N210 Week-1 Lab Vitals Signs

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N210 Week-1 Lab Vitals Signs
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2015-10-12 21:46:48
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N210 Week Lab Vitals Signs
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  1. a. Define the terminology relating to vital signs (Ch. 24, pp. 581-595)
    • 1. T: Temperature
    • a. The difference between the amount of heat produced by the body and the amount of heat lost to the environment
    • 2. P: Pulse Rate
    • a. A throbbing sensation that can be palpated over a peripheral artery
    • 1. Radial artery
    • 2. Carotid artery
    • b. Apical Pulse
    • 1. Lub-dubs of the heart
    • 3. R: Respiration Rate
    • a. Respiration: Involves…
    • 1. Ventilation (breathing), aka Respirations (This is what is measured!)
    • 2. Inspiration (inhalation)
    • 3. Expiration (exhalation)
    • 4. BP: Blood pressure
    • a. Refers to the force of moving the blood against arterial walls
    • 1. Systolic Pressure
    • i. THE HIGHESTPRESSURE, created during ventricular contraction
    • 2. Diastolic Pressure
    • i. THE LOWEST PRESSURE present on arterial walls
  2. b. Explain physiologic processes involved in homeostatic regulation of temperature, pulse, respirations, and blood pressure. (Ch. 24, pp. 581-595)
    • Homeostatic Regulation of…
    • 1. Temperature
    • a. The hypothalamus regulates body temperature
    • b. Receptors throughout the body help to conserve, increase, or decrease body heat
    • 2. Pulse
    • a. Regulated by the Autonomic Nervous System through the sinoatrial node (SA) (the pacemaker) of the heart
    • 3. Respirations
    • a. Rate and depth of breathing depends on change in response to tissue demands for O2 or an over abundance of CO2
    • 4. Blood Pressure
    • a. Elasticity of the arterial walls, in addition to the resistance of the arterioles, helps maintain blood pressure
  3. c. Compare and contrast factors that increase or decrease body temperature, pulse, respirations, and blood pressure.
    1. Refer to Week 1 Pre-Lab Assignment - Vital Signs Worksheet
  4. d. Identify sites for assessing temperature, pulse, and blood pressure.
    • 1. Temperature
    • a. Oral
    • b. Axial (armpit)
    • c. Tympanic
    • 2. Pulse
    • a. Carotid Artery (Neck)
    • b. Radial Artery (Lower arm)
    • c. Apical Pulse (Chest)
    • a. Midclavicular Line, between the 5th and 6th intercostal, below the left nipple
    • 3. BP
    • a. Radial Pulse
    • b. Brachial Artery
  5. e. Discuss the steps to accurately obtaining temperature, pulse, respirations, and blood pressure.
    1. Practiced in Lab
  6. f. Discuss the factors that contribute to false readings for blood pressure. (Ch. 24, pp. 601, Table 24-10)
    • 1. FALSELY LOW assessments
    • a. Hearing deficit
    • b. Noise in the environment
    • c. Viewing the meniscus from above eye level
    • d. Applying too wide a cuff
    • e. Inserting earpieces of stethoscope incorrectly
    • f. Using cracked or kinked tubing
    • g. Release the valve rapidly
    • h. Misplacing the bell beyond the direct area of the artery
    • i. Failing to pump the cuff 20-30mm Hg above the disappearance of the pulse
    • 2. FALSELY HIGH assessments
    • a. Using a manometer not calibrated at the zero mark
    • b. Assessing blood pressure immediately after exercise
    • c. Viewing the meniscus from below eye level
    • d. Applying a cuff that is too narrow
    • e. Releasing the valve too slowly
    • f. Reinflating the bladder during auscultation
  7. g. Discuss the normal ranges for body temperature, pulse, respirations, and blood pressure.
    1. Refer to Week 1 Pre-Lab Assignment - Vital Signs Worksheet
  8. h. Demonstrate documentation of vital signs.
    1. Practiced in lab
  9. i. Discuss the steps to obtaining an orthostatic blood pressure and pulse as well as their indications. (Ch. 24, pp. 599, Guidelines for Nursing 24-5)
    • 1. If orthostatic blood measurements are ordered…
    • a. Assess for signs an symptoms of hypotension THROUGHOUT THE PROCEDURE
    • a. Dizziness
    • b. Lightheadedness
    • c. Pallor
    • d. Diaphoresis
    • e. Syncope
    • b. If patient is attached to a cardiac monitor
    • a. Assess for arrhythmias.
    • c. If symptoms appear during the procedure…
    • a. Immediately return patient to supine position
    • d. DO NOT HAVE PATIENT STAND IF SYMPTOMS OF HYPOTENSION OCCUR WHEN THE PATIENT IS SITTING
    • 2. Procedure
    • a. Lower head of bed.
    • b. Place bed in low position
    • c. Ask patient to lie in a supine position for 3 to 10 minutes
    • a. At the end of the time record the initial BP an pulse measurements
    • d. Assist the patient to sit on the side of the bed with legs dangling
    • a. After 1 to 3 minutes, take the BP and pulse measurements
    • e. Assist the patient to stand (unless contraindicated)
    • a. Wait 2 to 3 minutes and then take BP and pulse measurements
    • f. Record measurements for each position
    • 3. Readings
    • a. A decrease in systolic > or equal to 20 mmHg or a decrease in diastolic BP of > or equal to 10mm Hg within 3 minutes of standing when compared with BP from the sitting or supine position

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