea: abnormally slow Tachypnea: abnormally fast Observe for one full minute


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Depth Normal: diaphragm moves inch

Deep

Shallow

Rhythm Assessment of the pattern

Abnormal

Cheyne stokes, Kusmaul,


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Effort Work of breathing

Dypsnea: labored breathing

Orthopnea: inability to breath when horizontal

Observe for retractions, nasal flaring andrestlessness


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Wheeze High pitched continuous musical sound; heard on

expiration

Rhonchi

Low pitched continuous sounds caused bysecretions in large airways

Crackles Discontinuous sounds heard on inspiration; high

pitched popping or low pitched bubbling


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Stridor Piercing, high pitched sound heard during

inspiration

Stertor Labored breathing that produces a snoring sound


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Hyperventilation Rapid and deep breathing resulting in loss of CO2

(hypocapnea); light headed and tingly

Hypoventilation Rate and depth decreased; CO2 is retained

Cheyne Stokes Irregular, alternating periods of apnea and

hyperventilation


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ABGdirectly measures the partial pressures ofoxygen, carbon dioxide and blood ph

normal= paCO2 80-100)

Pulse oximetry

non invasive method for monitoringrespiratory status; measures O2 saturation

normal= >95%


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Force exerted by blood against arterial walls Work of the heart reflected in periphery via BP Systolic

Peak pressure exerted against arterial walls as the

ventricles contract and eject blood Diastolic

Minimum pressure exerted against arterial wallsbetween contraction when the heart is at rest


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Measured in millimeters of mercury (mm Hg) Recorded as systolic over diastolic

Pulse pressure Difference between systolic and diastolic


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The body constantly adjusts arterial pressure

to supply blood to body tissues Influenced by three factors

Cardiac function

Peripheral vascular resistance

Blood volume Normal = 5000 ml

Volume increases=BP increases

Volume decreases= BP decreases

Viscosity= reaction same as volume


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Elasticity Less elasticity creates greater resistance to blood

flow= > systolic BP

Decreased in smokers and increased cholesterol


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Palpation Used when BP is too weak to hear

Errors Wrong size cuff, deflating too rapidly, incorrect

placement Thigh

Measures 30-40 mm HG less than normal


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Age Stress

Gender

race

Circadian Medications

nutrition


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Values Normal: < 120/80 mm Hg

Hypotension: < 100mm HG

Pre hypertension: > 120/80 mm Hg

Hypertension: 140/90= Stage 1; 160/100= Stage 2 Persistant increase in BP

Damage to vessels; loss of elasticity; decrease inblood flow to vital organs


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Indirect Most common, accurate estimate

Direct In patient setting only

Catheter is threaded into an artery under sterileconditions Attached to tubing that is connected to monitoring

system Displayed as waveform on monitoring screen


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Indirect Equipment

Sphygomanometer and stethescope

Korotkoffs sounds

1st

2nd

3rd

4th

5th


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1st As you deflate the cuff; occurs during systole

2nd

Further deflation of the cuff; soft swishing sound

3rd Begins midway through; sharp tapping sound

4th

Similar to 3rdsound but fading

5th Silence, corresponding with diastole


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Orthostatic or postural hypotension Sudden drop in BP on moving from lying to sitting

or standing position

Primary or essential hypertension Diagnosed when no known cause for increase Accounts for at least 90% of all cases of

hypertension


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Combination of skills which provide anindication of state of health and bodyfunctionality

Nurses can delegate the activity of VS, but are

responsible for interpretation, trending anddecisions based on the findings


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5th vital sign It is what the client says it is

Nurse must know how to assess for it

Establish acceptable comfort levels

Follow up within appropriate time frame afterintervention


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Data collection Location (place and position)

Intensity

1-10

Strength and severity What is your pain at present? What makes it worse? What is

the best that it gets?


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Describe Aching, stabbing, tender, tiring, numb,..

Duration When did it start? Is is always there?

Aggrevate/alleviate What makes it better/worse?


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Energy Appetite

Sleep

Activity Mood

Relationships

Memory

concentration

Nurse checks for VS

Knowledge of pain

Med history

Side effects of meds Use of non

pharmacologicaltherapies

vital signs (1).ppt

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