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Vital Signs
- ·Temperature
- ·Pulse
- ·Respirations
- ·Blood Pressure
- ·Pulse Oximetry Pain Assessment
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Health status
is reflected by indicators of bodily function
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Change in VS may indicate
a change in health status
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Who is ultimately responsible for accuracy of data and assessment/reporting abnormal values appropriately?
Nurse
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Vital Signs
- Provide a baseline
- Must know accepted normal values
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Temperature
- Difference in heat produced and heat lost
- Measured in degrees
- Varies due to many factors
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Temperture varies due to many factors
- Location taken (core vs surface)
- Circadian rhythms
- Age/gender
- Stress
- Environmental temperature
- Exercise
- Food/smoking
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Normal temperature range
36.0C (97F) – 37.5C (99.5F)
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Elevated temperature
37.0C (98.6F)
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Decreased temperature
Decreased- < 36.0C (97F)
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Temperature Assessment Equipment
- Digital
- TM
- Glass
- TA
- Disposable
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Temperature Assessment Site
- Affected by:
- Age
- LOC, pain
- Treatment in progress
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Temperature Assessment
Core vs Body Surface
- Rectal--CORE
- Tympanic--CORE
- Sublingual--SURFACE
- Axillary--SURFACE
- Temporal--SURFACE
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Pulse
Throbbing sensation palpated or auscultated as a result of left ventricular contraction
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Pulse regulated by...
the ANS via the SA node
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Pulse Characteristics
- Rate
- Rhythm
- Quality/amplitude
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Pulse measured in?
beats per minute(bpm)
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Factors affecting pulse
- Age/gender
- Exercise/conditioning
- Stress
- Fever
- Medications
- Volume status
- Pain
- Position changes
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Pulse Measurements:
-Normal
-Elevated
-Decreased
- Normal- 60-100 bpm
- Elevated- 100-180bpm
- Decreased- 60bpm
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Examples of Elevated pulse- >100-180bpm
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Examples of Decreased pulse < 60bpm
- Bradycardia
- Potential Causes:
- Vagal stimulation
- Meds
- Hypothermia
- MI or increased ICP
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Pulse Assessment
Palpation peripheral arteries or auscultating apical pulse
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Peripheral pulse sites
Radial, brachial, temporal, popliteal, posterior tibial, dorsalis pedis
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Central pulse sites
Carotid, Femoral, Apical
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Pulse Assessment (4)
- Rate
- Rhythm
- Quality/amplitude
- Pulse deficit
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Respirations include several physiologic events (3)
- Pulmonary Ventilation
- Inspiration
- Expiration
- --External expiration
- --Internal respiration
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What is the portion measured as a vital sign?
Pulmonary Ventilation
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Respirations Regulated by?
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Repiration rate and depth change in response to body’s demands
- Inhibition/stimulation of respiratory centers in medulla and pons
- Chemoreceptors in aortic arch and carotids, stretch/irritant receptors in lungs
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Respirations measured in breaths/min, what is the normal range?
Normal range: 12-20 breaths/min
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Respirations varies due to many factors:
- Age
- Exercise
- Disease process
- Acid-base imbalancesMedications
- Trauma/pain
- Infection
- Emotions
- Altitude
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Elevated respirations?
Decreased respiration?
elevated= >20 breaths/min
decreased= <12 breaths/min
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orthopnea
sitting upright to ease breathing
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Respiration rate increases how many breaths/min of every 1 degree F over normal temp?
4 breaths/min for every 1 degree F over normal temp
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Respiratory Assessment (3)
Rate
Rhythm
Depth
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Respiratory rate assessment
- Eupnea
- Tachypnea, hyperventilation
- Bradypnea, hypovenitlation
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Rhythm
- Regular
- Irregular
- Patterned
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Cheyne stokes breathing
- near death breathing pattern
- breath...stop....breath....stop
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Biots breathing
- Irregular
- seen in patients with miningitis and severe brain damage
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Kussmaul breathing
rapid shallow, rapid deep
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Respirations Diagnosis
- Ineffective Breathing Pattern
- Impaired Gas Exchange
- Risk for Activity Intolerance
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Blood Pressure
Force of blood against arterial walls
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3 types of (blood) pressures
- Systolic pressure
- Diastolic pressure
- Pulse pressure
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How is Blood Pressure measured?
