Maslow's Hierarchy of Needs and Vital Signs

Maslow's Hierarchy of Needs

• A model in nursing that helps nurses understand a patient's level of wellness.
• A person must meet needs at the base of the pyramid before advancing higher.
• Needs higher on the pyramid enhance life but aren't essential for it.
• Nutrition needs must be met before esteem needs like self-respect.
• Patients prioritize needs based on their own value systems.
• Food, water, warmth, and rest (physiological needs) must be met before self-actualization can be achieved.

Vital Signs

• Include temperature, pulse, respirations, blood pressure, and pain (considered the fifth vital sign).
• Patients should wait at least 20 minutes after smoking or eating before vital signs are measured.
• Educate patients about hypertension risks (obesity, smoking, alcohol, high cholesterol, stress).
• Teach patients signs and symptoms of hypoxemia (low blood oxygen): headache, confusion, dusky color, shortness of breath, dysrhythmia.
• Teach deep breathing and coughing exercises.

Guidelines for Obtaining Vital Signs

• Know normal ranges for all vital signs according to age (see Table 12.1 on page 281).
• Know patient's medical history, therapies, and medications, as these can cause changes in vital signs.
• Vital signs are only one aspect of a patient's health; treat the patient, not just the monitor.
• Intervene and communicate significant changes in vital signs to healthcare providers.

When to Assess Vital Signs

• Upon patient admission.
• As prescribed by the provider.
• As hospital policy dictates (e.g., every four hours, once a shift, weekly in extended care).
• Before and after administering certain medications (e.g., blood pressure or pain medications).
• When there is a change in patient condition (e.g., confusion).
• Before and after certain nursing interventions (e.g., walking the patient).
• The more ill the patient, the more frequent the vital sign assessments.

Age-Related Variations in Vital Signs

• Differences between adults and older adults are generally small, though older adults may have slightly higher blood pressure.

Life Span Considerations in Older Adults

• Assess their environment for temperature sensitivity (hypothermia, hyperthermia).
• Older adults often have lower baseline temperatures (around $95$ degrees Fahrenheit).
• Infection might not always present with a fever; look for tachypnea, anorexia, falls, and delirium.
• Pulse irregularities (e.g., atrial fibrillation) are common.
• Respiratory depth often decreases, with an increased rate to compensate.
• Breathlessness may occur at low exercise levels.
• Skin is more fragile, and orthostatic hypotension is common. Educate about slow position changes.
• Carefully monitor older adults taking antihypertensives and vasodilators.
• Pulse oximetry might need to be measured on earlobes or toes if fingers are cold.

Temperature

• Normal temperature: $98.6$ degrees Fahrenheit ($97$ to $99.6$ is considered the normal range).
• The hypothalamus regulates body temperature.
• Increased metabolism generates heat.
• Peripheral vasoconstriction conserves heat.

Core vs. Surface Temperature

• Core temperature stays constant; best measured rectally or orally (rectal is most accurate).
• Surface temperature changes easily; measured via axillary or temporal routes.

Hyperthermia

• Hyperthermia, pyrexia, and febrile, are all terms describing a fever (temperature greater than $100.4$).
• Fever is a body defense mechanism, often the first sign of illness.
• Elevated temperature helps destroy invading bacteria.
• Temperatures greater than $105$ degrees Fahrenheit can destroy normal body cells.

Types of Fever

• Constant: elevated consistently.
• Intermittent: rises and falls, may be normal in the morning and spike in the afternoon.
• Remittent: rises and falls but does not return to normal until the patient recovers.

Signs and Symptoms of Elevated Body Temperature

• Anorexia.
• Disorientation.
• Progression to convulsions (especially in infants and children).
• Elevated pulse and respiratory rates (compensation).
• Flushed, warm skin.
• Glassy eyes or photophobia (sensitivity to light).
• Headache.
• Increased perspiration.
• Irritability.
• Restlessness, or excessive sleepiness.
• Thirst.

Hypothermia

• Abnormally low body temperature.
• Death is a risk below $93.2$ degrees Fahrenheit.
• May be induced for surgical procedures.
• Can be caused by illnesses like hypothyroidism.

