Chapter 32 Vital Signs - MCCC

Chapter 32 Vital Signs - MCCC

Chapter 32 Vital Signs NRS 102 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. General Survey Physical appearance Age

Sex Level of consciousness Skin color Facial features Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 2 General Survey Body structure

Stature Nutrition Symmetry Posture Position Body build, contour Mobility Gait

Range of motion Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 3 General Survey Behavior Facial expression Mood and affect

Speech Dress Personal hygiene Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Guidelines for Measuring Vital Signs

Establish a baseline for future assessments. Be able to understand and interpret values. Appropriately delegate measurement. Communicate findings. Ensure equipment is in working order. Accurately document findings. Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Body Temperature Physiology

Body temperature: Temperature range: Heat produced Heat lost 98.6 F to 100.4 F or 36 C to 38 C

Temperature sites: Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Body Temperature Regulation Neural and vascular control Heat production Heat loss

Skin temperature regulation Behavioral control Thermoregulation Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Factors Affecting Body Temperature Age Exercise

Hormonal level Circadian rhythm Environment Temperature alterations Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Abnormal Body Temp Hypothermia

Heat loss during prolonged exposure to cold Classified by core temp (mild-severe) May be intentional (surgery) Early signs- uncontrolled shivering, loss of memory, poor judgment Later signs- Cyanosis, decreased VS, cardiac dysrhythmias, loss of consciousness Frostbite- body exposure to subnormal temps Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

9 Abnormal Body Temp Hyperthermia Elevated body temp related to bodys inability to promote heat loss or reduce heat production Heatstroke- prolonged exposure to sun or high environmental temp. Heat depresses hypothalamus function

Heat Exhaustion- profuse diaphoresis result in fluid & electrolyte loss Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Nursing Process and Temperature

Assessment Diagnosis Planning Implementation Evaluation Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Pulse, Physiology, and Regulation

The indicator of circulatory status Electrical impulses originate from the sinoatrial (SA) node. Cardiac output, heart rate, stroke volume Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume. Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Assessment of Pulse Sites Use of stethoscope Character of pulse Nursing process and pulse determination Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

16 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 17 Knowledge check! Which patient would be most likely to present with a pulse rate that is lower than normal? A. A 70-year-old telephone salesman presenting with dehydration. B. A 20-year-old runner who had surgery 4 days ago for a fractured leg. C. A 67-year-old who presented with an exacerbation of his COPD

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 18 Respiration Ventilation Diffusion Perfusion Physiological control Mechanics of breathing

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 19 Assessment of Ventilation Easy to assess Respiratory rate Ventilatory depth Ventilatory rhythm Diffusion and perfusion

Arterial oxygen saturation Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 20 Assessing Respirations Assessing rate- observe full inspiration & expiration Assess for full minute

Normal adult 12 20 breaths/minute Varies with age, rate declines throughout life Apnea Monitor Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 21 Normal & Abnormal Respirations Eupnea- normal respirations

Bradypnea- abnormally slow < 12 Tachypnea- abnormally fast >20 Hyperpnea- labored, after exercise Hyperventilation/Hypoventilation Cheyne-Stokes Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 22 Nursing Process and Respiratory Vital Signs Measurements include:

Respiratory rate, pattern, depth, SpO2, ventilation, diffusion, perfusion Nursing diagnosis Interventions Planning Evaluation Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 23

Arterial Blood Pressure and Physiology Force exerted on walls of an artery Systolic and diastolic Cardiac output Peripheral resistance Blood volume Viscosity Elasticity

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 24 Factors Influencing Blood Pressure Age Stress

Ethnicity Gender Daily Variation Medications Activity, weight Smoking Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 25 Hypertension and Hypotension Hypertension More common than hypotension Thickening of walls

Loss of elasticity Family history Risk factors Hypotension 90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs Orthostatic/postural Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

26 Factors controlling Blood Pressure Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 27 Measurement of Blood Pressure Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Vital Signs

Blood pressure Systolic pressure Diastolic pressure Pulse pressure Mean arterial pressure Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Slide 9-29 Measurement of Blood Pressure Equipment Auscultation Children Ultrasonic stethoscope Palpation Lower extremity

Electronic blood pressure Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 30 Nursing Process and Blood Pressure Determination Assessment of blood pressure and pulse evaluates the general state of cardiovascular health. Hypertension, hypotension, orthostatic hypotension, or narrow/wide pulse

pressures define nursing diagnoses. Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Knowledge check! Significant elevation in blood pressure measurements from one day to the next could be attributed to: A. A decrease in cuff size B. An increase in cuff size C. New onset of pain or anxiety D. A and C Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

32 Measurement of Arterial Oxygen Saturation Pulse oximeter Allows indirect measurement of oxygen saturation SpO2 is a reliable estimate of SaO2 Measurement is affected if extremity is cold, edematous or if nail polish is present (interference with light transmission)

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 33 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 35 Slide 9-35 Health Promotion and Vital Signs

Monitor vital signs. Include age-related factors. Include environmental and activity factors. Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. 36

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