NR224_Unit_2_Vital_sign_and_mobility

Vital Signs Overview

• Vital Signs: Critical indicators of a patient's overall health status, providing essential information about physiological functions that are vital for sustaining life.

Acceptable Ranges for Adults

• Pulse: 60 to 100 beats per minute; a strong and regular pulse generally indicates adequate blood circulation.

• Temperature: Normal body temperature range is between 36° to 38° C (96.8° to 100.4° F).

  • Average oral/tympanic temperature is typically around 37° C (98.6° F).

  • Average rectal temperature tends to be slightly higher, at 37.5° C (99.5° F).

  • Axillary measurements, which are slightly lower than oral readings, average around 36.5° C (97.7° F).

• Respirations: Normal respiratory rate falls between 12 to 20 breaths per minute; breathing should be deep and regular to ensure appropriate oxygen exchange.

• Oxygen Saturation (SpO2): Normal oxygen saturation levels are 95% or greater; lower values indicate possible respiratory or circulatory issues.

• Blood Pressure:

  • Systolic Pressure: Average of 120 mm Hg, indicating pressure during heart contraction.

  • Diastolic Pressure: Average of 80 mm Hg, representing pressure in the arteries during heart relaxation.

  • Pulse Pressure: The difference between systolic and diastolic pressure, ordinarily ranging between 30 to 50 mm Hg, reflecting the vigor of the heart's contraction.

Monitoring Vital Signs

• Vital signs must be monitored regularly to detect any fluctuations that might indicate health issues. Abnormal readings should be promptly reported to the healthcare provider, and follow-up data should be collected for trend analysis.

• Accurate documentation of the routes and sites used for obtaining vital signs is crucial for providing a comprehensive health overview.

When to Take Vital Signs

• Vital signs should be assessed upon patient admission to establish a baseline.

• They are taken prior to discharge to ensure the patient is stable for leaving.

• Vital signs should also be measured after any invasive procedures or whenever blood products are administered to monitor for potential complications.

• Additionally, assessments before and after administration of specific medications are essential to identify their effects, and they are required when a quick assessment is deemed necessary due to changes in the patient's condition.

Body Temperature

• Body temperature measurement reflects the balance between heat production and heat loss in the body.

• The hypothalamus plays a significant role in regulating body temperature, maintaining core temperatures constant while surface temperatures can vary due to blood flow and environmental factors.

Heat Loss Mechanisms

• Radiation: Heat transfer occurs without direct contact, where heat emanates off the body's surface into the surrounding environment.

• Conduction: Direct contact with cooler surfaces leads to heat transfer; significant in caring for patients.

• Convection: Heat removal occurs through air movement, often facilitated by fans or drafts.

• Evaporation: Heat loss through the process of liquid turning into gas, significant during sweating.

Factors Affecting Body Temperature

• Various factors can influence body temperature, including age (children have a higher baseline), gender (women may experience fluctuations due to menstrual cycles), hormonal levels (thyroid function), and physical exercise.

• Circadian rhythms can create normal variations based on the time of day, along with stress and environmental factors impacting metabolic rates and body temperature.

Temperature Imbalance

• Normal Body Temperature: Is defined as being between 36° C - 38° C.

• High Body Temperature: A fever is indicated by body temperatures of 38° C and above and can signal infection or illness.

• Low Body Temperature: Hypothermia is diagnosed with body temperatures below 35° C, creating a medical emergency that requires immediate attention.

Temperature Measurement Methods

• Mercury Thermometers: These are no longer commonly used due to health risks associated with mercury exposure.

• Electronic Thermometers: They are widely accepted for reliable readings in oral, rectal, and axillary sites.

• Tympanic Thermometers: Provide core temperature measurements via the tympanic membrane and are commonly used in clinical settings.

• Temporal Artery Thermometers: Offer non-invasive scanning options across the forehead, providing quick and convenient readings.

• Chemical Dot Thermometers: Although available for home use, their accuracy is often questioned compared to electronic devices.

• Skin Patch Thermometers: These measure surface temperature but can be significantly influenced by environmental conditions, making them less reliable for clinical assessments.

Temperature Measurement Sites: Advantages and Disadvantages

• Oral Measurements: Easy access and generally accurate, but readings can be delayed by recent food or drink intake.

• Rectal Measurements: Considered the most reliable method for core body temperature, however, may be uncomfortable or invasive.

• Axillary Measurements: Safe and non-invasive but typically less reliable as they may underestimate core body temperature.

Nursing Diagnoses Related to Temperature Alterations

• Risks for impaired thermoregulation, indicating a potential inability to maintain normal body temperature.

• Conditions such as hyperthermia and hypothermia require careful nursing assessments and interventions to restore thermal stability.

Pulse Measurement

• Rate: Measured in beats per minute; for a regular rhythm, the pulse can be counted for 30 seconds and multiplied by 2 for quick estimates. For an irregular rhythm, a full minute count is advised to ensure accuracy.

• Strength/Amplitude: Insights from pulse strength can be categorized as follows:

  • Bounding: 4 - strong and easily palpable.

  • Full/Strong: 3 - palpable and easy to feel.

  • Normal: 2 - regular and identifiable.

  • Diminished: 1 - weaker than normal.

  • Absent: 0 - no pulse detectable.

• Factors Impacting Pulse: Physical exercise can increase pulse rate, while temperature, pain, emotional states, medications, hemorrhage, and posture can influence both the rate and strength of the pulse.

