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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.
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
What do you need to know about taking an axillary temp?
- Takes longer than oral
- ~1degree lower than oral. Document site temp was taken.
Stuff to know about rectal temp
Don't give to pt with MI. May stimulate vagus nerve.
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:
- --Infrared (tympanic)
- --Scanning infrared (temporal artery): Preferred, accurate, low risk of hurting pt.
- --Temperature-sensitive tape
- Chemical disposable
Factors affecting core temperature
- Diurnal variations (circadian rhythms): highest at early evening/night. Lowest just before rising.
- Disease states
Terms and values for changes in core temp
- Fever (pyrexia): Abnormally high body temperature (>100°F or
- Hyperpyrexia: Fever >105.8°F (41.0°C): pt may have hallucinations.
- Hyperthermia: Heat stroke.
- Hypothermia: CORE temp < 95°F (35.0°C)
Priorities for caring for pt with fever
For every 1 degree F temp rises, HR should increase by 10BPM to maintain metabolic activity.
- 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?
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
- --1+=pulse diminished, barely palpable; thready
- --2+=Easily palpable, normal pulse
- --3+=Full pulse, increased
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
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
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
Components of Respiratory assessment
- Rate: BPM
- Rhythm: Regular/Irregular
- Depth: shallow/deep
- Eupnea: normal breathing
- Apnea: no breathing
Work of breath
- positions needed.
- 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.
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)
Know this chart!
Pulse pressure: difference between systolic and diastolic. Should be >40.
Bood pressure general info
- Measured in mm Hg
- Recorded as systolic over diastolic.
BP influenced by
- Cardiac function
- blood volume
- Direct: probes directly inserted into vascular system.
- --upper arm (brachial artery
- --thing (popliteal artery)
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.
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
- Normal = < 120/80
- 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
For pt with hypotension
Take BP lying down, sitting, and standing.
For pt with Hypertension...
- 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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