1. Metro Community College Nursing Program Nancy Pares, RN, MSN

2.  Objective data that contributes to all other nursing and medical information  Baseline values establish the norm against which subsequent measures are compared  Accurate information is essential  Information must be obtained and recorded accurately.

3.  One of the most frequent assessments made as a nurse  Nurse is ◦ Responsible for measuring, interpreting significance and making decisions about care ◦ Knowing normal ranges ◦ Knowing history and other therapies that may affect VS

4.  Nurse must ◦ Know environmental factors that affect vital signs  Exercise, stress, etc. ◦ Use a systematic, organized approach ◦ Verify and communicate changes in vital signs ◦ Monitor VS regularly ◦ Frequency determined by  MD order; nursing judgement, client condition and facility standards

5.  Hospital: ◦ Every 4-8 hours  Home health: ◦ each visit  Clinic: ◦ Each visit  Skilled facility ◦ Daily and as needed

6.  Degree of heat maintained by the body  Heat produced minus heat lost equals body temperature  Organs have receptors that monitor core body temperature

7.  Core temperature ◦ Normal  96.2 degrees F to 100.4 degrees F  36.2 degrees C to 38 degrees C  Surface temperature ◦ Lower than core temperature ◦ Use oral and axillary method

8.  Neural control ◦ Hypothalmus acts as thermostat  Vascular control ◦ Vasoconstriction ---hypothalmus directs the body to decrease heat loss and increase heat production ◦ If cold, vasoconstriction will conserve heat— shivering will occur

9. Vasodilation – If body temp is above normal, the hypothalmus will direct the body to decrease heat production; – Perspiration and increased respiratory rate Body heat production – Body’s cells produce heat from food—releasing energy. – Kilocalorie= energy value; – BMR= rate of energy used in the body to maintain essential activities

10.  If metabolism increases, more heat is produced  More muscle= greater metabolism  Shivering is an early response for thermoregulation that increases heat production.

11.  Conduction ◦ Transfer of heat from a warm to cool surface by direct contact  Convection ◦ Transfer of heat through currents of air or water  Radiation ◦ Loss of heat through electromagnetic waves from surfaces that are warmer than the surrounding air  Evaporation ◦ Water to vapor lost from skin or breathing

12.  Age  Exercise  Hormones  Circadian cycle  Stress  Ingestion of food  smoking

13.  Fever (pyrexia) ◦ Abnormally high body temperature (>100.4 F) ◦ Occurs in response to pyrogens (bacteria) ◦ Pyrogens induce secretion of prostoglandins that reset the hypothalmic thermostat to a higher temperature  Hyperpyrexia ◦ Fever > 105.8

14.  Temp increases: ◦ Immune system stimulates hypothalmus to new set point ◦ Chills, shivers  Feels cold even though temp increasing  When body temp is reset, chills subside

15.  Metabolism increases  O2 consumption increases  HR and RR increase  Energy stores are used  Dehydration and confusion  When cause is removed, set point drops

16.  Vasodilation ◦ Warm flushed skin and diaphoresis  Benefits ◦ Activates the immune system ◦ Interleukin 1 stimulates antibody production ◦ Fights viruses by stimulating interleukin ◦ Serves as a diagnostic tool

17.  Chill stage: ◦ Temp every 1-4 hours ◦ Reduce activity ◦ Warm blankets  Throughout course ◦ Fluids, tepid baths, limit activity, keep dry ◦ Provide oral hygiene ◦ Provide air circulation

18.  Heat stroke ◦ Prolonged exposure to heat ◦ Depression of hypothalmus ◦ Emergency ◦ S/S: hot, dry skin, confusion, delirium  Hypothermia ◦ Below 95 degrees ◦ Uncontrolled shivering, loss of memory,LOC decreases  Limits: 77-109 degrees F

19.  Oral ◦ Most accessible and accurate ◦ Do not use if unconscious, confused recent oral or facial OR  Rectal ◦ 99 F ◦ Avoid with MI and after lower GI  Axillary ◦ 97 F—least accurate, most safe  Tympanic ◦ 98 F—avoid with infection, after exercise, w hearing aid

20.  The wave begins when the left ventricle contracts and ends when the ventricle relaxes  Indirect measure of cardiac output

21.  Each contraction forces blood into the already filled aorta, causing increased pressure within the arterial system  Systole: ◦ Peak of the wave; contraction of the heart  Diastole ◦ Resting phase of the heart

22.  Rate ◦ Measured in beats per minute (bpm) ◦ Normal  60-100 bpm  Females slightly higher ◦ Average  70-80 bpm

23.  Apical is most accurate  Use a standard stethescope to auscultate the number of heartbeats at the apex of the heart  A heartbeat is one series of the LUB and DUB sounds

24.  Apical: at the apex of the heart  Carotid: between midline and side of neck  Brachial: medially in the antecubital space  Radial: laterally on the anterior wrist  Femoral: in the groin fold  Popliteal: behind the knee  Post tibial  Dorsalis pedis  ulnar

25.  Bradycardia: rate < 60 bpm  Tachycardia: rate> 100 bpm  Is the rate regular?  What is the quality? ◦ Bounding? ◦ Thready?  Dysrhythmia (arrhythmia)  Pulse deficit ◦ Difference between radial and apical

26.  Exercise  Body temperature  Anxiety  position  Emotions  Medications  Hemorrhage  Pulmonary condition

27.  Stroke volume ◦ The quantity of blood pumped out by each contraction of the left ventricle  Cardiac output ◦ Stroke volume x pulse (heart) rate

28.  Pallor ◦ Paleness of skin when compared with another part of the body  Cyanosis ◦ Bluish-grayish discoloration of the skin due to excessive carbon dioxide and deficient oxygen in the blood