Factors Affecting Body Temperature

• Age: unstable in infancy, lower in older adults.
• Exercise.
• Hormonal influences: greater variations in women, fluctuations during menopause and ovulation.
• Diurnal (daily) variations: lowest between 1 AM and 4 AM, highest between 4 PM and 6 PM.
• Stress and anxiety.
• Environment: exposure, humidity, ingestion of hot/cold liquids.
• Smoking: increases temperature by $0.2$ degrees Fahrenheit.

Nursing Interventions for Abnormal Body Temperature

• Repeat measurement at a different site.
• Remove/reduce external coverings.
• Keep clothing and linens dry.
• Administer antipyretics (e.g., acetaminophen) as ordered.
• Limit physical activity.
• Increase oral fluids (if not contraindicated).
• Assess for infection sites.
• For low temperature: cover with linens, eliminate drafts, encourage warm liquids.

Auscultating with a Stethoscope

• Earpieces should point towards the user's face.
• Tap lightly on the chest piece to determine which side is active.
• Auscultate means to listen for sounds within the body.

Diaphragm

• The flat side, transmits high-pitched sounds created by high-velocity movement of air and blood.
• Press firmly to leave a temporary red ring on the skin.

Bell

• Transmits low-pitched sounds created by low-velocity movement of blood.
• Use to auscultate heart and vascular sounds.
• Apply lightly; ensure tubing is free of rubbing or bumping.

Pulse

• Normal adult pulse rate: $60$–$100$ beats per minute.
• Pulse volume: the amount of blood being pushed against the artery wall with each beat.

Tachycardia

• Considered over $100$ beats per minute.
• Causes: shock, hemorrhage (leading to hypovolemia), exercise, fever, medications, substance abuse, acute pain.

Bradycardia

• Less than $60$ beats per minute.
• Causes: unrelieved severe pain (parasympathetic stimulation), heart blocks, beta blockers, supine position.

Dysrhythmia

• Irregularity in the normal rhythm of the heart. Time between each beat should be even and regular.

Pulse Strength

• Weak: difficult to palpate.
• Bounding: easily felt with light palpation.
• Imperceptible: unable to feel at all.

Factors Influencing Pulse Rate

• Acute pain: increases pulse (sympathetic nervous system).
• Anxiety: increases pulse rate.
• Age: decreases pulse over time.
• Exercise: increases during activity but decreases with conditioning.
• Fever and heat: increase pulse.
• Hemorrhage: increases pulse (sympathetic stimulation).
• Medications: epinephrine increases, beta blockers decrease.
• Metabolism: hyperthyroid increases, hypothyroid decreases.
• Postural changes: lying down decreases, standing/sitting increases.
• Pulmonary conditions: increase pulse due to poor oxygenation.
• Chronic pain: decreases pulse (parasympathetic nervous system).

Pulse Sites

• Radial: thumb side of the inner wrist.
• Brachial: above the elbow at the antecubital fossa.
• Femoral: felt with the first three fingers over the inguinal area.
• Popliteal: behind the knees.
• Dorsalis pedis: top of the foot.
• Posterior tibial: behind and below the ankle bone.

Carotid Pulse

• Never measure both carotid pulses simultaneously (can occlude brain blood supply).
• Do not reach across the patient's neck.
• Measure on the side facing you.
• Best site for quick pulse assessment during deterioration.

Apical Pulse

• Essential for cardiac patients.
• Needed when the radial pulse is irregular.
• Required with certain medications (e.g., digoxin).
• Represents the actual beating of the heart.
• Best site for infants.

Obtaining Apical Pulse

• Patient supine or sitting.
• Locate fifth intercostal space on the left side at the midclavicular line.
• Place the bell of the stethoscope over the apical area and count for a full 60 seconds (especially if irregular).

Pulse Deficit

• The difference between radial and apical pulse rates.
• Confirmed by one nurse listening to apical and another palpating radial simultaneously for one full minute.
• Deficit exists when radial rate is less than apical rate.
• Example: apical $92$, radial $88$, deficit = $4$. Anything above two is considered a pulse deficit.
• Signifies faulty heart pumping action or peripheral vascular issues (often seen in atrial fibrillation).

