3. Vital Signs & General Survey

WHAT MAKES UP VITAL SIGNS?

temperature, pulse, respirations, BP, oxygen saturation, pain level

what do vitals reflect?

health status, cardiopulmonary function, overall body function

what do vitals establish & do

• establishes baseline

• monitor condition, evaluate responses, identify problems, monitor risks for alterations in health

what are the 7 things you should do before/while entering the patients room

1. review patient medical history

2. introduce yourself: state your name & purpose

3. room surveillance: make sure the room is safe & clear

4. hand hygiene & ppe

5. provide privacy: close the curtain

6. patient identification: ask name verbally & verify with wrist band, ask for birthday

7. allergies: normally on chart of wristband color (red)

what does a red wristband mean?

allergy

what does a yellow wristband mean?

fall risk

what does a pink wristband mean?

you’re not allowed to do anything to that patients limb (ex: draw blood, IV)

when would a rapid response team be called?

• An acute change in mental status

• Stridor

• Respirations <10 or >32 breaths/min

• Increasing effort to breathe

• Oxygen saturation <92%

• Pulse <55 or >120 beats/min

• Systolic BP <100 or >170 mm Hg

• Temp <35° or > 39.5°C (<95°F or >103.1°F)

• New onset chest pain

• Agitation or restlessness

what is stridor?

• upper airway obstruction (throat is closing up, higher pitch) (respiratory arrest)

why does weight matter?

for medication dosages

what main medication should weight be considered?

diuretics: you must observe weight gain/loss on patient

what is the general process of obtaining vitals?

• obtain height & weight

• obtain temperature, pulse, respirations, BP

• obtain oxygen saturation

• obtain pain level

• assess for orthostatic hypotension

  • doppler pulse & BP, if needed

what is orthostatic hypotension

a sudden drop in blood pressure when you stand up from a sitting or lying down position

how to you determine if a patient has orthostatic hypotension?

measure BP while patient is lying down, measure BP while patient is sitting, measure BP while patient is standing

• if there is a drop is systolic (SBP) >15 (greater than 15) from lying to standing, this indicted orthostatic hypotension

what is a doppler pulse?

a handheld device that is used to hear blood flow

when should you use a doppler pulse?

when you can’t hear a pulse or its weak, poor circulation, used after vascular surgery

what equipment is necessary?

• scale

• height bar

• stethoscope

• thermometer

• watch with second hand measurement

• Sphygmomanometer

• pulse oximeter

what should you make sure you do before taking vitals?

• have the patient rest for at least 5 minutes (to reset their BP & shit to baseline)

• make sure patient hasn’t eaten, drank, or smoked in at least 30 minutes before measurement

• remove clothing constrictive to upper arm

how often should vitals be obtained

depends on the floor & hospital protocol & providers orders

• med surge is normally every 4-6 hours, ICU could potentially be less time in between

when should vitals be taken?

• new admission

• during & after administration of medication, especially if they’re just starting it

what does the general survey assess?

• physical appearance

• mobility

what do you look at for physical appearance for the general survey?

• overall appearance: “patient appears their stated age” “dress is appropriate for age & weather”

• hygiene, dress

• skin color; body structure, development

• behavior; facial expressions

• level of consciousness; speech

what do you look at for mobility for mobility for the general survey?

• posture; range of motion; gait

  • watch how they move throughout the interaction to see their gait

what is normal body temperature?

•  36.5°C to 37°C - 97.7°F to 98.6°F

how does rectal, tympanic, temporal artery temperature range differ from normal range

0.4°C to 0.5°C (0.7°F to 1°F) > oral measurements (higher than oral)

how does axillary temperature range differ from normal range

averages 0.5°C (1°F) < oral temperatures (lower than oral)

what are the different thermometer types

electronic, disposable, oral, tympanic, temporal artery, rectal

what is considered the most accurate type of temperature measurement

rectal

when would you take a rectal temperature?

• when the patient is unconscious

• oncology patients w/ no immune system

what is temperature regulated by?!

the HYPOTHALAMUS

what is a pulse?

a throbbing sensation palpated over a peripheral artery

apical pulse; where can you take it

over the apex of the heart (patients left below the nipple line)

radial pulse

at the wrist below the thumb

what is the normal heart rate for adults?