Respiratory Assessment

• It is imperative to assess respiratory rate immediately after pulse measurement to prevent influence by patient awareness or anxiety.

• Respiration Measurement: Count the number of complete breathing cycles (both inspiration and expiration) within a minute, noting any abnormalities in depth and rhythm during the assessment.

Respiratory Patterns and Alterations

• Bradypnea: Characterized by a slow respiratory rate of fewer than 12 breaths/min; may indicate central nervous system issues or metabolic conditions.

• Hyperpnea: An increase in the depth of breathing that may occur with exercise or respiratory distress.

• Periodic Breathing: Includes patterns such as Cheyne-Stokes (cyclic increasing and decreasing pattern) and Kussmaul's breathing (deep, labored breathing pattern).

Factors Influencing Respiration

• Factors such as physical activity increase oxygen needs, while pain and anxiety can drastically alter breathing patterns. Body position also plays a significant role in oxygenation, while medications have potential effects, either depressing or stimulating the respiratory rate.

Blood Pressure Basics

• Definition: Blood pressure refers to the forced exerted by circulating blood on the walls of blood vessels, critical for determining cardiovascular health.

• Systolic Pressure: Peak arterial pressure observed during the contraction of the ventricles of the heart.

• Diastolic Pressure: Arterial pressure observed between heartbeats, indicating relaxation phases.

• Pulse Pressure: The difference between systolic and diastolic blood pressure represents the force the heart generates with each contraction.

Factors Influencing Blood Pressure

• Blood pressure can be impacted by a wide variety of factors including age, levels of physical and emotional stress, genetic predisposition, environmental influences, gender differences, the time of day, dietary intake, medications, body weight, and smoking habits.

Hypotension

• Hypotension is clinically defined as a noticeable drop in blood pressure while standing, often referred to as orthostatic hypotension, which may lead to dizziness or fainting.

Blood Pressure Measurement Considerations

• Selection of appropriate blood pressure measurement sites is essential to obtaining accurate readings; avoid areas with IV lines, trauma, or paralysis.

Korotkoff Sounds and Phases

1. Phase 1: Initial clear sounds correspond to the systolic reading.

2. Phase 2: Muffled sounds indicate damping.

3. Phase 3: Clear, crisp sounds precede diastolic.

4. Phase 4: Soft, blowing sounds arise as pressure decreases.

5. Phase 5: A complete silence indicates the diastolic reading.

Common Errors in Blood Pressure Measurement

• Errors can arise from the use of an incorrect cuff size, crossed legs during measurement, physical activity preceding the assessment, and patient anxiety—all affecting the accuracy of results.

Oxygenation Assessment

• Pulse Oximeter: A device that measures SpO2 levels; normal values range between 95-100%. Values below this range may indicate oxygenation issues and necessitate further assessment and potential intervention.

• Factors such as jaundice, anemia, or peripheral vascular disease may yield unreliable readings from pulse oximeters, warranting alternative evaluation methods.

Psychological Complications of Immobility

• Prolonged immobility can lead to psychological complications such as depression, anxiety, disrupted sleep patterns, difficulty coping with daily scenarios, and withdrawal from social interactions and life.

Systemic Effects of Immobility

• Impacts include:

  • Integumentary: Increased risk for pressure injuries or bedsores.

  • Metabolic: Potential for weight gain and calcium loss from bones leading to other complications.

  • Musculoskeletal: Loss of muscle mass and the development of osteoporosis due to disuse.

  • Respiratory: Increased risk for pulmonary secretions and infections.

  • Cardiovascular: Risk for thrombosis and hypotensive episodes upon standing.

  • Urinary: Higher chances of urinary stasis and infections.

  • Gastrointestinal: Increased frequency of constipation due to decreased mobility.

Nursing Interventions for Immobility Complications

• Essential interventions include frequent repositioning, providing nutritional support to optimize health, implementing individualized exercise regimens, ensuring adequate respiratory care, and promoting hydration to prevent complications linked to immobility.

Range of Motion (ROM) Exercises

• Types: Includes active (performed by the patient), passive (assisted by the caregiver), and active-passive exercises (a combination of both).

• Care should be taken to perform these exercises slowly, ensuring support for extremities, and emphasizing that movements should never be forced to avoid injury.

Positioning Techniques

• Supine: Patient lies flat on their back.

• Fowler’s Position: Involves various degrees of elevation, assisting lung expansion and feeding.

• Prone Position: Patient lies face down, which is not suitable for individuals with certain spinal issues or respiratory problems.

Safe Patient Mobility Assessment

• A comprehensive assessment of patient mobility includes evaluating their weight, strength, balance capabilities, and any fall history.

• Additionally, it's crucial to ensure hygiene and patient privacy during all assessments to maintain dignity and comfort.

Mechanical Lifts and Gait Belts

• Mechanical lifts are indispensable for safely transferring bariatric or non-weight-bearing patients to minimize the risk of injury to both patients and caregivers.

• Gait belts assist in maintaining patient balance during support, ensuring safety during mobility assistance.

Documentation for Restraint Use

• Comprehensive documentation is essential when restraints are used; monitor every 2 hours, evaluate the necessity of restraints, and detail client responses and care provided during the use of restraints.

Assistive Devices for Mobility

• Various assistive devices are available, including walkers, canes, and crutches, which should be tailored to meet the specific needs and mobility conditions of each patient. Effective measurement and proper use of these aids are pivotal to preventing falls and enhancing stability in mobility.