Nursing Interventions for Abnormal Pulse

• If weak or difficult to palpate, assess all peripheral pulses and check for altered tissue perfusion (cyanosis, coldness, level of consciousness).
• Check for decreased cardiac output (hemorrhage, hypothermia, heart muscle damage).
• If above normal, assess for pain, fear, anxiety, recent exercise, low blood pressure, elevated temperature, inadequate oxygenation.
• Check for dyspnea, fatigue, chest pain, orthopnea, or syncope.
• Check an apical pulse if above or below normal, weak, or thready.

Respirations

• Internal respiration: gas exchange at the tissue level (cellular oxidation).
• External respiration: breathing movements that are observed.
• Inspiration: breathing in oxygen.
• Expiration: exhaling carbon dioxide.
• One inhalation and exhalation equals one respiration.
• Controlled by the medulla oblongata.
• Increased metabolism increases oxygen need, increasing respiratory rate.
• Normal rate: $12$–$20$ (depending on the patient).
• Tachypnea: greater than $20$.
• Bradypnea: less than $12$.
• Depth: the amount of air taken in (usually around $500$ ml).
• Should be regular and uninterrupted.
• Normal respirations are quiet, not audible without a stethoscope.
• Occasional sighs are normal to aerate alveoli.

Assessment of Respiration

• Note rate, depth, quality, and rhythm.
• Assess the depth by observing the movement of the diaphragm and intercostal muscles.
• Observe for retractions around collarbones or between ribs.
• Quality should be quiet, and rhythm should be regular.
• Dyspnea, labored breathing, pursed lips, flared nostrils, and clavicular/costal retractions are signs of distress.

Factors Influencing Respiration

• Pain: increases respirations.
• Age: lung capacity increases with age, so respiratory rate decreases. Older adults have decreased lung capacity, which causes decreased depth and increased rate.
• Body position: slumped position versus sitting erect allows for full expansion. Slumping does not. Avoid lying flat because it limits chest expansion.
• Brain stem injury: decreases respirations.
• Disease/illness: can increase or decrease respiratory rates.
• Exercise: increases respirations.
• Fever: increases respirations.
• Gender: men have greater lung capacity than women.
• Hemoglobin function: decreased hemoglobin function increases respiration rate (body compensates).
• Medications: narcotics and bronchodilators decrease; amphetamines/cocaine increase.
• Smoking: increases respirations.
• Stress: increases respirations.

Patterns of Respiration

• Apnea: lack of spontaneous respiration.
• Cheyne-Stokes respirations: alternating periods of apnea and deep, rapid breathing (critically ill/terminal).
• Hyperventilation: volume and depth increase.
• Hypoventilation: rate and depth decrease.
• Kussmaul's respirations: rapid, deep, and labored (often seen in diabetics).

Nursing Interventions for Abnormal Respirations

• Occasional periods of apnea are a symptom of underlying disease in adults.
• Report to healthcare provider.
• Assess for comfort; discomfort can cause the patient to breathe more.
• Allow for periods of rest.
• Observe for obstructed airway.
• Observe for signs/symptoms: cyanotic nail beds, lips, mucous membranes, restlessness, irritability, confusion, dyspnea, shortness of breath, productive cough, abnormal breath sounds.
• Assist patient to a sitting position and administer oxygen as ordered.

Blood Pressure

• Normal blood pressure: $120/80$.
• Normal pulse pressure: $40$ mmHg (indication of cardiac function).
• Blood pressure reflects cardiac output (the amount of blood discharged from the heart per minute). Greater amount of blood means greater pressure.
• Constricting arteries increase pressure.
• Increased viscosity (thickness) causes slower flow.

Blood Pressure Categories

• Normal, pre-hypertension, hypertensive crisis.
• Hypotension (low blood pressure) is healthy if no ill effects (vertigo, syncope).