Measured in millimeters of mercury (mmHg)
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BP controlled/maintained via
- Peripheral vascular resistance (PVR)
- Neural mechanisms
- SNS, PNS, Baroreceptors
- Humoral mechanisms
- Epinephrine, Renin-Angiotensin-Aldosterone system
- Cardiac output
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Blood pressure =
cardiac output X systemic vascular resistance
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cardiac output
the amount of blood pumped from heart each minute
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peripheral vascular resistance
PVR
- Arterioles in a state of partial contraction, resulting in relatively constant level of resistance
- One of the main factors affecting BP
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ANS control mechanisms for short term BP control
- Within circulatory system: Chemo and baro receptors
- Outside circulatory system: Pain, cold, ischemia, mood or emotion
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Hormones/Humoral responses
- Kidneys: Renin-andiotensin-aldosterone
- Posterior Pituitary: ADH, vasopressin
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Average CO=
3.5-8.0 L/min
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What would be the CO for an adult with a SV of 70ml and a HR of 90?
6.3 L/min
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Increased CO=
Increased Blood Pressure
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Decreased CO=
Decreased Blood Pressure
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Cardiac Output=
Heart Rate X Stroke Volume
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Factors affecting BP
- Age/gender
- Race
- Circadian rhythm
- Eating
- Exercise and weight
- Body position
- Emotions/mood
- Medications
- Blood volume
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Blood Pressure Measurement
normal
- Normal: SBP<120 & DBP <80
- Normotensive
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Blood Pressure Measurement
elevated
> normal for sustained period
- Primary hypertension
- No known cause
- Secondary hypertension
- Identifiable cause
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Blood Pressure Measurement
decreased
< normal for sustained period
HypotensionOrthostatic hypotension
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Hypertension (the silent killer)
- Major risk factor for heart disease
- Most important risk factor for stroke
- Sustained HTN results in permanent thickening and remodeling of vessels
- Increased PVR
- Back-up pressure to organs
- MI, CHF, CVA, Myopathy, Kidney damage
- Risk Factors
- Treatment
- Meds and lifestyle modification
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Hypotension
Results from vasodilation, pump failure or volume loss
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BP Signs/Symptoms that should be identified and reported
- Hypotension
- Pallor
- Tachycardia
- ALOCDiaphoresis
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Orthostatic Hypotension
- Low BP associated with weakness, dizziness or fainting when moving to erect position
- Vasodilation without rise in CO
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At risk population with Orthostatic Hypotension
- Elderly
- Dehydrated
- Blood loss
- Prolonged bed rest
- Medications
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How can we prevent orthostatic hypotension from happening?
- -if moving patient from bed (laying down) to chair or bathroom, lift up bed, sit them up, let feet dangle, stand up, walk.
- -take time and ask how they are feeling along the process
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Blood Pressure Assessment Equipment
- Stethoscope
- Sphygmomanometer
- Doppler
- NIBP or Invasive BP monitor
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Blood Pressure Assessment Site
Brachial artery (most common)
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Blood Pressure Assessment
Site Contraindications
- IV or PICC line arm
- AV fistula or shunt
- Avoid arm with axillary node dissection or mastectomy
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Korotkoff Sounds
5 phases
- Phase 1: first sound you hear is SBP
- Phase 2: muffled or swishing sound
- Phase 3: loud distinct sound
- Phase 4: abrupt muffling
- Phase 5: last sound you hear is DBP
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Error: Fasle Low
Potential Cause:?
- Hearing deficit
- Noise
- Too large cuff
- Stethoscope earpieces inserted incorrectly
- Release valve to fast
- Not placing diaphragm over artery
- Not pumping 20-30mmHG over baseline
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Error: False High
Potential Cause:?
