Transcript
Begins when first meet client
Physical appearance
Mental Status
Mobility
Behavior
Attention to detail - clues to problems for further assessment
General appearance: healthy, obvious conditions
Age: close to stated age
Skin: color (variations), lesions
Hygiene: cleanliness, grooming, odors
Stature: height appropriate for age
Nutritional status: well nourished,
cachectic, obese
Symmetry: R/L sides similar
While client is responding to
questions and giving information
about history
Affect and mood
Level of anxiety
Orientation to person, place & time
Speech
Body movement
Gait
Posture
Range of Motion
Dress and Grooming
Body odors
Facial expression
Mood and affect
Ability to make eye contact
Level of anxiety
Ask client first before getting
measurements
Helps establish baseline data and
helps determine health status
Medication dosage calculation
Adult height attained between 18 and
20 years
Baseline indicators of a client’s health status
A change can indicate a change in physiological function
Vital Signs:
T = Temperature
P = Pulse
R = Respiratory Rate
BP = Blood Pressure
O2 sat = Oxygen Saturation
Pain
Nurse’s responsibility/delegation
Knowledge of equipment
Knowledge of client’s range
Knowledge of client’s history and current status
Environmental factors
Systematic approach
Approach with the client
Frequency of assessment
Assessment for medications
Analysis and verification of results
Communication of results
Regulated by hypothalamus: heat gain vs.
heat loss
96.4° to 99.1° F (36.8° to 37.3° C)
98.6° F (37° C) core temp
Cellular metabolism most efficient
Stays relatively constant despite
environmental changes and physical
activity
Age
Diurnal variations:
Lowest in early morning (0100-0400), higher in late afternoon/evening (max @ 1800)
Menstrual cycle: temp and persists until ovulation (due to progesterone )
Exercise also increases temp (metabolism)
Stress temperature
Oral: glass, paper, or electronic thermometer (normal 98.6F/37C)
Axillary: glass or electronic thermometer (normal 97.6F/36.3C)
Rectal or "core“: glass or electronic thermometer (normal 99.6F/37.7C)
Tympanic: electronic thermometer (normal 99.6F/37.7C)
Of these, axillary is the least and rectal is the most accurate.
Normal 97 – 99.9F
Delay 10 minutes if ingested hot/cold liquids
Electronic thermometer (sheathed): under
tongue, place in either right or left posterior
sublingual pocket (15-30 seconds)
Safe for children/confused adults
Don’t take oral temp if had oral surgery or
lesions
Normal 99.6F/37.7C
Probe covered, placed in external ear
canal; in contact with all sides of canal (2-
3 seconds)
Questionable reliability in children
(direction of beam)
Less than 3 years: pull down
Over 3 years: pull up
Adults: pull up and back
Normal 97.6F/36.3C
Common site for infants and children
Not close to major blood vessels
Low sensitivity to detect fever (febrile patients)
Electronic: middle of axilla with arms folded
Alternative site for those with oral inflammation,
wired jaws, oral surgery, mouth breathers
(nasal surgery)
Normal 99.6F/37.7C (.7 to .8o higher)
Used less frequently with newer methods
Used more common in comatose or seizing clients
Do not use if client had rectal surgery, hemorrhoids or lower GI disorders
Adults: less comfortable, more time, increased risk of infectionSims’ position
1.5 inches into rectum (electronic)
Children: last resort1 inch
Newborns, Infants: risk of rectal perforation½ inch
Shake down, verify
Insert cover, position properly
Wait 2-3 minutes
Read correctly
2 opportunities
Pat the axilla dry if moist
Bulb is placed in the middle of the
axilla
Wait 6-9 minutes
Compare reading to oral (one degree
less than oral)
Wear gloves, water soluble lubricant
Position in Sims or lateral
Insert ½ to 1 ½ inches depending on
age
(½ infant; 1 child; 1-1 ½ adult)
Wait 2-3 minutes
Compare reading to oral (one degree
higher than oral)
Know how to document on flow sheet
Terminology:
Hyperthermia: very high fever
Febrile: fever
Hypothermia: low fever
Afebrile: no fever
Factors Affecting Temperature:
Diurnal variation
Menstrual cycle
Exercises
Stress
Valuable information about cardiovascular system
Information regarding strength of the pulse and perfusion of blood to various parts of the body
Indirect reflection of heart contraction
Measure:
Rate: beats per minute
Rhythm: regularity (time between
beats)
Strength: volume of blood ejected with
each beat
Equality: comparison of same pulse in
opposite extremities by taking
simultaneously
Rhythm:
Regular rhythm
Evenly spaced beats; 30” x 2; 15” x 4
Irregular rhythm
Full minute
Regularly irregular: regular pattern overall with
“skipped” beats
Irregularly irregular: chaotic, no real pattern, very
difficult to measure rate accurately
Strength:
Bounding, strong, weak or thready
Pulse assessment sites:
Temporal
Carotid
Apical
Brachial
Radial
Femoral
Popliteal
Posterior tibial
Pedal
WHAT IS A NORMAL PULSE?
