NUR 111 unit 6 vital signs

what do vital signs monitor?

the functions of the body

who’s job is it to interpret vital signs

the registered nurse

When should you take vital signs?

• essentially all the time

• pre/post nursing interventions that can affect VS

• pre/post surgery or procedure

• on admission

• upon meeting pt for first time

• before/ during/after blood transfusions

• per facility protocols

• per specific HCP orders

• when pt reports non specific symptoms (like feeling “funny”)

• when pt condition changes

pulse rate for infant

120-160

normal respiration rate for infant

30-60

normal temperature range for an adult

96.8-99.5 F

adult normal pulse rate

60-100

adult normal pulse oximetry

at or above 95 %

normal respiration rate for an adult

12-20

normal blood pressure for adult

119/79

systolic < 120

diastolic 60-78

Normal mean arterial pressure range

70-100 mm hg

normal pulse pressure range

30-50 mmhg

tachycardia for an adult

over 100 bpm

tachycardia for infant

over 160 bpm

bradycardia for an adult

less than 60 bpm

bradycardia for infant

less than 100 bpm

pulse rhythm

regular- regular interval, LUB,DUB

irregular- irregular/ wacky interval on and off

The heart is your….

pump

Pulse strength

0-4 pulse scale (What does pulse feel like when you palpate it)

0 on pulse force scale

pulse is absent cant feel it at all

1 on pulse force scale

pulse is weak (hard to feel, barely palpable)

2 on pulse force scale

pulse is normal can feel well

3 on pulse force scale

pulse is increased easily felt

4 on pulse force scale

pulse is bounding very strong can see it before you even feel it

pulse equality

check peripheral pulses bilaterally are they equal on each side

pulse deficit

the discrepancy between the rapid apical heart pulse and a slower peripheral pulse

assessed by taking apical pulse and radial pulse at same time or directly after one another

apical pulse

• found by asculation

• count of pulse when listening to patient’s chest with a stethoscope

• found in adults at the midcavicular line on the left and the 5th intercostal

Peripheral pulses

• found by palpation or doppler

where is temporal pulse site located

sides of forehead

where is carotid pulse site located

side of neck

where is radial pulse site located

on the wrist in a notch under the thumb

where is the femoral pulse site located

in the hip/groin area

what is the advantage of the femoral artery pulse site

it is a good core pulse site for to feel patients that do not have blood flow in other areas or hard to feel in other sites

where is the popliteal pulse site located

behind the knee

where is the posterior tibial pulse site found

ankle

where is the dorsalis pedis pulse site found

top of the foot

Blood pressure measures the flow of the…..

river

systolic blood pressure

top # of blood pressure

should be less than 120 mmhg in adults

pressure of ventricles when contracting

diastolic blood pressure

bottom #

should be btwn 60-78 for adults

the pressure in the ventricles when they are at rest waiting to be filled

Pulse pressure

the difference btwn systolic and dyastolic BP

should be btwn 30-50 mmhg in adults

Mean arterial pressure (MAP)

• should be btwn 70-100 mmhg for adults

• pressure of blood being delivered to the bodies vital organs (brain,kidneys, coronary arteries)

• anything less than 60 blood is not perfusing to vital organs (brain, kidneys, coronary arteries) BIG PROBLEM

• anything over 100 means too much blood flow which can cause problems such as blood clots, stroke, kidney damage)

Factors that impact BP

• age

• sex

• race

• medication

• weight gain

• circadian rhythm

• head injury

• increased blood volume

• sodium

• shock

• emotions

• vasodilation

• vasoconstriction

age affect on BP

older pt’s do not have vessels that are as elastic as they were at a young age

sex affect on BP

women have lower BP till menopause then they see a spike

race affect on BP

African american and hispanic induvial tend to have higher BP due to genetics

medication affect on BP

narcotics can lower it, birth control and bronchodilators can raise it

weight gain affect on BP

can cause an increase in BP

circadian rhythm and Bp

BP is the lowest after pt first wakes up from extended sleep

if pt works night shift this may be in the afternoon works day shift this may be in morning

weight gain affect on BP

can cause increase in BP

Head injury affect on BP

can cause increase in BP

Increased blood volume affect on BP

can cause increase in BP

sodium affect on bp

can cause increase in BP

emotions affect on Bp

can cause increase in BP

Pain affect on BP

can cause increase in BP

pain affect on BP

can cause increase in Bp

shock affect on bp

can cause decrease in BP

vasodilation affect on BP

decrease BP less effort to move around

vasoconstriction affect on BP

can cause an increase in BP

reasons to use alternate site for BP measurement

• mastectomy

• iv site

• excessively large arm

• amputee

• diseased area

• lymph node procedure

• hemodyalsis/fistula site

• extremely painful

• surgery site

• cast/bulky dressing

• implant

• blood glucose monitor

correct BP assessment

• ensure correct cuff size should be 40% of width of pt arm make sure it is with in indicator lines

