NURS1921 Exam II: Vital Signs and Pain
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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).
- The diff. between heat produced and heat lost.
- Normal Accepted Values for Adults - 36.0°C and 37.5°C.
- 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.
Equipment used for Temperature Assessment
- 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)
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
Core vs. Body Surface in Assessing Temperature
- Core: Rectal & TM
- Surface: Subligual & Axillary
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).
- 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).
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)
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.
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.
- Environmental Temp: Working outdoors in a warm climate; ice fishing.
- Exercise: Increases temp.
- Food/Smooking/Chewing Gum
- 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.
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.
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.
Site of Pulse Assessment
- Carotid: Central
- Brachial: Peripheral
- Radial: Peripheral
- Posterior Tibial: Peripheral
- Dorsalis Pedis: Peripheral
- Popliteal: Peripheral
- Femoral: Centeral
- 5th ICS (intercostal space)
- MCL (midclavicular line)
- PMI - Point of Maximum Impulse
- 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.
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.
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.
Regulated by the ANS with some Voluntary Control
- Includes several physiologic events:Ventilation
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
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)
- 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).
- 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
- 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
- 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.
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?
- 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.
Blood Pressure Measurements
- Systolic: Top #
- Diastolic: Bottom #
- Pulse Pressure: Difference btwn systolic and diastolic. Should be around 40 mmHg.
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)
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
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.
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.
- 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.
- Results from vasodialation, pump failure or volume loss.
- Signs and Symptoms which shuold be reported:
- ALOC (altered level of consciousness)
- Diaphoresis (excessive sweating)
- Low BP associated with weakness, dizziness or fainting when moving to erect position.
- Vasodialation without rise in Cardiac Output
- At Risk Population:
- Blood Loss
- Prolonged bed rest
- Have pts. who are at risk change positions slowly.
Equipment used in assessing Blood Pressure
- NIBP or Inasive BP monitor
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.
Reasons for Blood Pressure Assessment Errors
- False Low:hearing deficit
- 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
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?
- 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.
What kind of patients might require pulse ox?
- Receiving O2 therapy
- titrating O2 therapy
Equipment use in assessing Pulse Ox
- Pulse oximeter with appropriate probe sensor
- Nail polish remover PRN
Assessment Sites for Pulse Ox
Depends on type of probe available
- Finger: most common - finger nail polish, cold hands, poor perfusion or hypotension may give false reading.
- Bridge of Nose
- 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
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.
Sources of Pain
- Superficial: On the surface
- Somatic: On body's exerior wall
- Visceral: Organ
Pain outside of where injury or damage occured.
In nerve endings
- Pain in a limb which no longer exists
Expericing pain with no physical cause
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
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.
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
Physiologic Indicators of Pain
Hypertension, tachycardia, etc...
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