NUR 304 - Fundamentals in Nursing Practice: Vital Signs Review

Course Introduction to NUR 304: Fundamentals in Nursing Practice

• Course Metadata:     * Course Identity: NUR 304 – Fundamentals in Nursing Practice.     * Course Instructor: Dr. Ruth Everett-Thomas $Ph.D., MSN, RN, CHSE$, Associate Professor of Clinical.

• Course Purpose and Scope:     * This class is designed to build a foundation of knowledge and skills required for nursing school and professional nursing careers.     * Components: Includes a skills lab, simulation sessions, and clinical site portions to allow for the application of knowledge to real-world situations.     * Focus: Fundamentals consist of the primary day-to-day duties performed by a nurse.

• Today’s Schedule:     * Course Orientation and Syllabus Review.     * Chapter 1 – Nursing Today (Assigned as independent reading).     * Chapter 29 – Vital Signs.     * Jared Ross – Sherpath Orientation ($11:00am$).

Skills Lab Logistics and Requirements

• Attendance: All students must report to the $5^{th}$ floor (Room 5409) of the SONHS Simulation Hospital this Thursday from $7:30am$ to $3:30pm$.

• Grouping: Students will be divided into clinical groups with clinical instructors (Sections NUR 304-01 to 304-08, as listed in CaneLink).

• Pre-work Requirements:     * Students must complete specified Skills Videos and Quizzes.     * Deadline: Wednesday at $11:59pm$.

• Dress Code:     * Official SONHS uniform with ID badge.     * If the uniform is unavailable: Business casual attire is required.     * Prohibited Attire: Shorts, ripped jeans, tank tops, and flip-flops.

The Nursing Process (ADPIE)

• Assessment: The phase involving observing and gathering data/information.

• Diagnosis: Using gathered information to make a formal nursing diagnosis.

• Planning: Creating a plan of action to care for the patient, including setting goals.

• Implementation: Taking action and implementing the treatment plan (the specific actions the Registered Nurse will take).

• Evaluation: Evaluating the outcome of the interventions against expected goals.

Introduction to Vital Signs

• Definition: Assessment of vital or critical physiological functions.

• Contextual Evaluation: Vital signs must always be evaluated within the context of the patient's clinical condition.

• Components of Vital Signs:     * Temperature.     * Pulse.     * Respiratory rate.     * Oxygen saturation ($SpO_2$).     * Blood pressure.     * Pain (referred to as the $5^{th}$ Vital Sign).

• General Assessment Guidelines:     * Measuring vital signs is the direct responsibility of the nurse.     * The nurse must ensure equipment is functioning correctly and select appropriate equipment (e.g., correct cuff size) for the patient.     * The nurse must know the patient's usual range of vital signs for baseline comparison.     * Significant changes must be verified and communicated.     * The nurse should be aware of the patient's health history, current therapies, and medications (both prescribed and over-the-counter).     * Environmental factors must be controlled, and the nurse must remain organized.     * Findings should be used to provide patient teaching.

Body Temperature Physiology and Measurement

• Physiological Regulation: Includes neural and vascular control, heat production (metabolism/movement), heat loss (skin/breathing), and behavioral control.

• Heat Production Mechanisms:     * Basal Metabolic Rate (BMR).     * Skeletal Muscle Movement.     * Nonshivering Thermogenesis.

• Heat Loss Mechanisms:     * Radiation.     * Convection.     * Evaporation.     * Conduction.

• Standard Temperature Ranges:     * Average Range: $96.8^{\circ}F$ to $100.4^{\circ}F$ ($36^{\circ}C$ to $38^{\circ}C$).     * Average Oral/Tympanic: $98.6^{\circ}F$ ($37^{\circ}C$).     * Average Rectal: $99.5^{\circ}F$ ($37.5^{\circ}C$).     * Average Axillary: $97.7^{\circ}F$ ($36.5^{\circ}C$).

• Factors Affecting Temperature:     * Age: Infants and older adults have diminished thermoregulatory capacity.     * Exercise: Increases heat production.     * Hormone Level: Variations (e.g., menstrual cycle) affect core temp.     * Circadian Rhythm: Temperature is typically lowest during sleep ($1:00am$ to $4:00am$) and highest in the late afternoon.     * Stress: Physical or emotional stress increases temperature.     * Environment: Ambient temperature affects heat loss/gain.

Temperature Variations and Abnormalities

• Hyperthermia/Pyrexia (Fever):     * Febrile Range: > 100.4^{\circ}F ($38^{\circ}C$).     * Heatstroke: Temperature > 104^{\circ}F ($40^{\circ}C$). Symptoms include confusion, dizziness, and unconsciousness. Can lead to death or permanent disability.     * Heat Exhaustion: Symptoms include heavy sweating, nausea, weakness, thirst, and dizziness. Can lead to heatstroke.

