Wha are the 6 Vital Signs
TemperATURE (T)PULSE (P)RESPIRATIONS(R)BLOODPRESSURE(BP)OXYGEN SATURATION(O2 SAT, PULSE OX, OR SPO2, PAIN
WHATS THE 5 OBJECTIVES OF VITAL SIGNS
To provide data regarding patients overrall condition. It reveals how certain systems are functioning.Its a base line against which changes can be measured.
If a patient is in pain what can it affect?
Pulse, Respirations, BloodPressure
Its a warning sign that tissues are injured or about to be injured
When should you asses Vital signs ?
According to facility policy
according to provider orders
admission
when a patient is complain of feeling unusual
when their is a change in condition
Whats the significance of vital signs
It monitors physiological condition
identify new problems
determine if an intervention needs to be performed
determine if intervention was effective
When should you asses vital signs
before, during and after administering certain medications , before during or after blood transfusion before during or after invasive surgery
at least every four hours or more when the vital signs are abmormal
When should you asses vital signs
A recheck when a vital sign is significantly different from the last assessment
every 5 to 15 minutes if the patient is unstable
Body Temp
Difference between the amount of heat the body produces and the amount of heat that is gained or lost to the external environment
Systemic Approach to vitals signs
Temp, pules, Respirations, Bp,Obtain pulse oximeter reading ( oxygen Saturation o2 sat) dont forget to ask about pain
Core Temp
Temp of the deeper structures and tissues
NOrmally slightly warmer then superficial body tissue
how do you asses the body surface or skin temp?
You have to place your hand on patients skin the dorsal part of hand
determine if skin is warm ,hot , cool or cold
What does the core temp do
Most important to maintain
determines the temp of the brain, heart, and internal organs
sterile thermometer probe inserted into the pulmonary artery, heart or urinary bladder
What is thermogenesis
production of heat
HOw is heat produced
digestion, absorption, breakdown synthesis of proteins
intake in food will metabolism which then heat production in the body
Any physical activity that increases metabolism will increase heat production
Muscle Contraction normally produce 25% of body heat in resting state, Shivering-involuntary skeletal muscle response increase heat production exercise can increase heat production
What does the liver do with heat
Produces 15 to 20% of body heat in the resting state, As well as the secretion of hormones
When you have elevated temp how does the body respond?
Blood vessels dilate-blood brought to skin surface-radiation
ortho static usual in older adults
you must perform bp
in supine position lying on back
sitting
standin
The greater the cardiac output
The higher the blood pressure
A pulse pressure less than 30 or greater then 50
is consider abnormal
Hypoxemia
decreased oxygen level in the blood
hypoxia
decreased delivery of oxygen to the tissues and cells
When do you see Cheyne stoke respirations
coma
heart failure
head injury
drug overdose
impending death
characteristics to asses for respiration
rate per. min
depth
rhythm
pattern
respiratory effort
When you are sleep what does the parasympathetic system do ?
Lowers the bloood pressure.
When you are below normal temp how does the body respond?
Constrict blood vessels-redirect blood flow to vital organs
femoral pulse site determines what
leg circulation
you use the carotid pulse site during what
When person is in cardiac arrrest
intracranial pressure
typically lowers the pulse rate any cause irregularity
Cardiovascular disease can do what to pulse rate
it varies on disorder or disease it can increase or decrease and cause irregularity
factor that can effect pulse rate
Increased fluid -fluid overload pulses full and bounding sometimes faster
hypoxia pulse rate
what are factors that decrease pulse rate
Decreased blood volume
Hemorrhage or dehydration
pulse rate increase
Attempt to transport oxygen to tissues faster
cafeine and nicotine does what ?
speed up the pulse rate
adult pulserate
60 to 100 bpm
What happens to older adults regarding body temperature
They have a difficult time maintaining normal body temp due to limited amount of fat that insulate the organs
Any circulatory impairment will inhibit the vas-constriction and vasodilation aspect of controlling blood pressure
What are factors that can affect body temp
Environment, Time of day , gender, physical activity and exercise ,medications, STRESS, food or drink and illness
What happens if the environment is hot
The body temperature will tend to be higher.
