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What to keep in mind when monitoring vital signs.
- Performed on a regular basis
- Frequency determined by
- --Physician order and/or nursing judgment
- --Client’s condition
- --Facility standards
- Analyze all vital signs at same time. Put the puzzle togther.
- Re-do
- Baseline
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When to assess VSs
- On admission: determine baseline to assess whether or not course of health is working.
- Change in client’s health status
- Client reports symptoms such as chest pain, feeling hot, or faint
- Pre and post surgery/invasive procedure
- Pre and post medication administration that could affect CV system
- Pre and post nursing intervention that could affect vital signs
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What do you need to know about taking an axillary temp?
- Takes longer than oral
- ~1degree lower than oral. Document site temp was taken.
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Stuff to know about rectal temp
Don't give to pt with MI. May stimulate vagus nerve.
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Stuff to know about assessing Temp
- Hypothalamus is the thermostat of the body
- Temperature controls:
- --skin: radiation, conduction, convection, evaporation, diaphoresis.
- --Vascular: vasconstriction, vasodilation, shunting.
- The “old standby” normal range: 97°F to 100.8°F
(36.1°C to 38.2°C) with some variation
- Typically 1°F to 2°F (0.6°C to 1.2°C) higher than skin temperature
- Types of Instruments:
- --Electronic
- --Infrared (tympanic)
- --Scanning infrared (temporal artery): Preferred, accurate, low risk of hurting pt.
- --Temperature-sensitive tape
- Chemical disposable
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Factors affecting core temperature
- Age
- Diurnal variations (circadian rhythms): highest at early evening/night. Lowest just before rising.
- Exercise
- Hormones
- Stress
- Environment
- Disease states
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Terms and values for changes in core temp
- Fever (pyrexia): Abnormally high body temperature (>100°F or
37.8°C)
- Hyperpyrexia: Fever >105.8°F (41.0°C): pt may have hallucinations.
- Hyperthermia: Heat stroke.
- Hypothermia: CORE temp < 95°F (35.0°C)
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Priorities for caring for pt with fever
- What are your priorities? Comfort-->bring temp down
- What are you, as the nurse, going to do? Cold cloths, cold packs, liquids. Need Dr. order for fever, even if Dr. has already Rx'd same med for pain.
- What are the pt educaiton factors?
For every 1 degree F temp rises, HR should increase by 10BPM to maintain metabolic activity.
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Documenting and knowning your pulse
- Rate and rhythm – how do you describe?
- Why is it important? Want to know if it's regular/irregular.
- Pulse assessments
- –Equality and symmetry
- --Strength of the quality; sometimes it is the quality and not the quantity
- --0=absent
- --1+=pulse diminished, barely palpable; thready
- --2+=Easily palpable, normal pulse
- --3+=Full pulse, increased
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What are normal ranges for HR?
- Normal range for healthy adults = 60–100 bpm
- Average = 70–80 bpm
- Normal range for healthy infants=120-160 bpm
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Checking for pulse deficit
- Apical-Radial Pulse
- Locate apical and radial sites
- Two nurse method: Decide on starting timeNurse counting radial says “start”Both count for 60 seconds Nurse counting radial says “stop”Radial can never be greater than apical
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Aspects of Respiration
- The exchange of oxygen and carbon dioxide in the body Two separate processes
- Mechanical: physical process of inhalation/exhalation
- Chemical: bonding of O2 to hemoglobin
- Newborn normal value = 30 - 60 / min. In newborns rate can double with stress/injury/illness/etc.
- Adult normal value = 12 - 20 / min
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Components of Respiratory assessment
- Rate: BPM
- Rhythm: Regular/Irregular
- Depth: shallow/deep
- Quality
- Effectiveness
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Breathing patterns
- Eupnea: normal breathing
- Apnea: no breathing
- Tachy
- Brady
- Cheyne-stokes
- Kussmauls
- Biots
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Work of breath
- labored/unlabored
- positions needed.
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Abnormal sounds
- Wheezing: results during expiration
- Stridor: inspiration
- Stertor: labored breathing (during sleep). sounds like snoring.
- Rhonchi/crackles: fluid in airways. Sounds like ricecrispies. Ronchi-deeper and wetter.
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Tools to measure oxygenation
- Arterial blood gasses (ABG) direct method
- Puse Oximetry: indirect because measures hemoglobin, not gas.
Normal CO values are >90%, national value >95% (good to know for NCLEX)
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Know this chart!
Pulse pressure: difference between systolic and diastolic. Should be >40.
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Bood pressure general info
- Measured in mm Hg
- Recorded as systolic over diastolic.
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BP influenced by
- Cardiac function
- perfusion
- blood volume
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Measuring BP
- Direct: probes directly inserted into vascular system.
- Indirect
- --Auscultatory
- --Palpation
- Sites
- --upper arm (brachial artery
- --thing (popliteal artery)
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Quibbles in taking BP.
- Sizing: needs to be at least 2/3 size of upper arm (child whole upper arm)
- Pump until systolic (radial) pulse stops, then add 30-40mm Hg on top of that.
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Phases of Korotkoff sounds when taking BP
- Auscultated Korotkoff Sounds
- Phase I – First heard, generally a loud thump = Systolic
- Phase II – A blowing or whooshing sound
- Phase III – A softer thump than Phase I
- Phase IV – A softer blowing sound that fades
- Phase V – Silence = Diastolic
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BP readings
- Normal = < 120/80
- Hypertension
- Mild (Stage 1) 140 -159 / 90-99
- Moderate (Stage 2) 160-179 / 90 -99
- Severe (Stage 3) > 180 / 110
- Staging is achieved after obtaining two diastolic readings at two different occasions that average > 90mmHg. Or Systolic readings which average >135
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For pt with hypotension
Take BP lying down, sitting, and standing.
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For pt with Hypertension...
- Prehypertension
- BP reading of 120–139 systolic or 80–89 diastolic
Obtained with three readings, taken days apart , with the client sitting.
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