Adult: 60 to 100
Newborn: 120-170
1 year: 80-160
3 years: 80-120
6 years: 75-115
10 years: 70-110
Average Pulse and Blood Pressure
in Normal Children
Age Birth 6mo 1yr 2yr 6yr 8yr 10yr
Pulse 140 130 115 110 103 100 95
Systolic BP 70 90 90 92 95 100 105
Most frequently measured
Arm is supported on a bed, chair or nurse’s arm
Wrist is extended (not bent)
Lightly compress tips of first 2 fingers against
radius, obliterate pulse initially, and then relax
pressure so pulse becomes easily palpable
For a regular pulse count for 30 seconds and
multiply by 2
Irregular pulse: count for a full 60 seconds
Apical pulse:
Auscultate for 1 minute
5th intercostal space midclavicular
line
Use stethoscope when assessing
Measure rate and rhythm
Brachial: located in groove
between the triceps and biceps
muscle medial to the biceps
tendon in the antecubital fossa
Carotid: located along the
medial edge of the
sternocleidomastoid muscle in
the lower third of the neck
Radial: Accurate count
Apical: 60 seconds
Apical/Radial: 60 seconds
2 opportunities for each
Know how to document on flow sheet
Factors affecting pulse:
with exercise, fever, stress
with males, age, athletes
Terminology:
Pulse sites
Rate: beats per minute
Rhythm: regularity (time between beats)
Pulse deficit: difference between radial and apical
Bradycardia: < 60 bpm
Tachycardia: > 100 bpm
Exchange of O2 and CO2: oxygen reaches body
cells and carbon dioxide is removed from the
cells
Respiration involves:
Ventilation: the movement of gases in and out of
the lungs
Diffusion: the movement of oxygen and carbon
dioxide between the alveoli and the red blood cells
Perfusion: distribution of red blood cells to and from
the pulmonary capillaries
Best done immediately after taking the patient's pulse. Do not announce that you are measuring respirations.
Without letting go of the patients wrist begin to observe the patient's breathing. Is it normal or labored?
Count breaths for 30 seconds and multiply this number by 2 to yield the breaths per minute.
In adults, normal resting respiratory rate is between 14-20 breaths/minute.
Note the rate, rhythm, depth and effort of
breathing
Rate = number of ventilatory cycles
(inhalation and exhalation) per minute
Males: diaphragmatic (abdominal)
Females: thoracic
Rhythm = regularity of breathing (equal
space between breaths)
Regular or irregular
Depth = observation of excursion
(movement) of chest wall
Deep (large amount of air)
Normal
Shallow (small amount of air)
Effort: even, quiet, effortless
Accurate count (best for 30 sec.)
2 opportunities
Document on flow sheet
Factors affecting respiration:
with exercise, fever, stress,
altitude
Varies with age
Terminology:
Rate: number of ventilatory cycles (inh + exh)
Rhythm: regularity of breathing (reg or irreg)
Depth: observation of excursion (movement of chest wall) deep or shallow
Effort: even, quiet effortless
Tachypnea: fast
Bradypnea: slow
Apnea: no breathing
Dyspnea: difficulty breathing
Orthopnea: diff lying
Retractions: intercostals or substernal
Force of blood against arterial wall
Relationship between cardiac output and peripheral resistance
BP dependent on blood volume, velocity, vessel elasticity
Measured in mm Hg: height of mercury column from blood pressure
Systolic: maximum pressure on arteries during ventricular contraction (ejection)
Diastolic: minimum pressure on arteries during ventricular relaxation
BP = CO x R
BP= blood pressure
CO=cardiac output (heart rate x stroke vol)
R = Peripheral vascular resistance
Resistance refers to the resistance to blood flow determined by the tone of vascular musculature and diameter of blood vessels
As resistance rises, arterial BP rises
As vessels dilate and resistance falls, BP decreases
Recorded = systolic/diastolic (not a fraction)
Pulse pressure: difference between systolic and diastolic pressure 120/80=40 (usually 30- 40 mm Hg)
Direct: arterial catheterization
Indirect measurement
Sphygmomanometer and stethoscope (auscultation)
NIBPM: electronic sensing of vibrations, not Korotkoff sounds
Factors that affect BP measurements:Age: gradual rise
Gender: females males after puberty; females males after menopause;
Race: HTN 2x higher in African Amer
Diurnal variations: in early am; highest in late afternoon or early evening
Emotions: anxiety, stress or anger can
Pain: acute pain can