What happens when the environmental temp is cold what does it do to the body ?
Body temperature will tend to be lower
Circadian Rythm
Body temp usually drops o.5 to f lower between midnight and dawn and rises 1 to 2 in the late afternoon and evening
Factors affecting body temp
Gender
Women tend to have a slight rise in body temperature during ovulation.
factors affecting body Temp
Exercise raises the body temp
Medications
Stimulants such as ephedrine increase the bodys metabolism -raise temperature
What lowers Temperature Acetaminophen
Lowers elevated Temperature
illness
Various diseases and injuries can directly affect the hypothalamus, resulting in changes i n body temp
Food intake
type of food intake or lack of food intakes can directly affect body
hot and cold fluids can have a mild effect on the oral temperature reading for 15 to 30 minutes after ingestion
what are common conditions affecting body temp
Inflammatory processes, fluid loss, central nervous system tumors, head injuries, and heat stroke
skin temp
Disposable topical stick on clean, dry skin affected by perspiration reflects surface temp
special thermometer with skin probe tape to skin monitor temp read out
When shouldn't you take tympanic Temp
should not have been lying on ear
Tympanic temp how do you take it ?
Must face tympanic membrane
adult pull pinna up and back
in kids you pull down and back
TYMPANIC TEMP
Unaffected by eating , drinking, smoking good for-people who have difficulty breathing
its affected by environmental factors
cannot use with ear infections or after ear surgery
AXILLARY TEMP
IS THE LEAST ACCURATE FORM OF MEASUREMENT TEMP WILL BE 1 DEGREE LESS THEN CORE TEMP
What are the routes for taking body temps
oral , Tympanic, TEMPORAL, RECTAL,AXILLARY, SKIN
ORAL ROUTES CONTRAINDICATIONS
SUICIDAL, SEIZURE DISORDER, INFANT AND YOUNG CHILDREN , ORAL SURGERY OR INJURY TO NOSE AND MOUTH OR RECEIVING OXYGEN
ORAL ROUTE CONTRAINDICATIONS
DO NOT USE IF ATE, DRANK OR SMOKED RECENTLY, WAIT 15 MIN GUM AND CHEWING TOBCCO AS WELL, UNCONSCIOUS PATIENT
CONFUSED OR UNCOOPERATIVE
IF YOU PUT A THERMOMETER THE ORAL ROUTE
LEAVE IN FOR 3 TO 5 MINS
WHAT ARE YOU SUPPOSE TO DO OVER A GLASS THERMOMETER
SHAKE DOWN BEFORE COVERING
APPLY A SHEATH OR PROBE COVER
ORAL
BEST NON INVASIVE ROUTE FOR TEMP MAKE SURE TO CHECK IF PATIENT HAD ANYTHING TO EAT OR DRINK WITHIN THE LAST 15 TO 30 MINUTES WILL AFFECT TEMP READING
what do you need for rectal route
thermometer
probe cover
lubricant
tissue
glove
rectal route
Most accurate route -provides core temp
Reflects temperature changes quickly
Not a route of choice because of risk of intestinal perforation
when shouldnt you use a rectal thermometer
Cannot be used for patients with diarrhea, severe hemorrhoids, rectal surgery
Caution -immunocompromised high risk for bleeding
whats the proper positioning of rectal route
left lateral ( on left side) it decreases risk of intestinal perforation
Cicaddian Rythm
pulse rates are lower slowest from predawn hours to dawn and faster as the day progress towards the evening
pulse deficit
Radial pulse is slower then the apical pulse rate
ex88 apical
radial 82
pulse deficit is 6
88-82 gives pulse defecit
when should you take an apical heart rate ?
