hi my name is Andrea Murdoch dnprn today we're going to be talking about measuring Vital Signs we're going to talk about the who the what the why the when and the where is of Vital Signs so let's get started what are Vital Signs and why are they important Vital Signs is an assessment of vital or critical physiological functions the main four vital signs are temperature pulse respiration and blood pressure they are the most frequent assessment a nurse will perform accurate measurements and documentation of each are a top priority therefore do not become complacent with normal vital signs for Grant taking normal vital signs for granted remember that all those stable Vital Signs May indicate physiological well-being they do not guarantee it they are limited in detecting or confirming some important physiological changes in other words evaluate the vital signs in the context of your overall assessment and relate them patients specifically vital signs of valuable subjective and objective indicators of one's health it gives a baseline data on a patient's condition what are other Vital Signs and their importance other vital signs are pain oxygen saturation which the normal range for oxygen saturation is 95 to 100 percent smoking status smoking greatly impacts body functions and therefore affects vital signs emotional distress can also have an impact on a person's overall physiological function when should you measure a patient's Vital Signs and many clinical settings vital signs are measured and documented in commonly occurring sub circumstances such as on admit most of the time a vital signs are taken when a person presents to the emergency room once if they are admitted to the hospital then another full set of vital signs are taken and that's to develop a baseline of that particular patient's current health status then at the beginning of a shift at the beginning of every shift a visit to the healthcare provider's office or clinic before administering certain meds to monitor the effects of medications or activities whenever there's a change in a patient's condition table 20-1 shows average normal findings for adults however it is critical to remember that each patient has their own Baseline for normal agency policies also determine the frequency of monitoring and recording vital signs in most hospitals vital signs are recorded routinely every four hours in the home health settings vital signs are taken at each visit also in the clinic at each visit however in a nursing home or a skilled facility vital signs are taken weekly or monthly however if the patient is getting medication that requires a specific Vital sign for instance antibiotics you have to take the temperature with any medicine medications contained into cardiovascular system you have to take a blood pressure heart rate especially with uh a medicine named digoxin you have to take a apical pulse before you give that also you can use your nursing judgment to monitor Vital Signs more frequently than uh prescribed let's start with temperature body temperature most facilities use a thermometer similar to this one body temperature is only the degree of heat maintained by the body it is the difference between heat produced by the body and heat lost to the environment what is thermal regulation thermal regulation is the process of maintaining a stable internal body temperature the body must balance heat production and heat loss the hypothalamus which works like a thermostat recognizes body temperature changes set by sensory receptors in your skin temperature is the degree of heat maintained by the body it is the difference between heat produced by the body and the heat loss to the environment core temperatures core temperature is the temperature deep within the body such as within the visceral rectal temperatures measure core temperatures and requires in order oral and axillary are surface temperatures viscera is the internal organs in the main cavities of the body such as the heart of the lungs and the chest and the liver pancreas or intestines in the abdominal area those core temperatures are relative core temperatures are relatively constant and are not influenced by the environment they are typically one degree Fahrenheit to 2 degrees Fahrenheit higher than surface skin and the temperature varies based on a person's age what is a normal temperature there's no single number normal because body temperature varies varies among individuals as a result of difference in metabolism each person's temperature fluctuates with age gender exercise and the environment however sea table 20-1 on page 413 for the average normal temperature research recommends that body temperatures be evaluated based on an individual's Norm or variability table 20-2 on page 14 shows age-related variations for all Vital Signs including temperatures however we will mainly focus on adults and older adults young adults middle adults and older adults there are slight variations in temperatures the average normal temperature is oral 98 degrees Fahrenheit to 98.6 degrees Fahrenheit it is usually not considered a fever until it reaches 100.4 degrees Fahrenheit a rectal temperature however the normal range is 99 degrees Fahrenheit to 99.6 degrees Fahrenheit and it is usually not considered a fever until 101 degrees Fahrenheit variations of temperature above or below normal if temporary usually are not significant however greater variations indicate a disturbance of function in some systems our region of the body some are cute even fatal infections may cause only a mild elevation in temperature however the caveat is a continuous elevation even slight is cause for concern and indicates a need for further