• Hypothermia:     * Definition: < 96^{\circ}F ($36^{\circ}C$).     * Symptom Threshold ($93.2^{\circ}F$ or $34^{\circ}C$): Uncontrolled shivering, loss of memory, depression, poor judgment.     * Physical Decline: Decreases in Heart Rate ($HR$), Respiratory Rate ($RR$), Blood Pressure ($BP$), and Level of Consciousness ($LOC$). Dysrhythmias and cyanosis may develop.     * Severe Cases: Clinical signs similar to death (lack of response to stimuli, extremely slow respirations/pulse).     * Frostbite: Localized injury due to freezing.     * Deliberately Induced Hypothermia: Used for specific surgical or emergency procedures.

Temperature Assessment Sites and Equipment

• Equipment Types:     * Electronic thermometers.     * Tympanic membrane thermometers.     * Temporal artery thermometers.     * Chemical dot thermometers.     * Infrared Forehead thermometers.

• Core Sites:     * Tympanic (shares blood supply with the carotid artery).     * Rectal.     * Critical Care sites: Pulmonary artery, urinary bladder, esophageal.

• Surface Sites:     * Oral.     * Axillary.     * Skin.     * Temporal artery.

• Site-Specific Characteristics:     * Tympanic: Fast ($2-5$ seconds), good for uncooperative clients. Inaccurate if cerumen (earwax) is impacted. Contraindicated in ear surgery or active ear infections.     * Oral: Affected by hot/cold drinks, ambient air, rapid respiratory rate, cigarette smoking, and oxygen flow. Patient must be able to follow directions.     * Axillary: Safe and easy for uncooperative clients but often underestimates core temperature.     * Rectal: Used when patients cannot follow directions. Risks include injury to the mucosa. Contraindicated for patients with impaired rectal mucosa or those who are immunocompromised (e.g., neutropenic, AIDS, transplant, or chemotherapy patients).

Nursing Interventions for Temperature Alterations

• Fever Management:     * Obtain culture specimens (urine, blood, sputum, wound sites) before starting medications.     * Administer antibiotics after cultures are obtained.     * Administer Antipyretics: Acetaminophen and Non-steroidal anti-inflammatory drugs (NSAIDs).     * Nonpharmacological therapies should be used but must not stimulate shivering.

• Heatstroke Management:     * Move to a cooler environment.     * Remove excess clothing.     * Use cool, wet towels and oscillating fans (convective heat loss).     * Emergency medical treatment: Administer IV fluids; Irrigate stomach and lower bowel with cool solutions; Apply hypothermia blankets.

• Hypothermia Management:     * Remove wet clothes and replace with dry ones.     * Wrap in blankets.

• Sample Nursing Diagnosis (NANDA):     * Hyperthermia related to decreased ability to perspire as evidenced by oral temperature of $104^{\circ}F$.

Pulse Assessment

• Definition: Palpable bounding of blood flow in a peripheral artery; an indirect indicator of circulatory status.

• Normal Range: $60$ to $100$ beats per minute (BPM).

• Cardiac Hemodynamics:     * Systole: Left ventricle contracts; blood is forced into arteries.     * Diastole: Left ventricle relaxes; arteries constrict.     * Cardiac Output ($CO$): The volume of blood pumped by the heart in one minute ($CO = HR \times SV$). Normal: $5-8\,L/min$.     * Heart Rate ($HR$): Number of times the heart pumps in one minute.     * Stroke Volume ($SV$): Volume of blood pumped from one ventricle with each beat. Normal: $50-100\,mL/beat$.

• Factors Influencing Pulse: Developmental level, exercise, emotion, temperature, disease, hemorrhage (blood loss), postural changes, medications, and foods.

• Assessment Locations:     * Temporal: Over temporal bone.     * Carotid: Along the sternocleidomastoid muscle. Caution: Never assess carotid pulses simultaneously to avoid cutting off brain circulation.     * Apical: Located at the $4^{th}$ or $5^{th}$ intercostal space at the left midclavicular line (MCL). Assessed via auscultation for a full minute if peripheral pulse is abnormal; it is the most accurate assessment of cardiac contraction.     * Brachial: Antecubital fossa.     * Radial: Thumb side of the wrist (easy to palpate).     * Ulnar: Opposite side of radial.     * Femoral: Groin.     * Popliteal: Behind the knee.     * Posterior Tibial: Inner ankle.     * Dorsalis Pedis: Top of the foot.

• Character of Pulse:     * Rate: Beats per minute.     * Rhythm: Regularity of intervals.     * Strength: Volume of blood pushed against the wall.     * Equality: Symmetry between left and right sides.

Respiration and Oxygen Saturation

• Components of Respiration:     * Ventilation: Mechanical movement of gases in and out of lungs.     * Diffusion: Movement of oxygen and carbon dioxide between alveoli and red blood cells.     * Perfusion: Distribution of red blood cells to and from pulmonary capillaries.

• Regulation: Regulated by the respiratory center in the brain stem, primarily via $CO_2$ levels, $O_2$ levels, and arterial blood $pH$ (Hydrogen ion concentration).     * Note: Patients with chronic lung disease are often sensitive to low $O_2$ levels (hypoxemia) as a stimulus to breathe.

• Mechanics:     * Inspiration: An active process.     * Expiration: A passive process.