60-100 beats/min

what does paplating arterial pulse points measure?

rate, rhythm, strength, elasticity

what does rate mean for pulse?

how many times the heart beans, per minute

what does rhythm mean for pulse?

regular or irregular

• if its regular, you only need to do 30 seconds

• if its irregular, you should do the full minute

what does strength mean for pulse?

how strong the heart beat is

what is the pulse scale out of?

5 points

what does a pulse score of 0 mean?

absent

what does a pulse score of 1+ mean?

palpable, but thready & weak; barely palpable; easily obliterated

what does a pulse score of 2+ mean?

normal; easily identifiable; not easily obliterated

what does a pulse score of 3+ mean?

increased pulse; moderate pressure for obliteration

what does a pulse score of 4+ mean?

full, bounding; cannot obliterate

what does elasticity mean for pulse?

how it feels

• smooth is normal

what is tachycardia?

pulse > (greater than) 100

• tachy=fast

what is bradychardia?

pulse < (less than) 60

• brady=slow

what is asystole?

no or 0 pulse

what is sinus arrhythmia?

breathing controls heart rate; increases during inspiration & decreases during expiration

what is the formula for one respiration?

1 inspiration + 1 expiration = 1 respiration

what is the normal respiratory rate for adults?

12 to 20 breaths/min

what is dyspnea?

difficulty breathing

what is bradypnea?

< 12 breaths/min

what is tachypnea?

> 20 breaths/min

what is apnea?

0 breaths/min

what is hypoventilation?

a breathing state that is too slow or too shallow to meet the body's normal needs, resulting in a dangerous buildup of carbon dioxide in the blood (google)

what does the suffix -pnea mean?

breathing

how should you assess a patients breathing?

do not let them know you are counting resps because they may change their breathing

• instead: when assessing pulse, do 30 seconds for the pulse & then 30 seconds of counting respirations so they don’t know, lie & say its a full minute of pulse

what is oxygen saturation?

percentage of hemoglobbin filled with O2

what is the normal pulse oximetry (Sp02)

92% to 99%

what does it mean if a patient has 85% to 89% ox saturation?

could possibly be acceptable for patients with specific chronic conditions, such as emphysema (a chronic lung disease that damages the tiny air sacs (alveoli) in the lungs, making it hard to breathe)

what may a pulse ox reading of 100% mean?

hyperoxemia (an excess of oxygen in the arterial blood)

what should you document when doing pulse oximetry?

whether the pulse ox was on room air OR oxygen

where should you put the pulse ox on patient with normal circulation & without normal circulation?

normal - fingernail / nail bed (remove nail polish if necessary)

abnormal - on ear or nose

what is systolic blood pressure (SBP)

left ventricular contraction: maximum pressure (top #)

what is diastolic blood pressure? (DBP)

left ventricular relaxation; minimum pressure (bottom #)

what are some factors that contribute to BP

• cardiac output; peripheral vascular resistance

• circulating blood volume; viscosity

• vessel wall elasticity

what is a normal SBP range for adults?

90-120 mm Hg

what is a normal DBP range for adults

60-80 mm Hg

what factors influence blood pressure?

• age, gender, ethnicity, weight, diurnal cycle (any pattern or process that repeats every 24 hours because of Earth turning one full time on its axis)

• position, exercise, emotions, stress, orthostatic hypotension

• medications, smoking

how quickly should the needle fall when measuring BP manually?

2-3 mm Hg per second

what is hypertension

elevated BP

what is hypotension

lower than normal limits BP

how to measure circulation when a patient has poor circulation?

use a doppler; record Bp as SBP/Doppler (ex: 88/Doppler)

what is the appropriate cuff size for taking bp?

80% of arm circumference

• a cuff too small can lead to false high reading

where can yoo measure bp?

arm or thigh

what do you document when taking bp?

• where the bp was taken

  • what position the patient was in

what are some advantages for using a vital sign monitor?

increased convenience, reduced examiner bias, detection of true BP

what should you do if you question the reading done by the vital signs monitor?

validate or disprove the reading with the manual method

how long does the general survey span?

from the first interaction with a patient and continues throughout the entire time the nurse provides care for them