evaluation such as close monetary because you do not want that temperature to get too high what is the response to variations in temperatures the neurofeedback mechanism in the hypothalamus senses internal temperature changes and initiates compensatory mechanisms to maintain a stable environment remember we want things to stay in homeostasis are stable decreasing the body temperature when heat senses are stimulated they send impulses to reduce the body's temperature by causing peripheral vasodilation and sweating and it inhibits heat production the vasodilation diverts core warmed blood to the body surface where heat can be transferred to the environment increasing the body temperature when the sensor in the hypothalamus detects cold it sends out impulses to increase heat production and reduce heat loss the battery response by shivering and the release of epinephrine which increases metabolism vasoconstriction occurs to conserve Heat by shunting blood away from the periphery to the core of the body where the blood is warmed behavioral Will Roll control of temperature when you feel cold you can turn up the thermostat put on more clothes or move to a warmer space when you feel warm you can turn on the air conditioning or fan remove some clothes and take a cool shower how is he produced in the body metabolism the sum of all physical and chemical processes and changes that take place in the body hyperthyroidism increases the metabolic the metabolic basal rate and they often complain of being warm or high where hypothyroidism they often complain of being cold non-shivering thermal a skeletal muscle movement the breakdown of fats and carbohydrates and muscles produces energy and heat and raises body temperature however if you go outside in this cold you shiver to produce heat non-shivering thermogenists the metabolism of brown fat and infants which we don't really talk about infants um however this mechanism disappears in a few months radiation heat loss through electromagnetic waves emitting from surfaces warmer than the surface area if the skin is warm is warmer than the air the body loses heat through the skin a room warms with more people in it a cool body can warm from a heat Source or being in the sun convection the transfer of heat through currents of air or water for instance immersing a hypothermic patient in a warm bath currents of cool air from a fan can help in reducing the fever evaporation water is converted to vapor and lost from the skin such as in perspiration or the mucous membranes through breathing evaporation causes cooling it is also called insensible loss more humid less cooling occurs y'all notice when it's really humid we're more we're much we feel much hotter than when it's not as humid conduction direct contact transfers heat from a warm to a cool surface putting on lighter clothes or touching it cooler surface what factors influence body temperature developmental level developmental level older adults have a slower metabolism they have decreased Vaso motor control and loss of subcutaneous tissue the environment warm rooms high humidity high beds can increase body temperature High external cancer High external temperatures can significantly increase internal temperatures causing heat stroke cold environment can lower body temperature if severe it causes hypothermia six a woman's temperature varies with her menstrual cycle and with pregnancy body temperature is low when progesterone is low and increases as progesterone levels increase hormonal fluctuations doing menopause can cause hot flashes exercise increasing Metabolism from hard work or strenuous exercise the sweat produced evaporates and helps to cool the body emotions and stress emotional stress excitement anxiety and nervousness stimulates the sympathetic nervous system causing the product the production of epinephrine and norepinephrine thereby increasing Body temp the Circadian rhythm body temperature can fluctuate over the course of 24 hours usually lowest in the early morning and look and high in the late afternoon or early evening sorry about that what is fever and fever is an oral temperature higher than 100 degrees Fahrenheit or 37.8 degrees Celsius or a rectal temperature 101 degrees a 30 80.3 degrees Celsius in an adult when a person has a fever they are considered febrile when they don't have a fever they are considered a febrile Baseline effects some people especially older adults have a lower than average Baseline diurnal effects body temperature can fluctuate throughout the day so you need several readings at different times of the day so we look at a patient's trends when assessing vital signs a moderate fever a moderate fever is a natural defense against infection and does not pose a threat to most people its benefit is that it enhances the immune response it kills or inhibits the growth of microorganisms enhances phagocytosis causes the breakdown of lysosomes and self-destruction of virally infected cells and releases interferon which protects cells from viral infections a caveat hyperpyrexia or fever above 100 point 105.8 degrees Fahrenheit or 41.0 degrees Celsius is dangerous and requires intervention to prevent damage to body cells especially in the brain leading to confusion delirium seizures or coma foreign pyrogens induce secretion of prostaglandins which resets the hypothetic hypothalic thermostat at a higher temperature which is called the set point the body's heat regulating mechanism then acts to bring the core temperature up to this new level when the stressor is removed the set point resets that normal pyrogens they are specialized white blood cells that ingest bacteria or foreign substances and then this us