Vital Signs and Pain

• ·Temperature
• ·Pulse
• ·Respirations
• ·Blood Pressure
• ·Pulse Oximetry Pain Assessment

is reflected by indicators of bodily function

a change in health status

Nurse

• Provide a baseline
• Must know accepted normal values

• Difference in heat produced and heat lost
• Measured in degrees
• Varies due to many factors

• Location taken (core vs surface)
• Circadian rhythms
• Age/gender
• Stress
• Environmental temperature
• Exercise
• Food/smoking

36.0C (97F) – 37.5C (99.5F)

37.0C (98.6F)

Decreased- < 36.0C (97F)

• Digital
• TM
• Glass
• TA
• Disposable

• Affected by:
• Age
• LOC, pain
• Treatment in progress

• Rectal--CORE
• Tympanic--CORE
• Sublingual--SURFACE
• Axillary--SURFACE
• Temporal--SURFACE

Throbbing sensation palpated or auscultated as a result of left ventricular contraction

the ANS via the SA node

• Rate
• Rhythm
• Quality/amplitude

beats per minute(bpm)

• Age/gender
• Exercise/conditioning
• Stress
• Fever
• Medications
• Volume status
• Pain
• Position changes

• Normal- 60-100 bpm
• Elevated- 100-180bpm
• Decreased- 60bpm

• Tachycardia
• Dysrhythmias

• Bradycardia
• Potential Causes:
• Vagal stimulation
• Meds
• Hypothermia
• MI or increased ICP

Palpation peripheral arteries or auscultating apical pulse

Radial, brachial, temporal, popliteal, posterior tibial, dorsalis pedis

Carotid, Femoral, Apical

• Rate
• Rhythm
• Quality/amplitude
• Pulse deficit

• Pulmonary Ventilation
• Inspiration
• Expiration
• --External expiration
• --Internal respiration

Pulmonary Ventilation

• ANS
• Voluntary control

• Inhibition/stimulation of respiratory centers in medulla and pons
• Chemoreceptors in aortic arch and carotids, stretch/irritant receptors in lungs

Normal range: 12-20 breaths/min

• Age
• Exercise
• Disease process
• Acid-base imbalancesMedications
• Trauma/pain
• Infection
• Emotions
• Altitude

elevated= >20 breaths/min

decreased= <12 breaths/min

sitting upright to ease breathing

4 breaths/min for every 1 degree F over normal temp

Rate

Rhythm

Depth

• Eupnea
• Tachypnea, hyperventilation
• Bradypnea, hypovenitlation

• Regular
• Irregular
• Patterned

• Deep
• Shallow

• near death breathing pattern
• breath...stop....breath....stop

• Irregular
• seen in patients with miningitis and severe brain damage

rapid shallow, rapid deep

• Ineffective Breathing Pattern
• Impaired Gas Exchange
• Risk for Activity Intolerance

Force of blood against arterial walls

• Systolic pressure
• Diastolic pressure
• Pulse pressure

Measured in millimeters of mercury (mmHg)

• Peripheral vascular resistance (PVR)
• Neural mechanisms
• SNS, PNS, Baroreceptors
• Humoral mechanisms
• Epinephrine, Renin-Angiotensin-Aldosterone system
• Cardiac output

cardiac output X systemic vascular resistance

the amount of blood pumped from heart each minute

• Arterioles in a state of partial contraction, resulting in relatively constant level of resistance
• One of the main factors affecting BP

• Within circulatory system: Chemo and baro receptors
• Outside circulatory system: Pain, cold, ischemia, mood or emotion

• Kidneys: Renin-andiotensin-aldosterone
• Posterior Pituitary: ADH, vasopressin

3.5-8.0 L/min

6.3 L/min

Increased Blood Pressure

Decreased Blood Pressure

Heart Rate X Stroke Volume

• Age/gender
• Race
• Circadian rhythm
• Eating
• Exercise and weight
• Body position
• Emotions/mood
• Medications
• Blood volume

• Normal: SBP<120 & DBP <80
• Normotensive

> normal for sustained period

• Primary hypertension
• No known cause
• Secondary hypertension
• Identifiable cause

< normal for sustained period

HypotensionOrthostatic hypotension

• 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

Results from vasodilation, pump failure or volume loss

• Hypotension
• Pallor
• Tachycardia
• ALOCDiaphoresis

• Low BP associated with weakness, dizziness or fainting when moving to erect position
• Vasodilation without rise in CO

• Elderly
• Dehydrated
• Blood loss
• Prolonged bed rest
• Medications

• -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

• Stethoscope
• Sphygmomanometer
• Doppler
• NIBP or Invasive BP monitor

Brachial artery (most common)

• IV or PICC line arm
• AV fistula or shunt
• Avoid arm with axillary node dissection or mastectomy

• 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

• 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

• Uncalibrated cuff
• Taking BP immdiately after exercise
• Too small cuff
• Release valve too slowly
• Reinflating bladder during auscultation

• Decreased CO
• Ineffective health maintenance
• Effective therapeutic regimen management
• Risk for falls

• Non-invasive technique to measure arterial oxyhemoglobin saturation
• Measures % of O2 carried by available hemoglobin
• Measured in %

• Receiving O2 therapy
• Titrating O2 therapy
• Post-op
• Sedation

Normal range: 95%-100%

• Pulse oximeter with appropriate probe
• Nail polish remover prn

• 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

• 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

• Acute
• Chronic
• Remission
• Exacerbation-reaccurance

• Superficial
• Somatic-exterior wall
• Visceral-organ

• Neuropathic-nerve
• Intractable-can't do anything to get rid of it
• Phantom-amputationand still feel what was removed
• Psychogenic

• Transduction
• Transmission
• PerceptionModulation

Activation of the pain receptors; converts painful stimuli into electrical impulses that travel to the spinal cord

peripheral nerve fibers that transmit pain

• Bradykinin
• Neurotransmitters (excite or inhibit target nerve cells)
• Prostaglandins, Serotonin, substance P

• A-delta-fibers (acute well-localized pain)
• C-delta-fibers (diffuse, visceral pain; burning aching)
• Protective pain reflex

• Pain threshold
• Lowest intensity that causes recognition of pain

• Process by which pain is inhibited or modified
• Regulated by neuromodulators

• Endorphins
• Enkephalins

• Culture
• --Ethnocultural groups
• --Family, age, gender
• --Religious beliefs
• Environment/Support Systems
• Anxiety and other stressors
• Past Experiences

• 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

• Pt description of pain
• Duration
• Location
• Intensity
• Quality
• Time started
• OPQRST
• Aggravating factors
• Alleviating factors
• Physiologic indicators
• Behavioral responses
• Effect on ADL’s

• Cognitively Impaired-cant communicate well; use # or pic scales
• Children-picture scale
• Elderly

Use open ended questions

• Acute
• Chronic

Set realistic goals with patient

• Trusting relationship with caregiver
• Manipulate factors affecting pain
• Non-pharmacologic therapy

• Pharmacologic intervention
• Pt teaching
• Legal/Ethical Responsibilities

Distraction, humor, imagery, relaxation, cutaneous stimulation, accupuncture, etc

• Analgesics
• Opioid Analgesics
• Adjuvant
• PCA
• MOD or On-QC-bloc
• Epidural
• Local

• Acetaminophen, NSAIDS, COX-2 inhibitors
• Side effects

• Attach to opioid receptors
• Morphine, Fentanyl, Dilaudid
• Side effects
• Physical Dependence
• Tolerance
• Addiction

• 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

• Pain experience
• Management regimens
• Patient and family response