• Ventilation Assessment:     * Rate: Normal Healthy Adult is $12-20$ breaths per minute.     * Depth: Deep or shallow, normal or labored.     * Rhythm: Regular or irregular (e.g., Cheyne-Stokes).     * Technique Tip: Patient should be unaware of assessment; typically performed immediately after pulse assessment.

• Oxygen Saturation ($SpO_2$):     * Assessed via pulse oximeter probe (bounces light off hemoglobin).     * Normal Range: $95-100\%$.     * Sites: Finger, earlobe, forehead, or bridge of nose.     * Special Needs: Patients with tremors or peripheral vascular disease require alternative sites (ear or nose). Clip-on or tape-on sensors are available for obesity or latex allergies.

• Capnography: Measures ETCO2; normal range is $35-45\,mm\,Hg$.

• Nursing Diagnoses: Activity Intolerance, Impaired Airway Clearance, Impaired Breathing, Impaired Gas Exchange.

Blood Pressure ($BP$) Assessment

• Definition: The force exerted on the walls of an artery by pulsing blood.     * Systolic Pressure: Peak pressure during ventricular contraction.     * Diastolic Pressure: Minimum pressure when ventricles are at rest.

• Physiological Determining Factors: Cardiac output, peripheral resistance, blood volume, viscosity, and elasticity of the arteries.

• Categories of BP in Adults:     * Normal: < 120\,mm\,Hg Systolic AND < 80\,mm\,Hg Diastolic.     * Elevated: $120-129\,mm\,Hg$ Systolic AND < 80\,mm\,Hg Diastolic.     * Hypertension Stage 1: $130-139\,mm\,Hg$ Systolic OR $80-89\,mm\,Hg$ Diastolic.     * Hypertension Stage 2: $≥ 140\,mm\,Hg$ Systolic OR $≥ 90\,mm\,Hg$ Diastolic.     * Hypotension: Systolic Blood Pressure ($SBP$) falls to $90\,mm\,Hg$ or below.

• Orthostatic Hypotension: Occurs when blood volume is decreased, causing a drop in BP when changing positions. Defined as a drop of at least $20\,mm\,Hg$ SBP or $10\,mm\,Hg$ DBP within 3 minutes of standing.     * Nursing Action: Help patient to a lying position to prevent falls. Do not delegate orthostatic BP measurement to a CNA.

• Measurement Technique:     * Cuff Size: Width should be $40\%$ of upper arm circumference; Length should be $80\%$ of the upper arm (cover about $2/3$ of the extremity).     * Sphygmomanometer (Manual): Generally more accurate, common in clinics.     * Automated Oscillometric (Dynamic): Common in hospitals.     * Two-Step Method: First, palpate the radial pulse and inflate the cuff until the pulse disappears to estimate the systolic pressure; then, auscultate for the BP using the stethoscope.

• Korotkoff Phases:     * Phase 1: Sharp thump (Systolic pressure).     * Phase 2: Blowing or whooshing sound.     * Phase 3: Crisp, intense tapping.     * Phase 4: Softer blowing sound that fades.     * Phase 5: Silence (Diastolic pressure).

• Contraindications for Electronic BP: Irregular heart rate, known hypertension, peripheral vascular obstruction (clots), shivering, seizures, excessive tremors, inability to cooperate, or SBP < 90\,mm\,Hg.

Clinical Guidelines and Safety

• When to Measure Vital Signs:     * On admission to a health care facility.     * During home care visits.     * In clinics before a provider exam and after invasive procedures.     * On a routine hospital schedule (hospital standards or provider orders).     * Before, during, and after surgery or blood product transfusions.     * When the physical condition changes (loss of consciousness, increased pain).     * Before/after interventions that influence vitals (ambulation after bed rest).     * If a patient reports nonspecific symptoms like feeling "funny."

• Safety Guidelines:     * Clean devices between patients to prevent infection.     * Rotate sites for repeated BP or oximetry to prevent skin breakdown.     * Analyze trends rather than isolated values.     * Determine patient stability before delegating vital sign tasks.

Questions & Discussion

• Scenario Question: An older adult is admitted unconscious with high temperature, increased heart rate, and nonreactive pupils. Which intervention is expected?     * Response: Irrigating the stomach and lower bowel with cool solutions. This is because heatstroke results in high mortality and brain damage without rapid cooling. Antibiotics are for fever of unknown origin (infection), not heatstroke. Warm blankets are for hypothermia.

• Prioritization Exercise (Think-Pair-Share): Using clinical judgment to prioritize following shift handoff:     * Patient A: 84-year-old, pneumonia, $RR\,28$, $SpO_2\,85\%$. (High Priority due to respiratory distress/low oxygen saturation).     * Patient B: 54-year-old, post-fracture surgery, $BP\,160/86$, $HR\,72$.     * Patient C: 63-year-old, diabetic venous ulcers, $Temp\,37.3^{\circ}C$, $HR\,84$.     * Patient D: 77-year-old, post-mastectomy 36 hours ago, $Temp\,38.3^{\circ}C$, $HR\,110$, $RR\,22$, $BP\,148/62$.