- Uncalibrated cuff
- Taking BP immdiately after exercise
- Too small cuff
- Release valve too slowly
- Reinflating bladder during auscultation
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Blood Pressure-Nursing Process Diagnosis
- Decreased CO
- Ineffective health maintenance
- Effective therapeutic regimen management
- Risk for falls
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Pulse Oximetry
- Non-invasive technique to measure arterial oxyhemoglobin saturation
- Measures % of O2 carried by available hemoglobin
- Measured in %
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Pulse Oximetry used for monitoring patients:
- Receiving O2 therapy
- Titrating O2 therapy
- Post-op
- Sedation
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Normal Pulse Oximetry
Normal range: 95%-100%
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Pulse Oximetry Assessment Equipment
- Pulse oximeter with appropriate probe
- Nail polish remover prn
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Pulse Oximetry Assessment Site
- Finger (most common)
- If nail polish/fake nails, cold hands, poor perfusion, hypotension may give false reading
- Bright light can affect sensor and alter rea
Toe, forehead, bridge of nose, earlobe are alternate sites (depending on type of probe available)ding
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Pain
- One of the body’s defense mechanisms that lets them know there is a problem
- Is whatever the person says it is when they say it is
- Considered the 5th vital sign
- Subjective assessment
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Pain Duration
- Acute
- Chronic
- Remission
- Exacerbation-reaccurance
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Pain Source
- Superficial
- Somatic-exterior wall
- Visceral-organ
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Pain Etiology
- Neuropathic-nerve
- Intractable-can't do anything to get rid of it
- Phantom-amputationand still feel what was removed
- Psychogenic
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The Pain Process
- Transduction
- Transmission
- PerceptionModulation
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The Pain Process-Transduction
Activation of the pain receptors; converts painful stimuli into electrical impulses that travel to the spinal cord
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Nociceptors
peripheral nerve fibers that transmit pain
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Substances that can stimulate nociceptors
- Bradykinin
- Neurotransmitters (excite or inhibit target nerve cells)
- Prostaglandins, Serotonin, substance P
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The Pain Process-Transmission
- A-delta-fibers (acute well-localized pain)
- C-delta-fibers (diffuse, visceral pain; burning aching)
- Protective pain reflex
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The Pain Process-Perception
- Pain threshold
- Lowest intensity that causes recognition of pain
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The Pain Process-Modulation
- Process by which pain is inhibited or modified
- Regulated by neuromodulators
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Naturally occurring morphine–like chemical regulators in brain and spinal cord
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Factors affecting Pain Experience
- Culture
- --Ethnocultural groups
- --Family, age, gender
- --Religious beliefs
- Environment/Support Systems
- Anxiety and other stressors
- Past Experiences
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Pain Assessment Misconceptions
- Fear of addiction to narcotics
- Healthcare personnel assumptions/biases
- To deal with pain is better than side effects of meds
- Wait until gets bad before asking for meds
- It’s natural to have pain, it will get better soon
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Pain assessment (many)
- Pt description of pain
- Duration
- Location
- Intensity
- Quality
- Time started
- OPQRST
- Aggravating factors
- Alleviating factors
- Physiologic indicators
- Behavioral responses
- Effect on ADL’s
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Pain Assessment Variations
- Cognitively Impaired-cant communicate well; use # or pic scales
- Children-picture scale
- Elderly
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Pain- Nursing Process Assessment
Use open ended questions
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Pain- Nursing Process Diagnosis
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Pain- Nursing Process Plan
Set realistic goals with patient
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Pain- Nursing Process Implementation
- Trusting relationship with caregiver
- Manipulate factors affecting pain
- Non-pharmacologic therapy
- Pharmacologic intervention
- Pt teaching
- Legal/Ethical Responsibilities
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Non-pharmacologic therapy
Distraction, humor, imagery, relaxation, cutaneous stimulation, accupuncture, etc
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Pain-Pharmacologic intervention
- Analgesics
- Opioid Analgesics
- Adjuvant
- PCA
- MOD or On-QC-bloc
- Epidural
- Local
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Analgesics--Non-opioid
- Acetaminophen, NSAIDS, COX-2 inhibitors
- Side effects
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Opioid Analgesics
- Attach to opioid receptors
- Morphine, Fentanyl, Dilaudid
- Side effects
- Physical Dependence
- Tolerance
- Addiction
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Patient controlled analgesia
- Loading dose: given initially to raise blood levels to therapeutic level and control pain
- Bolus dose: pt pushes button for small preset (prescribed dose)
- Dose interval
- Lock-out interval
- Basal rate: continuous infusion of low dose to maintain a level of analgesia in blood
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Pain-Nursing Process-Evaluation
- Pain experience
- Management regimens
- Patient and family response
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