Vital Signs and Pain

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Anonymous
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102601
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Vital Signs and Pain
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2011-09-19 00:18:17
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nursing 1921
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exam 2 vatial signs and pain
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  1. Vital Signs
    • ·Temperature
    • ·Pulse
    • ·Respirations
    • ·Blood Pressure
    • ·Pulse Oximetry Pain Assessment
  2. Health status
    is reflected by indicators of bodily function
  3. Change in VS may indicate
    a change in health status
  4. Who is ultimately responsible for accuracy of data and assessment/reporting abnormal values appropriately?
    Nurse
  5. Vital Signs
    • Provide a baseline
    • Must know accepted normal values
  6. Temperature
    • Difference in heat produced and heat lost
    • Measured in degrees
    • Varies due to many factors
  7. Temperture varies due to many factors
    • Location taken (core vs surface)
    • Circadian rhythms
    • Age/gender
    • Stress
    • Environmental temperature
    • Exercise
    • Food/smoking
  8. Normal temperature range
    36.0C (97F) – 37.5C (99.5F)
  9. Elevated temperature
    37.0C (98.6F)
  10. Decreased temperature
    Decreased- < 36.0C (97F)
  11. Temperature Assessment Equipment
    • Digital
    • TM
    • Glass
    • TA
    • Disposable
  12. Temperature Assessment Site
    • Affected by:
    • Age
    • LOC, pain
    • Treatment in progress
  13. Temperature Assessment
    Core vs Body Surface
    • Rectal--CORE
    • Tympanic--CORE
    • Sublingual--SURFACE
    • Axillary--SURFACE
    • Temporal--SURFACE
  14. Pulse
    Throbbing sensation palpated or auscultated as a result of left ventricular contraction
  15. Pulse regulated by...
    the ANS via the SA node
  16. Pulse Characteristics
    • Rate
    • Rhythm
    • Quality/amplitude
  17. Pulse measured in?
    beats per minute(bpm)
  18. Factors affecting pulse
    • Age/gender
    • Exercise/conditioning
    • Stress
    • Fever
    • Medications
    • Volume status
    • Pain
    • Position changes
  19. Pulse Measurements:

    -Normal
    -Elevated
    -Decreased
    • Normal- 60-100 bpm
    • Elevated- 100-180bpm
    • Decreased- 60bpm
  20. Examples of Elevated pulse- >100-180bpm
    • Tachycardia
    • Dysrhythmias
  21. Examples of Decreased pulse < 60bpm
    • Bradycardia
    • Potential Causes:
    • Vagal stimulation
    • Meds
    • Hypothermia
    • MI or increased ICP
  22. Pulse Assessment
    Palpation peripheral arteries or auscultating apical pulse
  23. Peripheral pulse sites
    Radial, brachial, temporal, popliteal, posterior tibial, dorsalis pedis
  24. Central pulse sites
    Carotid, Femoral, Apical
  25. Pulse Assessment (4)
    • Rate
    • Rhythm
    • Quality/amplitude
    • Pulse deficit
  26. Respirations include several physiologic events (3)
    • Pulmonary Ventilation
    • Inspiration
    • Expiration
    • --External expiration
    • --Internal respiration
  27. What is the portion measured as a vital sign?
    Pulmonary Ventilation
  28. Respirations Regulated by?
    • ANS
    • Voluntary control
  29. Repiration rate and depth change in response to body’s demands
    • Inhibition/stimulation of respiratory centers in medulla and pons
    • Chemoreceptors in aortic arch and carotids, stretch/irritant receptors in lungs
  30. Respirations measured in breaths/min, what is the normal range?
    Normal range: 12-20 breaths/min
  31. Respirations varies due to many factors:
    • Age
    • Exercise
    • Disease process
    • Acid-base imbalancesMedications
    • Trauma/pain
    • Infection
    • Emotions
    • Altitude
  32. Elevated respirations?

    Decreased respiration?
    elevated= >20 breaths/min

    decreased= <12 breaths/min
  33. orthopnea
    sitting upright to ease breathing
  34. Respiration rate increases how many breaths/min of every 1 degree F over normal temp?
    4 breaths/min for every 1 degree F over normal temp
  35. Respiratory Assessment (3)
    Rate