then they are the phagocytes secretes pyrogens there are four ways I mean I'm sorry there are three phases of a fever the initial phase is when the temperature is increasing but has not reached a new set point it may be sudden gradual and usually make you feel chilly uncomfortable or even shiver the second phase is the course body temperature reaches reaches its Max and remains constant a person becomes flush and feels warm and dry which may last a few days to a few weeks the third phase is the is the definitions of the crisis temperature returns to normal the persons feel warm and appears to be flush because of vasodilation diaphoresis which assists in heat loss by evaporation that's when the fever is breaking then you have four ways to describe a fever the intermittent fever the temp temperature alternates from fever to normal or below normal without pharmacological interventions or returns to normal at least once in a 24-hour period you have a remitting fever it fluctuates a fluctuation in temperature All Above normal for 24 hours a constant or a sustained fever the temp May fluctuate slightly but it's always above normal relapsing or recurrent fever you have sharp periods of fever alternating with periods of normal temperature each less than one to two days let's talk about our example problem hyperthermia heat exhaustion heat stroke their theoretical knowledge the temperature above normal or higher than the set point if untreated heat stroke can cause damage to the heart brain kidney or other vital organs resulting in permanent disability and even death ideology overexposure to high temperatures and inadequate fluid replacement a person loses the ability to sweat therefore is unable to cool down or either rigorous physical activity in hot weather dehydration and excessive alcohol intake in hot weather your assessment you should assess and monitor body temperature and also refer to your the Practical knowledge section on page 418. signs and symptoms of heat exhaustion are diaphoresis weakness nausea vomiting syncope tachycardia tachypnea muscle aches headache flushed skin signs and symptoms of a heat stroke are the body is unable to sweat rapid breathing rapid strong pose throbbing headache delirium confusion slur speech impaired judgment lethargy red hot dry skin dizziness seizures and coma what are your analysis and diagnosis hyperthermia and effective thermal regulation deficient fluid volume your outcomes you want a person's body temperature to become within normal range with the pulse and respirations and normal normal range as well no clinical signs of fever no damage to vital organs good skin terga no alteration and mental status your collaboration and Minister Miss is prescribed muscle relaxant if shivering antibiotics if it is because of a bacterial infection your interventions are you are going to refer to the knowledge on Section on page 418 for each um however we're gonna elaborate on each heat exhaustion and heat stroke interventions for heat exhaustion are have the patient rest in a cool dry place which makes sense right encourage plenty of fluids loosen and remove excess clothes apply ice packs a cool wash clothes to the Head the groin the neck and the axillary provide cool warm water Mist like uh fan skin and or use a fan of skin while it's moist y'all know they have those moistures um those fans that sprays moisture and stuff that the with the sports centers and stuff when it's hot that's what they're talking about interventions for heat stroke collect specimens to determine the cause of the fever have an IV access administer cool IVF on fluids cooling blankets minimal bed covers keep linen dry to prevent chilling and shivering provide appealing nutritional Foods mouth care with water-soluble lubricant to prevent cracked lips and swollen tongue monitor temperature every two hours or as prescribed urine output you want to measure urine output you want to move the person to a shady area if if outside and provide cooling measures what are your teachings you're going to teach preventative measures to minimize the risk of hyperthermia plenty of fluids avoid sugar alcohol or caffeine wear loose clothing lightweight light colored clothes avoid long sun exposure limit time working or exercising in hot weather teach size of heat exhaustion and to notify the physician of science present for older adults you want to teach them to stay in a AC cool stay in the AC take cool baths or showers limit physical activity um plenty of non-alcoholic beverages unsweetened uncaffeinated fluids advise the family to check on elderly Neighbors at least two times a day and make sure those people have a fan example problems with hypothermia hypothermia is an abnormally low core body temperature of less than 95 degrees Fahrenheit 35 degrees Celsius as the temperature drops metabolic processes slow and with prolonged exposure shivering does not help and could be fatal it causes vasoconstriction coagulation in the microcirculation tissue ischemia and poor organ perfusion that can lead to vital organ failure such as the heart the kidney in the brain that's why when you hear about people being lost in the mountains or in the snow and stuff like that they have the um necrotic tissue and they don't do too well but I have heard of some to to survive but it's very very serious the cause is exposure to extreme cold some sometimes it can be a medically induced to reduce the need for oxygen and tissues metabolic or nervous system dysfunction or drug intoxication your assessment your initial assessment is you want to see you want to have cool skin you'll you'll see cool skin shivering fatigue confusion loss of coordination cyanosis of the