SM

Vital Signs and Assessment Procedures

Overview of Vital Signs

  • Vital signs refer to the essential body functions monitored to assess the health status of patients.

Normal Ranges of Vital Signs

  • Pulse Rate
    • Normal range: 60 to 100 beats per minute (bpm).
  • Blood Pressure
    • Normal systolic: 100 to 120 mmHg (top number).
    • Normal diastolic: 60 to 80 mmHg (bottom number).
  • Respirations
    • Normal range: 12 to 20 breaths per minute.
  • Temperature
    • Normal range: 97.6°F to 99.5°F.
    • Note: Celsius equivalents may be provided in parentheses during assessments.

Clinical Judgment in Vital Signs Assessment

  • To determine which vitals to prioritize:
    • Focus on abnormal values, assessing the greatest value or the one with the potential to harm the patient.
    • Establish a baseline for each patient upon their admission or first assessment.
    • Frequency of checks depends on clinical judgment and patient condition.
    • For instance, if a patient's heart rate rises significantly, increase monitoring frequency.

Key Procedures for Vitals Assessment

  • Essential equipment includes:
    • Digital watch (for pulse and respirations).
    • Blood pressure cuff and stethoscope (provided during lab).
    • Thermometers for temperature.
    • Pulse oximeters for oxygen saturation.
  • Before measuring blood pressure:
    • Patient positioning: legs flat, arms at heart level without crossing legs.
    • Ensure no recent exercise, food or drink for accurate results.

Factors Affecting Vital Signs

  • Exercise:
    • Increases heart and respiratory rates.
  • Nicotine and Caffeine:
    • Act as vasoconstrictors and can raise blood pressure.
  • Fluid Intake and Hydration:
    • Effects on blood pressure.
  • Medications:
    • Certain medications can influence heart rate, blood pressure, and overall vital statistics.

Standardized Values Reference

  • Utilize the provided Galen standardized lab values, located in online modules.
  • Important for exams and practical assessments throughout the course.

Thermal Regulation and Temperature Control

  • Vulnerable populations for heat regulation issues:
    • Elderly and infants are at greater risk of temperature management problems.
    • Elderly people may experience heat stroke and hypothermia more readily due to lower subcutaneous fat.
  • Mechanisms of heat loss include:
    • Radiation, conduction, convection, and evaporation.
  • Factors affecting body temperature: exercise, hormonal changes, circadian rhythms.

Understanding Temperature-Related Terms

  • Hyperthermia: Elevated body temperature indicating fever, heat stroke, heat exhaustion.
  • Hypothermia: Low body temperature, which can be life-threatening.
  • Body temperature scales: Fahrenheit and Celsius; conversion knowledge is essential for understanding results.

Measuring and Documenting Temperature

  • Ensure appropriate methods are used based on the patient’s condition (oral, rectal, axillary).
  • Proper equipment maintenance and sanitation between uses to prevent infection.

Pulse Assessment Techniques

  • Normal pulse range: 60 to 100 bpm.
  • Assessing pulse involves rate, regularity, and strength (documented as 2+ and regular).
  • Bradycardia: Heart rate under 60 bpm.
  • Tachycardia: Heart rate over 100 bpm.
  • Apical Pulse: Location found at the left midclavicular line, fifth intercostal space.

Assessment of Respirations

  • Controlled by the medulla and pons in the brain.
  • Normal respiration: 12 to 20 breaths per minute.
  • Abnormal breathing patterns:
    • Tachypnea: Rapid breathing over 20 breaths, Bradypnea: Under 10 breaths, Eupnea: Normal breathing.
  • Abnormal sounds include wheezing or stridor. Look for signs of labored breathing or abnormal utilization of accessory muscles.

Blood Pressure Measurement and Implications

  • Components:
    • Systolic Pressure: Pressure during heartbeats (the peak).
    • Diastolic Pressure: Pressure when heart is at rest (the lowest).
  • Normal reading: Systolic 100-120 mmHg and Diastolic 60-80 mmHg.
  • Hypotension: Abnormally low blood pressure.
  • Hypertension: Abnormally high blood pressure
  • Orthostatic Hypotension: Notable drop in blood pressure when transitioning from laying to sitting/standing, increasing fall risk.

Proper Techniques for Measuring Blood Pressure

  • Ensure correct cuff size, inappropriate sizes can lead to inaccurate readings.
  • The two-step method increases accuracy by checking baseline before measuring.
  • Sounds heard during measurement (Korotkoff sounds) signal systolic and diastolic pressures.

Pulse Oximetry and Peripheral Circulation

  • Evaluates blood oxygen saturation levels, typically aiming for 95% to 100%.
  • Impaired circulation can affect readings; assess peripheral circulation before checking.
  • Proper placement and care of equipment to avoid false readings is crucial.

Infection Prevention and Control Practices

  • Farmed healthcare-associated infections (HAIs) can arise from poor hand hygiene, contamination of medical equipment, or unsterilized medical procedures.
  • Examination of risk factors includes:
    • Age, immune status, chronic conditions, and surgical history.
  • Key symptom recognition for localized and systemic infections is vital.
  • Implementation of standard precautions, contact precautions, droplet precautions, and proper PPE (personal protective equipment) training is essential to prevent transmission of infections.

Conclusion

  • Importance of knowledge and application of vital signs in patient assessment for effective clinical decision-making.
  • Continuous review of standardized values and protocols for successful nursing practice and patient safety.