Nursing 151- Vital Signs – Flashcards
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Vital signs
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-Temperature, pulse, blood pressure, SpO2, Respiration Rate -indication of general health -only as good as technique and equipment
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When to take vitals
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upon admission before, during, after procedure/surgery before, during, after medication when applicable physical distress condition changes as ordered by doctor per P&P of facility before, after nursing interventions influencing VS before, during, after transfusion/blood products unspecific signs of physical distress
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Delegating Vitals
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Patient should be stable Frequency What is normal When you need to be alerted Nurse is ultimately responsible
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Normal Vital Sign Ranges
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Temperature: 96.8 to 100.4 F Pulse: 60-100 bpm Respirations: 12-20 /min Blood Pressure: >120/80 SpO2: <90%
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Temperature measurement sites
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Oral, Axilla, Rectal, Tympanic, Temporal
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Factors influencing Temperature
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Age (younger: unstable, older: lower) Exercise (up) Hormones (esp. women) Cicadian Rhythm (lowest early AM, highest evening) Stress (up) Environment (warmth/humidity) Food (hot and cold: wait 15 minutes)
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Fever (pyrexia)
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hypothalamic reset of of set point for temp 100.5-102.2 Mild, not harmful sustained, intermittent, remittent, relapsing stimulates WBC and interferons
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Hyperthermia
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abnormally high body temperature due to temperature regulation overload (not change in setpoint like fever) Heat exhuastion Heat stroke (emergency)
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Hypothermia
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Heat loss overwhelms ability to produce heat temp below 96.8 frostbite
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Pulse sites
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temporal carotid (when condition suddenly changes) apical (most common-use stethoscope) brachial radial(most common) ulnar femoral popliteal tibial dorsalis pedis
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Pulse strength
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Strong, Bounding (4+) Strong/Normal (3+) Weak (2+) Thready (1+) Absent (0) -regular vs irregular
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Pulse deficit
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Difference between peripheral pulse and heart rate (apical)caused by inadequate cardiac output and/or failure to transmit pulse wave =Apical-Radial pulse (in 60 sec) should be <2
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Factors influencing pulse
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exercise(up) temperature (fever (up)/hypothermia(down)) emotions (up) drugs hemorrhage (up) postural changes (lying to sitting to standing) pulmonary conditions (COPD) age dehydration (up)
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Ventilation assessment
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color level of consciousness(LOC) use of accessory muscles nasal flaring temperature depth rhythm
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Oxygen saturation
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measures diffusion and perfusion indirectly measured by SpO2 (as long as over 70%) which is amount of oxygen bound to hemoglobin
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Factors affecting SpO2
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bright, outside light carbon monoxide motion jaundice intravascular dyes nail polish/artificial nails dark skin pigment oxygen therapy
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Sites for SpO2
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finger (typical, capillary refill check) bridge of nose ear lobe sole of foot
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Blood pressure
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force exerted on the wall of an artery by pulsating blood ejected from heart =cardiac output x peripheral resistence -indicator of cardiovascular status
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Systolic
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peak of maximum pressure when blood is ejected from heart - ventricles contract (top number)
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Diastolic
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pressure exerted on arteries by blood left over when heart ventricles relax (bottom number)
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pulse pressure
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difference between systole and diastole normal: 30-50
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Factors affecting Blood Pressure
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cardiac output peripheral resistance blood volume (rapid infusion or blood loss/dehydration) viscosity (hematocrit) elasticity of artery walls (increase/decrease resistance) age stress (as much as 30) ethnicity gender diurnal variation (lowest early AM, highest when waking) medication smoking activity and weight crossed legs arm not supported at heart level
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Hypertension
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above 140/90 in at least two separate readings associated with thickening and loss of elasticity in artery walls stages: pre-hypertension: 120-140/80-90 stage 1: 140-160/90-99 stage 2: >160/>100
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Hypotension
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when systolic <90
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Orthostatic Hypotension
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bp falls when rising from sitting to standing position dehydration bed rest anemia blood loss medication
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Sites for blood pressure
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Upper arm thigh (10-40 higher systolic reading only, not diastolic*)
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Sites not to take blood pressure
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forearm/lower leg IV/PICC/Midline extremity mastectomy side site of injury/cast/splint side of shunt/fistula
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when not to use electronic BP
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irregular HR peripheral vascular impairment shivering seizures tremors hypotension inability to cooperate
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pulse
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-the transmission of pulse wave from blood volume pressure against arteries during ventricular contraction -tissue perfusion in extremities
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How long to measure pulse