    Rhythm

    Depth
  36. Respiratory rate assessment
    • Eupnea
    • Tachypnea, hyperventilation
    • Bradypnea, hypovenitlation
  37. Rhythm
    • Regular
    • Irregular
    • Patterned
  38. Depth
    • Deep
    • Shallow
  39. Cheyne stokes breathing
    • near death breathing pattern
    • breath...stop....breath....stop
  40. Biots breathing
    • Irregular
    • seen in patients with miningitis and severe brain damage
  41. Kussmaul breathing
    rapid shallow, rapid deep
  42. Respirations Diagnosis
    • Ineffective Breathing Pattern
    • Impaired Gas Exchange
    • Risk for Activity Intolerance
  43. Blood Pressure
    Force of blood against arterial walls
  44. 3 types of (blood) pressures
    • Systolic pressure
    • Diastolic pressure
    • Pulse pressure
  45. How is Blood Pressure measured?
    Measured in millimeters of mercury (mmHg)
  46. BP controlled/maintained via
    • Peripheral vascular resistance (PVR)
    • Neural mechanisms
    • SNS, PNS, Baroreceptors
    • Humoral mechanisms
    • Epinephrine, Renin-Angiotensin-Aldosterone system
    • Cardiac output
  47. Blood pressure =
    cardiac output X systemic vascular resistance
  48. cardiac output
    the amount of blood pumped from heart each minute
  49. peripheral vascular resistance
    PVR
    • Arterioles in a state of partial contraction, resulting in relatively constant level of resistance
    • One of the main factors affecting BP
  50. ANS control mechanisms for short term BP control
    • Within circulatory system: Chemo and baro receptors
    • Outside circulatory system: Pain, cold, ischemia, mood or emotion
  51. Hormones/Humoral responses
    • Kidneys: Renin-andiotensin-aldosterone
    • Posterior Pituitary: ADH, vasopressin
  52. Average CO=
    3.5-8.0 L/min
  53. What would be the CO for an adult with a SV of 70ml and a HR of 90?
    6.3 L/min
  54. Increased CO=
    Increased Blood Pressure
  55. Decreased CO=
    Decreased Blood Pressure
  56. Cardiac Output=
    Heart Rate X Stroke Volume
  57. Factors affecting BP
    • Age/gender
    • Race
    • Circadian rhythm
    • Eating
    • Exercise and weight
    • Body position
    • Emotions/mood
    • Medications
    • Blood volume
  58. Blood Pressure Measurement
    normal
    • Normal: SBP<120 & DBP <80
    • Normotensive
  59. Blood Pressure Measurement
    elevated
    > normal for sustained period

    • Primary hypertension
    • No known cause
    • Secondary hypertension
    • Identifiable cause
  60. Blood Pressure Measurement
    decreased
    < normal for sustained period

    HypotensionOrthostatic hypotension
  61. Hypertension (the silent killer)
    • Major risk factor for heart disease
    • Most important risk factor for stroke
    • Sustained HTN results in permanent thickening and remodeling of vessels
    • Increased PVR
    • Back-up pressure to organs
    • MI, CHF, CVA, Myopathy, Kidney damage
    • Risk Factors
    • Treatment
    • Meds and lifestyle modification
  62. Hypotension
    Results from vasodilation, pump failure or volume loss
  63. BP Signs/Symptoms that should be identified and reported
    • Hypotension
    • Pallor
    • Tachycardia
    • ALOCDiaphoresis
  64. Orthostatic Hypotension
    • Low BP associated with weakness, dizziness or fainting when moving to erect position
    • Vasodilation without rise in CO
  65. At risk population with Orthostatic Hypotension
    • Elderly
    • Dehydrated
    • Blood loss
    • Prolonged bed rest
    • Medications
  66. How can we prevent orthostatic hypotension from happening?
    • -if moving patient from bed (laying down) to chair or bathroom, lift up bed, sit them up, let feet dangle, stand up, walk.
    • -take time and ask how they are feeling along the process
  67. Blood Pressure Assessment Equipment
    • Stethoscope
    • Sphygmomanometer
    • Doppler
    • NIBP or Invasive BP monitor
  68. Blood Pressure Assessment Site
    Brachial artery (most common)
  69. Blood Pressure Assessment
    Site Contraindications
    • IV or PICC line arm
    • AV fistula or shunt
    • Avoid arm with axillary node dissection or mastectomy
  70. Korotkoff Sounds
    5 phases
    • Phase 1: first sound you hear is SBP
    • Phase 2: muffled or swishing sound
    • Phase 3: loud distinct sound
    • Phase 4: abrupt muffling
    • Phase 5: last sound you hear is DBP
  71. Error: Fasle Low

    Potential Cause:?
    • Hearing deficit
    • Noise
    • Too large cuff
    • Stethoscope earpieces inserted incorrectly
    • Release valve to fast
    • Not placing diaphragm over artery
    • Not pumping 20-30mmHG over baseline
  72. Error: False High