children less then 3 years old
when radial pulse is weak
prior to administering heart rate altering medication
how should you asses apical pulse
if in bed elevated head 60 to 90 degree
if out of bed sit up right in chair
pmi point of maximum impulse
where the heart contraction is the strongest the apex of the heart
what gives us a pulse
The pumping action of the heart produces a wave of blood that travels through the arteries as they expand and contract
left atrium and left ventricles
oxygenated blood
right atrium and right ventricle
deoxygenated blood
Hypothermia
core temp below 95f (35C)
slows body metabolism
If hypothermia is prolonged or severe periods of hypothermia can result in death
What is diaphoretic
Sweating alot
Some patients find it difficult to breathe unless sitting up right position such as sitting or standing
orthopena
dyspnea
A person who is having labored or difficulty breathing
apnea
when respiration cease or are absent
you only hav a brief window to restore respirations before brain damage and death occur
tachypenea
respirations are above 20
Bradypena
your respirations are below 12
how do you get someone respirations
While pressing two fingers against radial pulse site, count the respiratory rate for 30 seconds then multiply it by2 for 30 seconds
pules rate
3 + or bounding
is good
hypoxia
increases the pulse rate
Blood volume decreased as in hemorrhage and dehydration
hemorrhage and dehydration will increase the pulse rate in an effort to more quickly transport the oxygen carried by red blood cells to the body tissues
If your pulse rate is higher then 100 what is that called
tachycardia
If your pulse is less then 60 what is it considerd
bradycardia
what is a normal range for an adult pulse
60 to 100 bpm
what are three Characteristics of the pulse
rate, Rhythm,and volume
where are the peripheral pulse sites
temporal, carotid artery, brachial, femoral, ulnar and radial, posterior and tibal, dorsalis, pedis
what regulates the heart beat
medulla oblongata
whats an example of pulse defecit?
83bpm. 83-77=6
the radial pulse is 77bpm
their is a pulse defcit of 6
which should be reported
Where is the apex of the heart located? which is the primary site where the contraction is the strongest.
It located on the 5th intercostal space on the anterior wall. It is the central PRIMARY pulse site.
when the radial pulse is slower then the apical pulse is known as what?
pulse defecit
when heart sounds are normal what do you hear?
lub dub
The amount of blood pumped from the heart in one minute is called ?
Cardiac output
what kind of temp would you see if someone has hypothermia
elevations above 105 in temp
WHAT ARE SIGN AND SYMPTOMS OF DEHYDRATION
DRY MUOUS MEMBRANES
DECREASED SKIN TUGOR
CHANGE IN COLOR URINE
DECREASED AMOUNT OF URINARY OUTPUT
NURSING CARE FOR PATIENTS WITH FEVER
ASSES VITALS EVERY TWO HOURS
PROVIDE ALLOWED FLUIDS FREQUENT TO PREVENT DEHYDRATION MONITOR THE I AND O
WHAT IS PHOTOPHOBIA
EYES HAVE INCREASED SENSITIVITY TO LIGHT
SIGNS AND SYMPTOMS OF FEVER
HEADACHE,MYALGIA, LETHARGY OR DROWSINESS, DIAPHORIESIS, ANOREXIA,NAUSEA,CONFUSION
SEIZURES IN KIDS AND INFANTS
HOW MIGHT PATIENT FEEL WHEN THEY HAVE AN ELEVATED TEMP
FLUSHED, DRY,HOT SKIN THIRST
DRY MUCOUS MEMBRANES , GLASSY OR DROOPY EYES, RESTLESSNESS PHOTOFOBIA
ELEVATED TEMP
MOST PROVIDERS WILL NOT ATTEMPT TO REDUCE FEVER UNTILL IT ELEVATES ABOVE 102
ELEVATIONS ABOVE 105CAN RESULT TO DAMAGE OF BODY CELLS
ELEVATED TEMP TERMINOLOGY
FEVER,PYREXIA, HYPERTHERMIA, FEBRILE
WHAT ARE NORMAL RANGES FOR TEMP
97F TO 99.6 (36.1 C TO 37.5)
THE AVERAGE 98.6
NCIT
NONCONTACT INFRARED THERMOMETER
HOLD THERMOMETER 1 INCH AWAY FROM PATIENTS FOREHEAD
temporal temp
its quick comfortable for patient not affected by food AND DRINNK
PERSPIRATIION AFFECT IT
IF HAIR IS TO THICK IT IS NOT ACCURATE