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