NEO 111 Vital Signs Melanie Jorgenson, RN, BSN. Vital Signs include… ▫Blood Pressure (B/P)...
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Transcript of NEO 111 Vital Signs Melanie Jorgenson, RN, BSN. Vital Signs include… ▫Blood Pressure (B/P)...
Vital Signs include…
▫Blood Pressure (B/P)
▫Pulse (P or HR)—Radial or Apical
▫Respirations (RR)
▫Temperature—Oral, Rectal (R), Axillary (Ax),
▫Tympanic (Tymp), Temporal Artery
▫Pain Assessment Pulse Oximetry
Vital Signs – When?
•On admission•Based on policy and procedure•When there is a change in patient condition
•Before and after surgery or a procedure•Before and after activity that may increase risk
•Prior to medication administration that may affect CV or respiratory function
Pain “The 5th Vital Sign”
Pain is subjective—what ever the patient says it is
WILDA or HILDA assessmentWord/How does your pain feel (description)Intensity (pain scales)Location (new or chronic?)Duration (constant or intermittent?)Aggravating and Alleviating Factors (what
makes the pain worse/better, what interventions have been tried?)
Pain “The 5th Vital Sign”Nonverbal indicators of pain
GrimacingGuardingDecreased activity/mobility Increased pulse & B/P (acute pain only)Shallow respiration
Regular ongoing re-evaluation & re-evaluation after an intervention to determine effectiveness
Blood Pressure•Blood pressure is the force of blood against
arterial walls
•Systolic pressure is the highest pressure and correlates with ventricular contraction (systole)
•Diastolic pressure is the lowest pressure and correlates with ventricular relaxation (diastole)
•Blood pressure is written as Systolic/Diastolic
Blood Pressure
• Blood pressure should be taken with the proper size cuff ▫Index line within the range on the cuff or ▫The cuff height should be approx 40% of the
circumference of the limb used▫Too small cuff results in a false high reading▫Too large cuff results in a false low reading
• Exercise, Caffeine & Nicotine may alter B/P and pulse
• Avoid BP on extremity that has AV fistula, Peripheral or central IV or side that has had mastectomy and/or axillary node dissection
Blood Pressure
•Line up the artery line indicator with the artery (position the tubes on either side of the artery—tubes always located distal)
•Estimate your patient’s systolic B/P•1st Korotkoff sound = systolic pressure•Cessation of sound = diastolic pressure •B/P is read and recorded to the nearest
even number•Important to know patient’s baseline
blood pressure for comparison as well as “normal blood pressure” values
Normal & Abnormal Blood Pressure Values
• Normal <120 mm Hg systolic*; <80 mm Hg diastolic
• Always consider what is “normal” for your particular patient. (medications, age, etc…)
• Pulse pressure is the difference between the systolic and diastolic reading▫An increased or widening pulse pressure (>60
mm Hg) is concerning for cardiac disease (stiffening of arteries, atherosclerosis or other medical condition)
Orthostatic Hypotension (postural hypotension)How are Orthostatic B/P readings performed?
Have pt lay down for 3-5 mins take BP and pulse, sit for 2 min take BP and Pulse, stand for 2 min take BP and pulse
What indicates positive orthostatic hypotension?Drop in systolic BP of 25 mm Hg (text) 20 mm Hg (practice)
or a drop in diastolic by 10 mmg Hg when changing from a lying to sitting or sitting to standing position
Increase in pulse by 20 beats per minute when changing form a lying to sitting or sitting to standing position
Teach pt to rise slowly, raise HOB, dangle on side, slowly stand, return to a sitting or lying position if symptomatic.
Pulse
Record rate, rhythm and amplitude/quality
Normal pulse rate for an adult is 60-100 bmp
Normal pulse rate for a child (6-8 year old) is 75-110
Normal pulse rate for an infant is 80-180 (newborn); 80-140 (1-3 year old)
Apical Pulse
•Where do you place the stethoscope to listen to the apical pulse?
•How long do you listen to apical pulse?
Respirations
Observe at the sternal notch
Assess rate, rhythm, effort, depth ( if applicable)
An increase in carbon dioxide is the most powerful respiratory stimulant
Pulse oximeter
Questions….What is a “normal” respiratory rate in an
adult?12-20 breaths per minute
What is a “normal” respiratory rate in an child?15-25 (6-8 year olds)
What is a “normal” respiratory rate in an infant?30-60 (newborn); 20-40 (1-3 year old)
Abnormal Respirations
•Hyperventilation, Hypoventilation
•Apnea—apnea that lasts longer than 4-6 minutes may lead to brain damage and death
•Dyspnea, grunting, nasal flaring, retractions
•Orthopnea, Tachypnea, Bradypnea
Oxygen saturation
•Measures arterial oxyhemoglobin saturation (SaO2 or SpO2)
•Often need to remove artificial nails and nail polish
•Alternative sites-toe, earlobe, bridge of nose
Questions
•What is considered a “normal SaO2 range?▫ 95%-100%
•When is less than 95% an expected finding?
•Know pt’s Hgb level…why?
Temperature
•Surface & Core Temperatures▫Surface—Temperature of skin—Oral &
Axillary▫Core—Deep tissue—Rectal, Temporal Artery
& Tympanic
Temps are lowest in early morning and highest in late afternoon
Normal Value Relative to SiteOral used as a baseline 98.6°F or 37.0°C
Oral Temperature
•Patient should not drink, smoke, eat, chew gum for 15-30 minutes prior
•You should avoid and oral temp:▫ disease of mouth ▫ surgery of nose/mouth,▫ receiving oxygen by mask ▫ unable to close mouth
Axillary Temperature
•Often used for newborns
•If axilla just washed wait 15-30 mins
•Watch placement
Rectal Temperature
•Most accurate
•When should you avoid a rectal temperature▫ Newborns▫ small children▫ pt who had rectal surgery▫ diarrhea or disease of rectum▫ people with certain heart diseases (vagus nerve)▫ neutropenic pt▫ some neurologic disorders
Tympanic Temperature
Need good seal
Point probe toward opposite eye/jaw
When should you avoid taking a tympanic temperature?Drainage from ear, scars on tympanic membrane,
infection, radiation, narrow ear canal, hat
The pinna should be positioned up and back for an adult and down and back for a child
Documentation•Pt’s age, gender, race •Vital Signs:•T Ax, Tympanic, Rectal, O (assumed)•P Rate, Rhythm, Amplitude•R Rate, Rhythm, Effort (Depth if
needed)•BP result, extremity used, pt position•SpO2 receiving O2 or RA, where
assessed•Pain Assessment
Documentation
•October 2, 2009•0730 34 yr old Caucasian male VS: T
98.2°F L Tympanic R 16 regular, shallow, unlabored, P 86 L radial, regular, 2+, BP 126/86 L arm sitting. SpO2 96% on 2L NC L index finger. Pt states pain in left leg 1 on 1-10 scale. Patient in bed watching TV. Call bell in reach.----------------M Jorgenson, RN