Personal habits: caffeine and smoking within 30 minutes before taking may
Weight: obese have
Medications
Upper arm most common site; thigh alternate site
(10-40 mm higher)
Blood flow occluded by inflated cuff
Cuff deflated until sounds of pulsing blood return
(1st Korotkoff sound); systolic pressure
Clear, rhythmic, thumping sound, increasing
intensity
2nd, 3rd, 4th Korotkoff sounds –
swishing/thump/muffled-low pitch sound
Pressure at which no sound heard indicates artery
completely open (5th Korotkoff sound); diastolic
pressure
Phase 1: sharp thuds, start at systolic blood
pressure
Phase 2: blowing sound; may disappear
entirely (the auscultatory gap )
Phase 3: crisp thud, a bit quieter than phase 1
Phase 4: sounds become muffled
Phase 5: end of sounds -- ends at diastolic
blood pressure
Common errors in BP measurement
Accuracy affected by technique
Research finds that providers incorrect
technique results from lack of
knowledge
False high/low measurements
Many errors due to wrong cuff size
False-high BP measurement:
Arm above level of heart
Cuff too narrow
Cuff too loose
Deflating cuff too slowly
Reinflating cuff without completely
deflating
Not waiting 1-2 minutes before repeat
measure
False-low BP measurement:
Arm below level of heart
Manometer higher than heart
Cuff too wide
Not inflating cuff enough
Deflating too rapidly
Pressing diaphragm too firmly on
brachial artery
Normal: <120/<80
Prehypertensive: 120-139/80-89
Stage 1 hypertension: 140-159/90-99
Stage 2 hypertension: >160/>100
Position the patient's arm so the antecubital fold is level with the heart. Support the patient's arm with your arm or a bedside table.
Center the bladder of the cuff over the brachial artery approximately 2 cm above the antecubital fold. Proper cuff size is essentialto obtain an accurate reading. Be sure the index line falls between the size marks when you apply the cuff. Position the patient's arm so it is slightly flexed at the elbow.
Palpate the brachial or radial pulse and inflate the cuff until the pulse disappears. Inflate an additional 20 mmHg higher and release cuff until you can again feel the pulse. This is a rough estimate of the systolic pressure.
Place the stethoscope over the brachial artery.
Inflate the cuff to 30 mmHg above the estimated systolic pressure.
Release the pressure slowly, no greater than 5 mmHg per second.
The level at which you consistently hear beats is the systolic pressure.
Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure.
Record the blood pressure as systolic over diastolic ("120/70" for example).
With fingers palpating radial or brachial artery, inflate
cuff rapidly until you can't feel the pulse, then 20 mm
higher
Release cuff at 2 to 3 mm Hg per second until you
again feel the pulse; this is the palpable systolic
pressure
Wait 30 seconds before measuring blood pressure
Measuring palpable pressure first avoids risk of
seriously underestimating blood pressure
Wash hands, clean stethoscope
Position patient
Obtain correct size BP cuff (40% width or 2/3 (80%) length)
Palpate brachial artery
Center bladder over artery
Wrap cuff securely, 1 inch above AC
Inflate cuff 30 above last heard or palpated systolic
Release valve slowly
Correct interpret readings (2 chances) within 4mmHg
Document on flow sheet
Factors affecting BP:
with age, after menopause, African Amer, in the PM, emotions, pain, caffeine, smoking, weight
after puberty and in the AM
Cuff size, medications, choice of arm
Terminology:
Systolic: top # (ventricle contracting)
Diastolic: bottom # (ventricle filling)
Pulse pressure: difference between systolic and diastolic
Orthostatic hypotension: drop in BP as you stand
When and why to avoid a certain arm:
Mastectomy
IV fluids or blood infusing
Burns
AV Grafts
Signs and symptoms of hypertension:
HA
Flushing
Ringing in the ears
Nose bleed
Signs and symptoms of hypotension:
Increased heart rate
Dizziness
Cool
Clammy
Included with vital signs
Pulse oximetry: oxygen saturation of hemoglobin
Probe on fingertip (other sites)
Digital readout
Saturation levels less than 90% necessitate further evaluation
Caregiver’s knowledge deficiency in measurement and interpretation reported
COLDSPAT
Character
Onset
Location
Duration (constant or intermittent)
Severity (On 0-10 scale)
Precipitating Factors
Alleviating Factors
Treatment
top related