NURS1921 Exam II: Vital Signs and Pain

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  1. What is the purpose of vital signs? Why do we take them?
    • Establish a baseline or reference point. Reassessments are used to see if interventions have changed vital signs (whether desireable or undesireable side effects of medication).
    • Nurse must be aware of normally accepted values for age and condition (athlete, etc...).
    • They can an indication of bodily function (alterations in their level of functioning).
  2. Temperature
    • The diff. between heat produced and heat lost.
    • Normal Accepted Values for Adults - 36.0°C and 37.5°C.
  3. Temperature Parameters
    • Normal: Afebrile (36.0°C - 37.5°C).
    • Elevated: Febrile & Pyrexia ( > 37.0°C) or Hyperexia & Hyperthermia ( > 41°C or 105.8°F - inconsistant with life).
    • Decreased: Hypothermia (< 36.0°C or 97°C).
    • Death may iccur at temp. less than 34°C (93.2°F)
    • Not dead until warm and dead.
  4. Equipment used for Temperature Assessment
    • Digital
    • TM - Tempanic Membrane
    • Glass - Not really used anymore. May be used in rural areas where it's easier to sterilize equiptment than buy new.
    • TA - Temperal Aterial (scanned across the forehead)
    • Disposable
  5. Site of Temperature Assessment
    • Choosing the site where temperature is assessed can be affected by:
    • Age - Oral route not recommeneded for children.
    • LOC, pain - Pts. in severe pain use quickest route (TM)
    • Tx in progress - No oral on pt. with oxygen mask; Do not use rectal on immunocompromised, rectal sx, neonates; use axillary
  6. Core vs. Body Surface in Assessing Temperature
    • Core: Rectal & TM
    • Surface: Subligual & Axillary
  7. Temperature in Regards to the Nursing Process
    • Assessment: Equiptment, Site and Core vs. Surface
    • Diagnosis: Hyperthermia, Hypothermia, Risk for Imbalanced body temp., Ineffective thermoregulation
    • Interventions: Elevated (aches, etc..) analgesics and antipyretics, cooling blankets, ice levage, cool compress on arterial points, tepid bath. Decreased warm fluids, warm IV fluids, lights, blankets.
    • Evaluation: Make sure interventions have done what we intended them to do & make a new plan (if necessary).
  8. Pulse
    • Throbbing sensation palpated or auscultated as a result of left ventricular contraction.
    • Regulated by the ANS (parasympathetic & sympathetic).
    • Pace set by AV Node.
    • Measured in BPM - Normal limits for adults is 60-100bpm (well-conditioned athletes around 40bpm).
  9. Pulse Assessment Data
    • Rate - Number in a given time period
    • Rhythm - Regular, Irregular or Regularly Irregular (skips every 5th beat).
    • Quality/Amplitude (can only be palpated not asculatated and is subjective)
  10. Factors Affecting Pulse
    • Age/Gender: Know the normal parameters for different age groups. HR above 140 in anyone is bad. HR below 40 in a child is bad.
    • Exercise/Conditioning: Highly conditioned athletes will have a normal low rate.
    • Stress: Can increase HR.
    • Fever: For every degree in °F HR accelerates 7-10bpm.
    • Medications: some meds can keep rate below normal and vice versa.
    • Volume Status: HR increases to compensate for volume loss (ex. nausea, vomitting & diarrhea will increase HR).
    • Pain: Increased pain can raise HR.
    • Position Changes: HR elevates from laying to standing.
  11. Factors Affecting Temperature
    • Circadian Rhythm: Temp is lowest in the am and higher in pm.
    • Age/Gender: during ovulation cycle for females.
    • Location: Core vs. Surface.
    • Stress
    • Environmental Temp: Working outdoors in a warm climate; ice fishing.
    • Exercise: Increases temp.
    • Food/Smooking/Chewing Gum
  12. Pulse Parameters
    • Normal: 60-100bpm
    • Elevated: > 100-180bpm: Tachycardia (SVT - Super Ventricular Tachycardia > 180)
    • Decreased: <60bpm Bradycardia
    • Dysrhythmia: Not just to number but abnormality in the rhythm of the HR.
  13. Potential Causes of Bradycardia
    • Vagal Stimulation: Bearing down for a bowel moverment (reg. by PNS).
    • Medications: Beta-blockers which improve cardiac output slow HR.
    • Hypothermia: slower metabolic rate.
    • MI or increased ICP (intercranial pressure): pressure on the pons & medulla decrease blood flow.
  14. Equipment used in Pulse Assessment
    • Palpatation peripheral arteries or auscultating apical pulse.
    • Stethoscope or Doppler (pulse is heard when it cannot be felt)
    • Reasons for inability to palpate or ascultate pulse could be due to inadequate perfusion.
  15. Site of Pulse Assessment
    • Carotid: Central
    • Brachial: Peripheral
    • Radial: Peripheral
    • Posterior Tibial: Peripheral
    • Dorsalis Pedis: Peripheral
    • Popliteal: Peripheral
    • Femoral: Centeral
  16. Apical Pulse
    • 5th ICS (intercostal space)
    • MCL (midclavicular line)
    • PMI - Point of Maximum Impulse
  17. Pulse Assessment
    • Rate & Rhythm: Objective
    • Quality/Amplitude: Subjective
    • Pulse Defecit: Diff. between the apical and radial pulses; not all beats are perfusing peripherially. True pulse deficit can only be measured with simulataneous peripheral & apical assessment.
  18. Quality/Amplitude Assessment Data
    • Absent: 0 - Nothing felt, dispite increased pressure.
    • Thready: 1+ - Not easily felt, disappears with slight pressure.
    • Weak: 2+ - Stronger than thready, may disappear with light pressure.
    • Normal: 3+ - Easily felt, may disappear with moderate pressure.
    • Bounding: 4+ - Strong, doesn't disappear with moderate pressure.
  19. Pulse in Regards to the Nursing Process
    • Assessment: Palpate, Ausculatate or Doppler.
    • Diagnosis: Decreased Cardiac Output; Ineffective Tissue Perfusion; Deficient Fluid Volume; Acute Pain.
    • Intervention: Identify and treat the cause.
    • Evaluation: Make sure interventions have done what we intended them to do and make a new plan if necessary.
  20. Respirations
    • Includes several physiologic events:
    • Ventilation
    • Inspiration
    • Expiration