    Potential Cause:?
    • Uncalibrated cuff
    • Taking BP immdiately after exercise
    • Too small cuff
    • Release valve too slowly
    • Reinflating bladder during auscultation
  73. Blood Pressure-Nursing Process Diagnosis
    • Decreased CO
    • Ineffective health maintenance
    • Effective therapeutic regimen management
    • Risk for falls
  74. Pulse Oximetry
    • Non-invasive technique to measure arterial oxyhemoglobin saturation
    • Measures % of O2 carried by available hemoglobin
    • Measured in %
  75. Pulse Oximetry used for monitoring patients:
    • Receiving O2 therapy
    • Titrating O2 therapy
    • Post-op
    • Sedation
  76. Normal Pulse Oximetry
    Normal range: 95%-100%
  77. Pulse Oximetry Assessment Equipment
    • Pulse oximeter with appropriate probe
    • Nail polish remover prn
  78. Pulse Oximetry Assessment Site
    • Finger (most common)
    • If nail polish/fake nails, cold hands, poor perfusion, hypotension may give false reading
    • Bright light can affect sensor and alter rea

    Toe, forehead, bridge of nose, earlobe are alternate sites (depending on type of probe available)ding
  79. Pain
    • One of the body’s defense mechanisms that lets them know there is a problem
    • Is whatever the person says it is when they say it is
    • Considered the 5th vital sign
    • Subjective assessment
  80. Pain Duration
    • Acute
    • Chronic
    • Remission
    • Exacerbation-reaccurance
  81. Pain Source
    • Superficial
    • Somatic-exterior wall
    • Visceral-organ
  82. Pain Etiology
    • Neuropathic-nerve
    • Intractable-can't do anything to get rid of it
    • Phantom-amputationand still feel what was removed
    • Psychogenic
  83. The Pain Process
    • Transduction
    • Transmission
    • PerceptionModulation
  84. The Pain Process-Transduction
    Activation of the pain receptors; converts painful stimuli into electrical impulses that travel to the spinal cord
  85. Nociceptors
    peripheral nerve fibers that transmit pain
  86. Substances that can stimulate nociceptors
    • Bradykinin
    • Neurotransmitters (excite or inhibit target nerve cells)
    • Prostaglandins, Serotonin, substance P
  87. The Pain Process-Transmission
    • A-delta-fibers (acute well-localized pain)
    • C-delta-fibers (diffuse, visceral pain; burning aching)
    • Protective pain reflex
  88. The Pain Process-Perception
    • Pain threshold
    • Lowest intensity that causes recognition of pain
  89. The Pain Process-Modulation
    • Process by which pain is inhibited or modified
    • Regulated by neuromodulators
  90. Naturally occurring morphine–like chemical regulators in brain and spinal cord
    • Endorphins
    • Enkephalins
  91. Factors affecting Pain Experience
    • Culture
    • --Ethnocultural groups
    • --Family, age, gender
    • --Religious beliefs
    • Environment/Support Systems
    • Anxiety and other stressors
    • Past Experiences
  92. Pain Assessment Misconceptions
    • Fear of addiction to narcotics
    • Healthcare personnel assumptions/biases
    • To deal with pain is better than side effects of meds
    • Wait until gets bad before asking for meds
    • It’s natural to have pain, it will get better soon
  93. Pain assessment (many)
    • Pt description of pain
    • Duration
    • Location
    • Intensity
    • Quality
    • Time started
    • OPQRST
    • Aggravating factors
    • Alleviating factors
    • Physiologic indicators
    • Behavioral responses
    • Effect on ADL’s
  94. Pain Assessment Variations
    • Cognitively Impaired-cant communicate well; use # or pic scales
    • Children-picture scale
    • Elderly
  95. Pain- Nursing Process Assessment
    Use open ended questions
  96. Pain- Nursing Process Diagnosis
    • Acute
    • Chronic
  97. Pain- Nursing Process Plan
    Set realistic goals with patient
  98. Pain- Nursing Process Implementation
    • Trusting relationship with caregiver
    • Manipulate factors affecting pain
    • Non-pharmacologic therapy

    • Pharmacologic intervention
    • Pt teaching
    • Legal/Ethical Responsibilities
  99. Non-pharmacologic therapy
    Distraction, humor, imagery, relaxation, cutaneous stimulation, accupuncture, etc
  100. Pain-Pharmacologic intervention
    • Analgesics
    • Opioid Analgesics
    • Adjuvant
    • PCA
    • MOD or On-QC-bloc
    • Epidural
    • Local
  101. Analgesics--Non-opioid
    • Acetaminophen, NSAIDS, COX-2 inhibitors
    • Side effects
  102. Opioid Analgesics
    • Attach to opioid receptors
    • Morphine, Fentanyl, Dilaudid
    • Side effects
    • Physical Dependence
    • Tolerance
    • Addiction
  103. Patient controlled analgesia
    • Loading dose: given initially to raise blood levels to therapeutic level and control pain
    • Bolus dose: pt pushes button for small preset (prescribed dose)
    • Dose interval
    • Lock-out interval
    • Basal rate: continuous infusion of low dose to maintain a level of analgesia in blood
  104. Pain-Nursing Process-Evaluation
    • Pain experience
    • Management regimens
    • Patient and family response

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