• left side better, feet flat on floor, legs uncrossed, upright in chair if possible

• palpate brachial artery and line up artery line on cuff

Tachypnea

abnormally fast shallow breathing

tachypnea rate for adult

any respiratory rate over 20

DANGER over 30!!! (will cause pt to exhaust and pass out)

tachypnea result for infant

any respiratory rate over 60

bradypnea

abnormally slow breathing rate

bradypnea rate for adult

respiratory rate of 10 or less

bradypnea rate for infant

respiratory rate less than 30

apnea

absence of breathing

eupnea

breathing at normal rate and depth

orthopnea

trouble breathing when lying flat

happens in elderly, pregnant ppl, COPD,asthma

dyspnea

difficult/labored breathing (general term) act of breathing looks difficult

oxygen saturation

estimate of % of hemoglobin saturated w/ o2

20-30 mins behind in reflecting current o2 sat

make sure pattern is nice and even on the pulse oximeter and you are getting the same pulse sometimes the device can be inaacurate

age affect on respiratory rate

Infants have faster respiratory rate it stabilizes around puberty

Exercise affect on respiratory rate

Increases rate due to increased demand on heart which causes need for increased amount of oxygen

Illness affect on respiratory rate

Increases rate body needs more energy to fight off infection, which increases oxygen demand

Medications street/ drugs affect on respiration

Depends on medication depressants like narcotics slow respiratory rate, stimulants like cocaine and meth cause respiratory rate to go up

Pain affect on respiratory rate

increases the respiratory rate

emotions affect on respiratory rate

increases the respiratory rate

How often should pulse ox clips/spring loaded be assessed

every 2 hours

Make sure it is the correct spot, lined up correctly and check the skin integrity

How often should the adhesive sticker pulse ox be checked

every 4 hours

make sure it is in the right spot it is lined up correctly and skin is intact

Diagnosis of hypertension criteria

• 2 or Systolic BP’s of of 140 or more

  OR

• 2 or more diastolic BP’s of 90 or more

Primary/ essential hypertension

The patient does and has done everything right (exercise, diet, doesn’t smoke or drink, reduces stress etc.) overall healthy patient but blood pressure is high

Secondary hypertension

Cause of high blood pressure is obvious (poor diet, does not exercise, obese, poor diabetes management, smokes, drinks etc.)

Modifiable factors

anything that can be changed/we can control (exercise, diet, stress level, alcohol consumption, smoking, weight)

Non modifiable

anything that we cannot control or cannot be changed (sex assigned at birth, age, race, genetics)

Hypotension causes

Medication side effects

dehydration

loss of lots of blood

how do you assess for orthostatic hypotension

have patient lay for 3-5 minutes then sit them up immediately check BP/pulse then have them sit for 3-5 minutes then have them stand and immediately check bp/pulse

Criteria for orthostatic hypotension

Increase in pulse greater than 20 BPM

decrease is systolic BP by 20 points

when it caused by position change

Assessment of pain

COLDSPA pneumonic

C- character

O- onset

L-location

D-duration

S- severity

P-pattern
A-associated factors

COLSPA Character

How does it feel?

Can you describe it?

Sharp, Burning, Stabbing

COLDSPA Onset

when did it start

COLDSPA Location

point with one finger to where it hurts

COLDSPA Duration

How long does it last?

Is it always there?

Does it come and go?

Is it constant?

COLDSPA- severity

on a scale of 1-10 how bad does it hurt 0 being no pain 10 being worst of your life

COLDSPA Pattern

is there something that makes it worse?

Something that makes it better

COLDSPA associated factors

The pain keeps me from playing pickle ball

Pain keeps me from my nightly walks

Can’t do something due to the pain?

wong baker faces pain scale rating

faces showing pain levels

• big Smile= 0, no pain

• small smile = 2, hurts a little

• flat face= 4 hurts little more

• small frown= 6 hurts even more

• bigger frown = 8 hurts a whole lot

• crying, big frown = 10, worst pain

FLACC scale

Typically only used for children or patients who are unconscious

Face - facial expression

Legs- still, restless, kicking legs up and down

Activity- sitting quietly, squirming, rigid jerking or arched

Cry- no cry, moans, whimpers, crying or sobs/screams

conosoiability- content, reassured by distraction, touching etc, difficult to console

what is the blood’s “job”

to supply oxygen to all our tissues

what are the 3 elements of blood

red blood cells (erythrocytes)

white blood cells (leukocytes)

platelets (thrombocytes)

Red blood cells

erythrocytes

transport 02 to cells and remove Co2 from the cells