NURS 344: Vital Signs (slides)

What is PERIPHERAL VASCULAR RESISTANCE?

The ability of the vessels to

accommodate increases blood flow without also increasing resistance or blood pressure

What is ELASTICITY?

The ability of the vessels to stretch and compress, then

return to their original shape

What is CARDIAC OUTPUT?

The amount of blood pumped into the circulatory system by the heart in one minute

What is STROKE VOLUME?

The amount of blood ejected by the ventricle during

one heart contraction

What are VITAL SIGNS?

clinical measurements that include blood pressure, heart rate, body temperature, respirations, and oxygen saturation

What do VITAL SIGNS provide?

a baseline of data upon which to compare future findings

What do VITAL SIGNS help identify?

trends, or patterns that may indicate a change in a patient's

condition

What do VITAL SIGNS guide?

treatment decisions and nursing interventions

What is BLOOD PRESSURE?

A measurement of the force, or pressure, of the circulating blood on the interior walls of the blood vessels

What is PULSE?

The rhythmic dilation of the arteries that occurs with the beating of the heart

What is BODY TEMPERATURE?

The balance of heat produced by the body and the heat lost to the environment

What is RESPIRATORY RATE?

The number of breaths taken per minute

What is OXYGEN SATURATION?

The estimated amount of oxygen bound to the hemoglobin molecule in red blood cells, indicating the amount of oxygen being transported to body tissues

What is SYSTOLIC BLOOD PRESSURE?

The maximum amount of pressure exerted when the heart contracts and forces blood into the aorta

What is DIASTOLIC BLOOD PRESSURE

The minimum amount of pressure exerted when the heart is relaxed

What is the correct POSITION for taking BLOOD PRESSURE?

the patient's legs must be uncrossed and their feet should be flat on the floor

What are TEN CONSIDERATIONS for measuring BLOOD PRESSURE?

• Patient education

• Patient baseline

• Patient position

• Correct cuff size

• Contraindicated sites

• Equipment (leaks, calibration)

• Skill level/technique of the clinician

• Timing

• Recognizing deviations

• Correlating results

What is the NORMAL blood pressure category?

SYSTOLIC: less than 120

AND

DIASTOLIC: less than 80

What is the ELEVATED blood pressure category?

SYSTOLIC: 120-129

AND

DIASTOLIC: less than 80

What is the STAGE 1 HYPERTENSION blood pressure category?

SYSTOLIC: 130-139

OR

DIASTOLIC: 80-89

What is the STAGE 2 HYPERTENSION blood pressure category?

SYSTOLIC: 140 or higher

OR

DIASTOLIC: 90 or higher

What is the HYPERTENSIVE CRISIS blood pressure category?

SYSTOLIC: 180 or higher

AND/OR

DIASTOLIC: 120 or higher

What is HYPERTENSION?

a blood pressure above the expected reference range

What CHRONIC ILLNESSES can HYPERTENSION cause?

• Chronic kidney disease

• Kidney failure

• Congestive heart failure

• Heart attack

• Stroke

What are TWO NURSING INTERVENTIONS for HYPERTENSIVE patients?

-Encourage the patient to adopt LIFESTYLE interventions

such as exercise, stress reduction techniques, a low-sodium diet, and weight loss if needed.

-Provide the patient with information about

ANTIHYPERTENSIVE MEDICATIONS, if prescribed by the provider, including expected adverse effects and when the provider should be notified.

What FOUR MEDICATIONS can be given for HYPERTENSION?

Lisinopril, Atenolol, Losartan, Amlodipine

What is LISINOPRIL?

Ace inhibitor, widens blood vessels to aid in easy blood flow

and reduce blood pressure

What is ATENOLOL?

Beta blocker, reduces heart rate which decreases blood

pressure

What is LOSARTAN?

ARB, helps relax blood vessels to lower blood pressure

What is AMLODIPINE?

Calcium channel blocker, reduces the amount of calcium

entering heart muscles, which reduces heart rate and controls blood pressure

What is HYPOTENSION?

a blood pressure that is

below the expected reference range as

determined by a client's usual baseline

measurement

Without baseline data, what would be considered HYPOTENSION?

systolic pressure less than 90 mm Hg or a diastolic pressure less than 60 mm Hg

What are MANIFESTATIONS of HYPOTENSION?

dizziness, nausea, blurred vision, increased pulse, and fatigue

What is ORTHOSTATIC HYPOTENSION?

Hypotension that occurs with positional changes

What are SEVEN NURSING INTERVENTIONS for HYPOTENSION?

• Increase fluids.

• Place in an upright position unless medically

contraindicated.

• Evaluate the medications the patient is taking.

• Instruct the patient about the risk for dizziness

and falling.

• Encourage the patient to change positions

slowly.

• Avoid extremes in temperature.

• Stay well hydrated.

What SEVEN factors INFLUENCE PULSE?

• Body position

• Age

• Activity

• Fitness level

• Health conditions

• Medications

• Body temperature

What is a grade pulse of 0?

pulse that is absent/nonpalpable

What is a grade pulse of +1?

pulse that is weak/diminished

What is a grade pulse of +2?

pulse that is normal

What is a grade pulse of +3?

pulse that is increased/strong

What is a grade pulse of +4?

pulse that is bounding

What are NINE NURSING CONSIDERATIONS for MEASURING PULSE?