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30 seconds if regular 60 seconds if irregular or weak
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Normal Respirations
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Adult: 12-20 Newborn: 30-60 Children: 20-30
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Ventilation
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mechanical movement of gases into and out of lungs (airlungs)
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Diffusion
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movement of O2 and CO2 between alveoli and the red blood cells (lungsblood)
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Perfusion
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distribution of red blood cells to and from the pulmonary capillaries (bloodtissue)
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Delegating Respirations
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-is patient breathing stable? -frequency of measurement -usual values for patient -when to report abnormalities
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factors influencing respirations
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-exercise (up - wait 5 to 10 min) -anxiety (up) -pain -smoking (up) -medications -body position (esp. lying flat) -neurological injury (down) -hemoglobin function (altitude, anemia) -age
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Labs-respiration
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-arterial blood gases -CBC -SpO2
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How to assess respirations
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-patients should be sitting or lying 45-60 deg (fowlers) -count when assessing pulse to avoid alterations -regular: count for 30 seconds -irregular: count for 60 seconds
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Size of cuff
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bladder should encircle 80% of the arm
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febrile
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presence of a fever, characterized by a fever
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afebrile
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absence of a fever
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What is Body Temperature
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=heat produced-heat loss -core temp kept within narrow range unlike surface temp -regulated by neural and vascular controls
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heat production
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-metabolism -shivering -excessive muscle activity (exercise)
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Heat loss
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-radiation -conduction -convection -diaphoresis/evaporation (sweating)
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Difference for Rectal Temp
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up .9 deg
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Difference for axillary and tympanic temp
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down .9 deg
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Delegating Temperature
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-frequency -appropriate route and device -normal temp range -when to report abnormalities
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delegating pulse
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-frequency -what is normal for patient -when to report abnormailties -cannot delegate apical pulse
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Pulse vales
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Infant: 120 to 160 Child: 90 to 140 Adolescence to Adult: 60 to 100
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bradycardia
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low pulse rate
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tachycardia
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high pulse rate
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Bradypnea
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slower than normal respiratory rate
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Tachypnea
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faster than normal respiratory rate
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Hyperpnea
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-breathing in labored -faster than normal respiratory rate -increased depth -ex: exercise
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Apnea
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absence of breathing
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Hyperventilation
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increased respiratory rate and depth
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Hypoventilation
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decreased respiratory rate and depth
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Cheyne-Stokes respirations
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ascending depth and rate followed by period of apnea
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Kussmaul's respirations
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respirations that are abnormally deep and fast
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Biot's respiration
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abnormally shallow for 2-3 breaths followed by period of apnea
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Factors affecting pulse oximetry reading
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-bright light -dark nail polish -dark pigment skin -intravascular dyes -jaundice -patient motion -carbon monoxide -peripheral vascular disease -hypothermia -hypotension -low cardiac output -peripheral edema -tight probe
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Factors affecting BP reading
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-loose cuff (up) -deflating too slowly (up) -deflating too rapidly (systolic down/diastolic up) -cuff too wide (down) -arm below heart (up) -arm above heart (down) -arm not supported (up) -stethoscope too firm (low) -inflating too slowly (high) -repeating assessments (high)
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advantage of oral temp
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reflects rapid changes in core temperature
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advantage of tympanic temp
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accurate core temp rapid measurement
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advantage of axilla
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newborns
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advantage of skin
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continuous reading
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advantage of temporal
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rapid measurement used for everyone rapid change in core temp
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Stroke volume
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the amount of blood entering the aorta with each ventricular contraction (60-70 mL)
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Cardiac Output
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the amount of blood pumped each minute by the heart =stroke volume times heart rate