lips in the fingers decrease heart rate and respirations followed by pain in the extremities the late symptoms are loss of ability to shiver and that's when you have the people with the frostbite and everything they lose that ability to shiver and then you see the uh necrotic tissue and the gangrene all setting in blue skin dilated pupils Amnesia hypotension cardiac arrhythmias that occurs when temperatures less than 70 degrees Fahrenheit to 75 degrees Fahrenheit however survival has occurred at 0.8 percent degrees of Fahrenheit sorry about that your analysis and your diagnosis could be ineffective thermalation thermolation I'm sorry ineffective thermal regulation hypothermia your outcomes you want thermal regulation right you want your vital signs to return to within normal range you want your peripheral tissue perfusion and you want to oral temperature greater than 97.6 degrees Fahrenheit or back to the patient's Baseline your interventions include hypothermia treatment temperature regulation monitor those Vital Signs monitoring the rate of rewarming because it should be gradual you don't want to take somebody from hypothermia to hyperthermia uh in a short period of time are to a normal temperature uh like immediately you want to do it gradually monitor skin color and temperature have them in a Supine position to minimize orthostatic changes and also warming measures you want them in a warm environment you want to remove any clothes if they're wet warm bath shower apply hair coverings such as a hat a warm it warms the chest and the head neck and groin first do not use electric blankets collaborating you want to administer warmed IV fluids skin care notify the healthcare provider if cardiac dysrhythmias for your teaching you want to teach the family or the patient to keep the home warm enough you want to teach them to wear socks slippers long underwear wear a hat or a cap even if they're indoors cover the legs and the shoulders wear a hat a scarf and gloves when going out in the cold dressing several layers of warm loose clothing foreign measurement scales electronic and tympanic membrane thermometers can usually measure temperature in either scale off often all you need to do is flip a switch and you'll see that when you start using your thermometers you can go from Celsius to Fahrenheit with just pressing a button this is the conversion this is the formula to convert Fahrenheit to Celsius and Celsius to Fahrenheit I'm not gonna go through that it is here for you to see and it's also in the book I'm sorry I didn't get the page number what equipment do you need there are various types of thermometers with advantages and disadvantages to each use critical thinking to choose the correct one and follow your facilities policy or procedure or your physician orders see table 20.3 and 20.4 on pages two um 424 through 425. you have the electronic thermometers they are rechargeable they beep when the temperature is reached the probe is covered covered with a disposable sheet to prevent spread of infection dispose of dispose of after each use most have a blue Pro and a red Pro the red one is for recto please do not use a red probe in somebody's mouth and it contains the infrared sensor and it I'm sorry um assure you use the correct probe the electronic infrared thermometer is rechargeable as well it contains the infrared sensor does not touch the actual site and the beep sounds and it has a beep sound when temperatures reach disposable chemical thermometer that's a thin plastic strip a patch I'll take that produces color changes at a designated Body temp most are one time used for oral or axillary beneficial for home use are for patients in isolation what site should you use you should always use the safest most accurate and most reliable follow your facilities guidelines and provide us orders sometimes if a person is mouth breathing they're not going to close their mouth they're not going to keep their mouth closed to get an oral temperature you may have to um take a oral temperature however remember you do not take a rectal temperature without an order the sights for core temperatures they're invasive they're in expensive and impractical they're mostly used in um your Critical Care areas or like your procedure areas the sites are um pulmonary artery esophagus in the bladder temperature variations at different sites you have axillary oral and rectum there is an approximately 0.8 degree Fahrenheit or 0.4 degrees Celsius difference between each always always always refer to your facilities guidelines and always record the value you obtained and the site used for instance if you take an axillary chip and it's 99.6 you record 99.6 axillary okay always document exactly what the reading was and what site was used now we're going to talk about the pulse the post is a rhythmic expansion of an artery when blood is forced into it by the heart Contracting to assess and support the regulation of a patient's post you will need to understand the concept of perfusion you have to know the normal range and how the pulse is produced and regulated and the fact is that influence the pulsory to identify with more advanced monitoring is required you must accurately assess the post what is a normal pulse rate the pulse rate is measured in beats per minute the normal range for a healthy adult is 60 to 100 beats per minute with an average of 70 to 80. c table 20.20-1 on page 419 for those very um for those ranges when there's a concern about the heart rate you will most likely use a cardiac monitor to detect the rate the Rhythm and the intensity of the pulse how does the body produce and regulate the pulse the pulse wave is initiated when the left