29.  The exchange of oxygen and carbon dioxide in the body  Two separate process ◦ Mechanical ◦ chemical

30.  Mechanical ◦ Pulmonary ventilation; breathing ◦ Ventilation:  Active movement of air in and out of the respiratory system ◦ Conduction  Movement through the airways of the lung

31.  Chemical ◦ Exchange of oxygen and carbon dioxide ◦ Diffusion  Movement of oxygen and CO2 between alveoli and RBC ◦ Perfusion  Distribution of blood through the pulmonary capillaries

32.  Inspiration ◦ Drawing air into the lung ◦ Involves the ribs, diaphragm ◦ Creates negative pressure-allows air into lung  Expiration ◦ Relaxation of the thoracic muscles and diaphragm causing air to be expelled

33.  Rate: regulated by blood levels of O2, CO2 and ph  Chemial receptors detect changes and signal CNS (medulla) ◦ Normal: 12-20 breaths per minute ◦ Apnea: no breathing ◦ Bradypnea: abnormally slow ◦ Tachypnea: abnormally fast ◦ Observe for one full minute

34.  Depth ◦ Normal: diaphragm moves ½ inch ◦ Deep ◦ Shallow  Rhythm ◦ Assessment of the pattern ◦ Abnormal  Cheyne stokes, Kusmaul,

35.  Effort ◦ Work of breathing ◦ Dypsnea: labored breathing ◦ Orthopnea: inability to breath when horizontal ◦ Observe for retractions, nasal flaring and restlessness

36.  Wheeze ◦ High pitched continuous musical sound; heard on expiration  Rhonchi ◦ Low pitched continuous sounds caused by secretions in large airways  Crackles ◦ Discontinuous sounds heard on inspiration; high pitched popping or low pitched bubbling

37.  Stridor ◦ Piercing, high pitched sound heard during inspiration  Stertor ◦ Labored breathing that produces a snoring sound

38.  Hyperventilation ◦ Rapid and deep breathing resulting in loss of CO2 (hypocapnea); light headed and tingly  Hypoventilation ◦ Rate and depth decreased; CO2 is retained  Cheyne Stokes ◦ Irregular, alternating periods of apnea and hyperventilation

39. ABG directly measures the partial pressures of oxygen, carbon dioxide and blood ph normal= paCO2 80-100) Pulse oximetry non invasive method for monitoring respiratory status; measures O2 saturation normal= >95%

40.  Force exerted by blood against arterial walls  Work of the heart reflected in periphery via BP  Systolic ◦ Peak pressure exerted against arterial walls as the ventricles contract and eject blood  Diastolic ◦ Minimum pressure exerted against arterial walls between contraction when the heart is at rest

41.  Measured in millimeters of mercury (mm Hg)  Recorded as systolic over diastolic  Pulse pressure ◦ Difference between systolic and diastolic

42.  The body constantly adjusts arterial pressure to supply blood to body tissues  Influenced by three factors ◦ Cardiac function ◦ Peripheral vascular resistance ◦ Blood volume  Normal = 5000 ml  Volume increases=BP increases  Volume decreases= BP decreases  Viscosity= reaction same as volume

43.  Elasticity ◦ Less elasticity creates greater resistance to blood flow= > systolic BP ◦ Decreased in smokers and increased cholesterol

44.  Palpation ◦ Used when BP is too weak to hear  Errors ◦ Wrong size cuff, deflating too rapidly, incorrect placement  Thigh ◦ Measures 30-40 mm HG less than normal

45.  Age  Stress  Gender  race  Circadian  Medications  nutrition

46.  Values ◦ Normal: < 120/80 mm Hg ◦ Hypotension: < 100mm HG ◦ Pre hypertension: > 120/80 mm Hg ◦ Hypertension: 140/90= Stage 1; 160/100= Stage 2  Persistant increase in BP ◦ Damage to vessels; loss of elasticity; decrease in blood flow to vital organs

47.  Indirect ◦ Most common, accurate estimate  Direct ◦ In patient setting only ◦ Catheter is threaded into an artery under sterile conditions ◦ Attached to tubing that is connected to monitoring system ◦ Displayed as waveform on monitoring screen

48.  Indirect ◦ Equipment  Sphygomanometer and stethescope ◦ Korotkoff’s sounds  1 st  2 nd  3 rd  4 th  5th

49.  1 st ◦ As you deflate the cuff; occurs during systole  2 nd ◦ Further deflation of the cuff; soft swishing sound  3 rd ◦ Begins midway through; sharp tapping sound  4 th ◦ Similar to 3 rd sound but fading  5 th ◦ Silence, corresponding with diastole

50.  Orthostatic or postural hypotension ◦ Sudden drop in BP on moving from lying to sitting or standing position  Primary or essential hypertension ◦ Diagnosed when no known cause for increase ◦ Accounts for at least 90% of all cases of hypertension

51.  Combination of skills which provide an indication of state of health and body functionality  Nurses can delegate the activity of VS, but are responsible for interpretation, trending and decisions based on the findings

52.  5 th vital sign  It is what the client says it is  Nurse must know ◦ how to assess for it ◦ Establish acceptable comfort levels ◦ Follow up within appropriate time frame after intervention

53.  Data collection ◦ Location (place and position) ◦ Intensity  1-10  Strength and severity  What is your pain at present? What makes it worse? What is the best that it gets?

54.  Describe ◦ Aching, stabbing, tender, tiring, numb,……..  Duration ◦ When did it start? Is is always there?  Aggrevate/alleviate ◦ What makes it better/worse?

55.  Energy  Appetite  Sleep  Activity  Mood  Relationships  Memory  concentration  Nurse checks for ◦ VS ◦ Knowledge of pain ◦ Med history ◦ Side effects of meds ◦ Use of non pharmacological therapies