    Regulated by the ANS with some Voluntary Control

    Rate and depth change in response to body's demands
    (running, sleeping, etc...) - Inhibition/Stimulation of resp. centers in the medulla and pons; Chemoreceptors in the carotids and aortic arch (sensing more more CO2) send stretch & irritant receptors in the lungs. All controlled by the ANS.

    • Measured in breaths/min - Normal range for adult is 12-20 breaths/min
  21. Factors effecting Respirations
    • Age: know parameters for different age groups - Anything resp. rate > 60 is abnormal regardless of age.
    • Exercise: Increase during exercise which decreases the resp. rate at rest.
    • Disease Processes: COPD, etc...
    • Acid-Base Imbalances: Acidosis - excess gases are "blown off" by increasing respirations (usually shallow).
    • Medications: Opioid Analgesics -depress respirations Theophylline - increases respirations.
    • Trauma/Pain: Fever, Injury increases respiratory rate (trying to fix the heart through aerobic metabolism)
    • Infection:
    • Emotions: Fear, anxiety, crying increase respiratory rate.
    • Altitude: To adjust to high altitude respirations increase until more cells are created (visitors vs. residents of Colorado).
  22. Respiration Parameters
    • Normal: 12-20 breaths/min. - Eupnea
    • Elevated: > 20 breaths/min - Tachypnea Rate increases 4 breaths/min fir every 1° in fever.
    • Decreased: < 12 breaths/min - Bradynpea
    • Difficulty Breathing: Dyspnea
    • Sitting upright to ease breathing: Othopnea
    • Periods of no breaths: Apnea
  23. Respiratory Assessment
    • Rate: Eupnea, Tachynpea (hyperventilation) or Bradynpea (hypoventilation) Ex. of Doc. Resp. of 12 breaths/min. Eupnea with periods of apnea.
    • Rhythm: Regular, Irregular (Biot's) or Patterned (Kussmauls, Cheyne-Stokes)
    • Depth: Deep or Shallow
  24. Respiratory Patterns
    • Kussmaul: Fruity acetone breath, DKA (Diabetic Ketoacidosis), ASA OD (Aspirin Overdose). Rapid breathing alternating deep and shallow.
    • Cheyne-Stokes: Near Death Breathing Pattern Overdose, Heart Failure, Increased ICP, Renal Failure. Fast deep breaths with periods of apnea.
    • Tachynpea: Fever, Anxiety, Exercise, Respiratory Disorders. Fast.
    • Bradynpea: Meds (opiod analgesics, sedatives), Brain Damage. Slow.
    • Biots: Meningitis, Severe Brain Damage. Irregular.
  25. Respirations in regarding to the Nursing Process
    • Assessment: Rate, Rhythm and Depth
    • Diagnosis: Ineffective Breathing Pattern; Impaired Gas Exchange; Risk for Activity Intolerance.
    • Intervention: Slow-Acting - intibating; stimulation; administration of O2. Fast-Acting - Meds to slow, meds to clear airway, suction.
    • Evaluation: What was intervened? Did it help? Do I need a new plan?
  26. Blood Pressure
    • The force of blood against the arterial walls which causes a constant state of tension/contraction.
    • Measured in millimeters of mercury (mmHG)
    • Low Volume = Higher BP becase arteries are clamping down.
    • BP is manipulated through Hearth Rate, output and contractability of the blood vessels.
  27. Blood Pressure Measurements
    • Systolic: Top #
    • Diastolic: Bottom #
    • Pulse Pressure: Difference btwn systolic and diastolic. Should be around 40 mmHg.
  28. How is Blood Pressure Controlled?
    • Autonomic Nervous System
    • PVR (Peripheral Vascular Resistance): One of the main factors affecting BP. Aterioles are in a constant state of partial contraction which results in a relatively constant level of resistance.