Factors Influencing Blood Pressure

• Alcohol and tobacco: increase blood pressure.
• Anxiety, fear, pain, emotional stress: increase blood pressure.
• Diet: unhealthy diets increase (sodium, fats, sugars).
• Diurnal variations: lower in the morning, higher during the day, lower at night.
• Gender: men have greater risk until age 45, women after age 65.
• Hormones: particularly during pregnancy.
• Medications: cold medications increase, diuretics/BP meds decrease.
• Obesity: increases workload on the heart, increasing blood pressure.
• Race: hypertension more common in African Americans.

Conditions Causing Alterations in Blood Pressure

• Hemorrhage: decreases blood pressure (decreased blood volume).
• Increased intracranial pressure: increases blood pressure.
• Acute pain: increases blood pressure (sympathetic stimulation).
• End-stage renal disease: increases blood pressure (increased blood volume from sodium/water retention).
• Primary essential hypertension: increases blood pressure (thickening of arterial walls).
• General anesthesia: decreases blood pressure (depression of vasomotor center).
• Postural changes: decrease blood pressure; teach patients to change positions slowly.

Orthostatic Blood Pressure

• Drop of $25$ mmHg in systolic pressure and $10$ in diastolic pressure when moving from lying to sitting or sitting to standing.
• Occurs when rising too quickly.
• Symptoms: light-headedness, instability.
• Advise patient to rise slowly.

Measuring Orthostatic Blood Pressure

• Start supine; check blood pressure in both arms (use the higher systolic reading).
• Help patient sit with feet dangling; wait 1-3 minutes, then check blood pressure.
• Help patient stand if able; wait 1-3 minutes, then check blood pressure.
• Terminate if orthostatic symptoms occur; assist back to bed.

Symptoms to Watch For

• Dizziness, weakness, lightheadedness, feeling faint, sudden power loss.
• Keep the blood pressure cuff in the same position throughout.
• Report the blood pressure readings and any symptoms that occurred. (e.g., $140/80$ supine, $132/72$ sitting, and $108/60$ standing).
• If positive, the patient should notify staff before getting out of bed.

Measuring Blood Pressure in Lower Extremities

• Use if upper extremities are inaccessible (e.g., bilateral mastectomy).
• Auscultate at the popliteal artery behind the knee.
• Place the cuff on the thigh (use a thigh cuff).
• Systolic pressure is usually $10$–$40$ mmHg higher in the lower extremities.

Electronic Blood Pressure Measurements

• Do not use on patients with:
  • Arrhythmias, excessive tremors, inability to cooperate, irregular heart rates, obese extremities, older adults, peripheral vascular obstructions, seizures, or shivering.

Nursing Interventions for Abnormal Blood Pressure

• Repeat assessment.
• Minimize noise interference.
• Patient should be sitting or lying with feet uncrossed for at least five minutes.
• Avoid temperature extremes.
• Ensure appropriate cuff size.
• Explain to children that it will feel like a tight hug.
• Explain that beeping doesn't mean anything is wrong.
• Measure blood pressure in the other arm if abnormal.
• Observe for symptoms of hypertension. Headache, nosebleed, flushed face.
• Observe for symptoms of low blood pressure such as weak thready pulse, weakness, vertigo, confusion, pale, dusky, or cyanotic skin, or cool mottled skin.

Clinical Question

• The nurse obtains a supine blood pressure reading of $130/64$. One hour later, the nurse obtains a supine blood pressure reading of $134/62$ and a sitting blood pressure reading of $95/62$. What should be the immediate action of the nurse?
  • The answer is 4) Question the patient about any symptoms
  • Assess your patient and not just rely on vital signs.

Weight

• Weight determines medication dosages in children, especially nutritional balance and water balance.
• $1$ liter of fluid = $1$ kilogram = $2.2$ pounds.
• Significant weight loss can indicate underlying disease.
• Weigh at the same time of day, on the same scale, with the same amount of clothing (ideally in the morning after voiding and before breakfast).

Assessment

• Vital signs should be taken first to guide further assessment. For example: if you have an abnormal respiratory rate, it would signal you to listen to the lungs.
• Sometimes you will only need to take one vital sign, such as after giving blood pressure medication, you would only need to take the blood pressure.
• Part of clinical judgment involves deciding which vital signs to assess and measure and when and how frequently.