ATI Vital Signs Module Notes

Blood-pressure cuff size

Cuff width = 20% greater than the diameter of the limb at its midpoint or 40% of circumference.

Body Surface temperature varies depending on

blood flow to the skin and the amount of heat lost to the external environment, sites reflecting core temperatures are more reliable indicators of body temperature.

temporal temperature

Temperature taken over the temporal area (front of head)

tympanic temperature

Temperature taken in the ear

Factors affecting patients body temperature

There is no single temperature reading that is "normal" for all patients. Age, exercise, hormones, stress, environmental temperature, time of day, body site, and medications can all influence body temperature

acceptable oral temperature range

96.8° F to 100.4° F (36.2° C to 38° C) "Normal" is considered 98.6

acceptable rectal temperature

usually 0.9° F (0.5° C) higher than an oral temperature. 97.7 to 101.3

acceptable axillary and tympanic temperatures

usually 0.9° F (0.5° C) lower than an oral temperature. 95.9 - 99.5. Axilla normal is 96.6- 98.

Converting Celsius to Fahrenheit

(C x 1.8) + 32

Converting Fahrenheit to Celsius

C = 5/9 (F-32)

Oral Temperature is appropriate for

Adults and children old enough to follow directions (3-4 years old)

Oral temperature taking stipulations

wait 20 to 30 minutes if the patient has been eating, drinking, smoking, or exercising, as these activities can alter the temperature. Avoid this route for patients who have mouth sores or facial injuries or cannot keep the mouth closed around the thermometer probe.

Rectal temperature is appropriate for

patients who are comatose, have facial injuries or deformities, or are critically ill or injured. Infants/children

Retal temperature contraindications

among pediatric clients who have certain diagnoses and in infants less than 1 month old

Rectal Temperature insert

1 to 1.5 inches (2.5 to 3.5 cm) into rectum and in direction of umbilicus. If you feel resistance when inserting the probe, remove it immediately. Do not force the probe into the rectum as this might injure the patient's rectal mucosa.

Axilla temperature is appropriate for

most adults and children, including infants. However, this site is not as accurate as the others and does not reflect core body temperature. if the axilla has open sores and rashes, use another site.

Adult normal pulse range

60 to 100 beats per minute

Oral temperature taking placement

Place the covered temperature probe under the patient's tongue in the posterior sublingual pocket. Instruct the patient to close the lips gently around the probe and to keep the mouth closed until the temperature has been measured. Remind the patient not to bite down on the temperature probe.

pulse points

1. Common carotid

2. Brachial

3. Radial

4. Femoral

5. superficial temporal

6.external maxillary

7. Ulnar

8. Popliteal

9. Dorsalis pedis

10. Posterior Tibial

Conditions that cause bradycardia

decreased thyroid activity, hyperkalemia, an irregular cardiac rhythm, and increased intracranial pressure. Many athletes who do a lot of cardiovascular conditioning have pulse rates in the 50s and experience no problems.

Conditions that cause tachycardia

congestive heart failure (CHF), hemorrhage, shock, dehydration, and anemia can all speed up the heart rate. Patients who have tachycardia might experience dyspnea, fatigue, chest pain, palpitations, and edema.

Pulse counts

Count for 30 seconds than multiply by 2. If irregular count for 1 full minute

apical pulse

Each pulsation you hear is a combination of two sounds, S₁ and S₂. S₁ is the sound you hear when the tricuspid and mitral valves close at the end of ventricular filling and just before systolic contraction begins. S₂ is the sound you hear when the pulmonic and aortic valves close at the end of systolic contraction

Apical pulse stethoscope placement

5th intercostal space, midclavicular = PMI (point of maximal impulse) stethoscope over the apex of the heart so that you can hear the heart sounds clearly. If the apical rate is regular, you can usually determine an accurate rate in 30 seconds. When the apical pulse is irregular, it is best to count for at least 1 minute to obtain the rate.

apical pulse uses

Use the apical pulse when the patient has a history of heart-related health problems or is taking cardiovascular medications. Count the apical pulse rate while the patient is at rest. If the patient has been active, wait at least 5 to 10 minutes before beginning.