    • Neural Mechinisms: SNS (increases BP under periods of stress, anxiety or pain), PNS (decreases BP by, for example, the vagus nerve being stimulated), Baroreceptors (stretch receptors).
    • Humoral Mechinisms: helps maintain BP by releasing Epinepherine, Renin-Angiotension-Aldosterone system.
    • Cardiac Output: As volume as lost stretch is lost and blood pressure decreases.
    • Outside of the Cirulatory System: Cold, pain, ischemia, mood or emotion.
    • BP = CO (cardiac output or amount of blood pumped out of the heart per minute) x SVR (systemic vascular resistance or ability to constrict and dialate)
  29. What would be the CO for an adult with a SV or 70ml and a HR of 90?
    • CO = HR x SV
    • CO = 630 ml/minute
  30. Factors Affecting Blood Pressure
    • Age/Gender: BP increases with age due to decreased elasticity of the blood vessels (arteries).
    • Race: Hypertension is more prevalent and more severe in African American men and women.
    • Circadian Rhythm: BP is usally lowest in the a.m., highest in the late afternoon and gradually falls during sleep.
    • Food Intake: BP increases after eating.
    • Exercise and Weight: systolic increases during periods of exercise; BP is usually higher in people who are obese.
    • Body Position: Laying (little work to move blood), Sitting (more to move blood), Standing (most effort to move blood).
    • Emotions/Mood: BP increases with anger, fear, excitement or pain but falls to normal when feelings pass.
    • Medications: Pain meds lower BP, raise HR and cause bradycardia. Oral contraceptives cause a mild increase in BP.
    • Blood Volume: As volume deceases, BP decrease and HR increases.
  31. Blood Pressure Parameters
    • Normal: SBP<120 & DBP<80 - Normotensive
    • Elevated: > normal for sustained period - Primary hypertensin: No known cause. Secondary Hypertension: Identifiable cause.
    • Decreased: < normal for sustained period - Hypotention.
  32. Hypertension
    • Major risk factor for heart disease.
    • Most important rish factor for stroke.
    • Sustained HTN results in permanent thickening and remodeling of vessels.
    • Increased risk for PVR
    • HTN backs up pressure to organs and can cause MI, CHF, CVA, Myopathy or kidnet damage.
    • Tx for HTN: Meds and lifestyle modification.
  33. Risk factors for HTN
    • Age
    • Diet
    • Weight
    • Lifestyle
  34. Hypotension
    • Results from vasodialation, pump failure or volume loss.
    • Signs and Symptoms which shuold be reported:
    • Hypotension
    • Pailor
    • Tachycardia
    • ALOC (altered level of consciousness)
    • Diaphoresis (excessive sweating)
  35. Orthostatic Hypotension
    • Low BP associated with weakness, dizziness or fainting when moving to erect position.
    • Vasodialation without rise in Cardiac Output
    • At Risk Population:
    • Eldery
    • Dehydrated
    • Blood Loss
    • Prolonged bed rest
    • Medications
    • Have pts. who are at risk change positions slowly.
  36. Equipment used in assessing Blood Pressure
    • Stethoscope
    • Sphygmomanometer
    • Doppler
    • NIBP or Inasive BP monitor
  37. Sites used to assess Blood Pressure
    • Brachial Artery: Most common.
    • Contraindications - IV or PICC line in the arm, AV fistula or shunt, avoid arm with axillary node dissection or mastectomy.
  38. Reasons for Blood Pressure Assessment Errors
    • False Low:
    • 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