• Patient baseline

• Patient ability to cooperate

• Patient position

• Correct time (30 or 60 seconds)

• Skill/technique of clinician

• Medical conditions

• Site based on purpose

• Factors that affect pulse rate

What is the correct time for MEASURING APICAL PULSE?

60 seconds

What is TACHYCARDIA?

Pulse greater than 100/minute

What are POTENTIAL CAUSES of TACHYCARDIA?

• infection

• Exercise

• Anxiety

• Certain medications

• Caffeine, nicotine, substances

• Abnormality in the electrical system of the heart

What is the biggest concern for TACHYCARDIA?

infection

Do all TACHYCARDIA patients experience symptoms?

some are asymptomatic

What might a TACHYCARDIA patient report?

a "racing" feeling in the

chest

What is BRADYCARDIA?

Pulse less than 60 beats per minute

What are POTENTIAL CAUSES of BRADYCARDIA?

• Expected in physically fit individuals

• Congenital cardiac abnormalities

• Heart failure

• Heart muscle damage

• Hypothyroidism

• Medications

Do PHYSICALLY FIT, BRADYCARDIC patients experience symptoms?

there are often no symptoms

What symptoms would BRADYCARDIC patients experience?

dizziness, fatigue, shortness of breath, chest pain, or confusion

What is BODY TEMPERATURE MEASURED in?

degrees Celsius

What is the EXPECTED BODY TEMPERATURE?

36-38C (96.8-100.4F)

What is the EXPECTED CORE BODY TEMPERATURE?

36-38° C (96.8-100.4° F)

What is the EXPECTED ORAL/SUBLINGUAL TEMPERATURE?

36° to 38° C (96.8° to 100.4° F)

What is the AVERAGE ORAL/SUBLINGUAL TEMPERATURE?

37° C (98.6° F)

What is the EXPECTED ORAL/SUBLINGUAL TEMPERATURE for older adults?

35° to 36.1° C (95° to 97° F)

Why is EXPECTED ORAL/SUBLINGUAL TEMPERATURE for older adults LOWER?

due to less body fat

What is EXPECTED RECTAL TEMPERATURE?

Usually 0.5° C and 0.9° F higher than oral

What is EXPECTED TEMPORAL TEMPERATURE?

Nearly 0.5° C and 1° F higher than oral

What is EXPECTED INFRARED TEMPERATURE?

Consistent with temporal

What is EXPECTED AXILLARY TEMPERATURE?

Usually 0.5° C and 0.9° F lower than oral

What is EXPECTED TYMPANIC TEMPERATURE?

Consistent with oral

What is a FEVER?

an increase in body temperature above the reference range of

38° C (100.4° F)

What is FEVER commonly caused by?

infection

What are the SYMPTOMS of FEVER?

flushed face, diaphoresis, skin that feels "hot," tachycardia, and increased respiratory rate

What is a good medication we can give for patients with a fever?

Acetaminophen aka Tylenol

What are SIX INTERVENTIONS for FEVER and HYPERTHERMIA?

Encourage sips of cool fluids.

Remove excess clothing.

REMOVE BLANKETS!

Administer medications as ordered.

Place the client in a cooler

environment

Give a tepid bath (temporary aid)

What medication should be used to REDUCE or PREVENT FEVER?

antipyretics

What medication should be used when INFECTION is PRESENT?

antibiotics or antivirals

What is RESPIRATORY RATE?

inspiration and expiration

What is INSPIRATION?

the intake of air by the lungs to oxygenate body tissues and support cellular function

What is EXSPIRATION?

expels carbon dioxide from the lungs

What is the EXPECTED REFERENCE RANGE for an ADULT?

12-20 breaths per minute

What PHYSICAL SIGN indicates GOOD RESPIRATIONS?

chest should rise and fall symmetrically

What EIGHT FACTORS influence RESPIRATORY RATE?

- physical activity

- body temperature

- emotions

- medications

- smoking

- certain diseases

- weather

- voluntary breathing by patient

What are possible CAUSES of TACHYPNEA?

Physical activity

Anxiety

Pain

Health conditions (e.g., asthma)

What are COMMON SYMPTOMS of TACHYPNEA?

Dizziness

Tingling in the hands

What are possible CAUSES of BRADYPNEA?

• Health conditions

• Medications

What MEDICATIONS can cause BRADYPNEA?

opioids, sedatives

What are COMMON SYMPTOMS of BRADYPNEA?

• Dizziness

• Fatigue

• Weakness

• Confusion

• Impaired coordination

What is OXYGEN SATURATION?

the estimated amount of oxygen bound to the hemoglobin

How is OXYGEN SATURATION EXPRESED?

as a percentage

What does OXYGEN SATURATION REVEAL?

a client's respiratory

status

What is the EXPECTED REFERENCE RANGE for OXYGEN SATURATION for patients ON OXYGEN?

95% to 99%

What is the EXPECTED REFERENCE RANGE for OXYGEN SATURATION for patients ON ROOM AIR?

95-100%

What are the other names for OXYGEN SATURATION?

"O2 Sat" or "Sats"

What is DECREASED OXYGEN SATURATION?

below 95%

What are potential causes of DECREASED OXYGEN SATURATION?

Health condition: pneumonia, chronic lung disease like COPD, pulmonary edema, poor cardiac output

What are COMMON SYMPTOMS of DECREASED OXYGEN SATURATION?

o Decrease in mental alertness

o Confusion