Breathing has how many phases

2, inspiration and expiration. Inspiration is an active process that involves the diaphragm moving down, the external intercostal muscles contracting, and the chest cavity expanding to allow air to move into the lungs. Expiration is a passive process that involves the diaphragm moving up, the external intercostal muscles relaxing, and the chest cavity returning to its normal resting state.

Factors can alter a patient's respiratory rate

Exercise, anxiety, fever, and a low hemoglobin level can all increase respiratory rate. A rate faster than 20 breaths per minute is called tachypnea. Neurological injuries and medications that depress the respiratory system, such as opiates, can slow the respiratory rate. A rate slower than 12 breaths per minute is called bradypnea.

Cheyne-Stokes

respirations are breathing cycles that increase in rate and depth and then decrease and are followed by a period of apnea. You might observe this pattern in patients who have heart failure or increased intracranial pressure. It can also be a sign that death is approaching.

Biot's respirations

involve a period of slow and deep or rapid and shallow breathing followed by apnea. This type of breathing pattern reflects central nervous system abnormalities.

Kussmaul's respirations

involve deep and gasping respirations, likely due to renal failure, septic shock, or diabetic ketoacidosis

The respiratory center is in the

Medulla

Blood pressure

Force that blood exerts against the vessel wall. High point = Systole occurs when the ventricles of the heart contract, forcing blood into the aorta. Low point = diastole and occurs when the ventricles relax and minimal pressure is exerted against the vessel wall

Normal Blood Pressure for adult

90 to 119 mm Hg systolic and from 60 to 79 mm Hg diastolic

Changes in BP can be caused by

Changes in this volume can affect blood pressure, as can age, ethnicity, gender, position changes, exercise, weight, anxiety, medications, time of day, and smoking

Cuff width should be

40% of the circumference of the midpoint of the limb on which you position the cuff, and the length of the bladder should be twice its width. The bladder should encircle at least 80% of the arm.

normal oxygen saturation in adult

95 - 100%

Things that can interfere with pulse ox

If you use a patient's finger, make sure nail polish and artificial nails are removed because they can interfere with obtaining an accurate reading. Patient movement, hypothermia, medications that cause vasoconstriction, peripheral edema, hypotension, and an abnormal hemoglobin level can also affect pulse-oximetry readings.

Placement of pulse ox

The fingers, toes, earlobes, and bridge of the nose are the most common sites

A pulse deficit is the difference between:

the apical pulse and the radial pulse rate

Explanation:

When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.

Typmpanic temperature procedure

Gently pull the pinna, also called the auricle, back, up, and out, and insert the tip of the covered thermometer probe into the patient's ear canal.

Temperature Documentation

the temperature reading

the route you used to measure the temperature

any signs or symptoms of temperature alterations

your nursing interventions ("antipyretic given")

the patient's response to care

Pulse Documentation

the rate, rhythm, and strength of the pulse

the site you used to palpate the pulse

any signs or symptoms of pulse alterations

the pulse deficit (if applicable)

your nursing interventions

the patient's response to care

Respiration Documentation

the rate, rhythm, and depth of respirations

any signs or symptoms of respiratory alterations

abnormal respiratory sounds

the type of oxygen therapy (nasal cannula, mask) and flow rate

respiratory status after a specific treatment (nebulizer therapy)

any specimens and cultures obtained and sent to the lab

your nursing interventions

the patient's response to care

Blood Pressure Documentation

the blood pressure reading

the site where you measured the blood pressure

any signs or symptoms of blood-pressure alterations

your nursing interventions

the patient's response to care

Pain Documentation

the location, intensity, quality, duration, and pattern of the pain

any signs or symptoms of pain

the patient's vital signs

your nursing interventions

the patient's response to care

Oxygen saturation Documentation

the patient's oxygen saturation

the site where you measured oxygen saturation

any signs or symptoms of abnormal oxygen saturation

type of oxygen therapy (nasal cannula, mask) and flow rate

oxygen saturation after a specific treatment (nebulizer therapy)

your nursing interventions

the patient's response to care