    • False High:
    • Uncalibrated Cuff
    • Taking BP immediately after exercise
    • Cuff too small
    • Release valve too slowly
    • Reinflating bladder during asculatation
  39. Blood Pressure in regards to the Nursing Process
    • Assessment: Systolic, Diastolic, Pulse Pressure
    • Diagnosis: Decreased Cardiac Output, Ineffective Health Maintenance, Effective therapeutic regimen management, Risk for Falls.
    • Implementation: Identify cause and intervene meds, Patient teaching (diet), stress management, etc..
    • Evaluation: Have interventions worked? Do I need to create a new plan?
  40. Pulse Oximetry
    • Non-invasive way to measure arterial oxyhemoglobin saturation
    • Normal Rage: 95-100%
    • Usually part of detailed assessment. Order needed or it's usually not done.
  41. What kind of patients might require pulse ox?
    • Receiving O2 therapy
    • titrating O2 therapy
    • Post-Op
    • Sedation
  42. Equipment use in assessing Pulse Ox
    • Pulse oximeter with appropriate probe sensor
    • Nail polish remover PRN
  43. Assessment Sites for Pulse Ox
    • Finger: most common - finger nail polish, cold hands, poor perfusion or hypotension may give false reading.
    • Toe
    • Forehead
    • Bridge of Nose
    • Earlobe

    Depends on type of probe available
  44. Pain
    • One of the body's defense mechinisms that lets them know there is a problem.
    • Is whatever the patient says it is.
    • Considered 5th vital sign.
    • Subjective Assessment
  45. Types of Pain
    • Acute: From seconds of onset to up to 6 mo.
    • Chronic: Pain for 6mo . or more.
    • Remission: Dx of chronic pain condition but currently no pain.
    • Exacerbation: Acute reoccurance of chronic pain.
  46. Sources of Pain
    • Superficial: On the surface
    • Somatic: On body's exerior wall
    • Visceral: Organ
  47. Referred Pain
    Pain outside of where injury or damage occured.
  48. Neuropathic Pain
    In nerve endings
  49. Intractable Pain
    No relief
  50. Phamtom Pain
    • Amputation
    • Pain in a limb which no longer exists
  51. Psychogenic
    Expericing pain with no physical cause
  52. Factors Affecting Pain Experience
    • Culture: family, age, gender, religous beliefs.
    • Environment/Support Systems
    • Anxiety or other stressors: Fear of the unknown - set pain expectations for patients.
    • Past Experiences
  53. The Pain Process
    • Transduction: Activation of pain receptors.
    • Transmission: How it gets from point A to point B.
    • Perception: Pain threshold.
    • Modulation: Process by which pain is inhibited or modified through neuromodulators.
  54. Pain in Regards to the Nursing Process
    • Assessment: OPQRST (onset, provoked, quality, radiation, severity and time).
    • Diagnosis: Acute or Chronic.
    • Plan: Set realistic goals with patient
    • Implementation: Trussuting relationship with caregiver; manipulate factors affecting pain; non-pharm therapy; Parm interventions
    • Evaluation
  55. Physiologic Indicators of Pain
    Hypertension, tachycardia, etc...

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NURS1921 Exam II: Vital Signs and Pain
2011-09-20 01:50:31
NURS1921 Exam II Vital Signs Pains

Based on lecture by Mrs. Pijut
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