ventricle contracts forcing blood into the aorta which is already filled right thereby increasing the pressure in that um in the aorta and it ends when the left ventricle relaxes it is the intermittent pressure in the expansion of the arteries that causes the blood to flow towards the capillaries systole is the peak and it is when the heart contracts diastole is the trough and that is when the heart relaxes our rest stroke volume is the quantity of blood forced with contraction and 50 million in I'm sorry I don't know what I meant there yeah it's in and it's usually 50 milliliters in a healthy adult if decreased the body will compensate by increasing the pulse rate cardiac output is the total quantity of blood pump per minute cardiac output equals stroke volume times the pulse automatic rig and automatic regulates the pulse by the sympathetic which by the sympathetic nerve increase in the heart rate or the cardiac output and the parasympathetic decreases it your parasympathetic nervous system is um responsible for rest and dilation and it lowers the heart rate and the sympathetic is your fight or flight and it increases the heart rate if that's better for you to remember what factors influence the pulse rate a healthy adult's peripheral rate is the same as the heart rate it's a quick way to assess the heart's condition blood vessels and circulation changes in response to changing volume of blood pump variations in the heart rate changing the elasticity of the ulterior walls conditions that interfere with heart function impaired function of the nervous system other factors that influence the post rate Rhythm or quality you have developmental level the heart rate gradually slows in old age with sex adult females have a slightly more rapid heart rate than males exercise exercises increases the rate yet it returns to normal quickly after exercising especially in a well-conditioned uh person a well-conditioned person usually has a lower heart rate than others food intake heart rate slightly increases for several hours after eating then you have stress stress triggers the sympathetic nervous system which increases the rate and the strength of your pulse fever fever 10 um you have 10 beats per minute per degree of elevation so if your temperature is a degree higher your heart rate is going to be 10 Beats per minute higher your nasal better masal metabolic basal rate increases and peripheral vasodilus dilation causes a decrease rate increases to compensate so peripheral vasodilation causes a decrease in your heart rate meta your meta your metabolic basal rate increases causing peripheral dilation which causes the decreasing heart rate and then your heart rate increases to compensate disease such as heart rate I mean heart disease hyperthyroidism respiratory disease and infections generally increases your heart rate hypothyroidism usually is associated with a decreased heart rate in your blood loss blood loss small loss usually doesn't increase your heart rate or it might increase it temporarily however large blood loss stimulates the sympathetic nervous system thereby increasing the heart rate to compensate for a decreased blood volume position changes standing and sitting um temporarily increases your heart rate and decreases your blood pressure the blood pools in the legs and the feet decreases blood flow to the heart and decreases blood pressure and increases your heart rate some medications some medications stimulate your heart rate cardiac cardiotonics opioids and sedatives however decreases your heart rate that's why we have to know the medications that we given the effects of those medications the expected effects of the those medications but also the side effects giving medication is very important especially when you're dealing with um Vital Signs and vital organs and stuff like that okay what equipment do you need um to count the post you need to watch or a clock with a second hand or digital display that shows the seconds to also take the post you need a stethoscope see page 429 for the description of stethoscopes what size should you use but apical apical post is assessed at the apex of the heart remember Apex apical and it is counted for a four minute we do not count by 30 and then multiply by two we must count apical pulse for a full minute that is a must especially when you're given digoxin or lanoxin you have to count able to pause for a full minute the routine and most common site is the radial artery for cardiopulmonary resuscitation CPR you use the Carotid artery when you're assessing circulation to the head on uh of no other site is not easy easily accessible you check it at the temporal ordering peripheral circulation is at the door Salis Peters that's down in your feet circulation to the legs and for children it's the femoral artery assessing circulation to the lower legs you want to assess the popliteal artery see if they get 20-5 on page 431 for those different sites what data should you collect you should collect the rate the Rhythm inequality the rate you have to count the number of beats per minute while palpating are by us while auscultating the Rhythm the intervals between the Beats if the intervals between the Beats is regular that that's normal if the if the intervals vary it is known as a dysrhythmia but you must also take time to determine if it is regularly irregular or irregular irregular irregular can be serious and requires a EKG or ECG to confirm your quality you want to assess by determining the pulse volume and bilateral equally you want to check the pulses at the same time to see if they're equal you want to make note of which one is stronger or more um and then we have the [Music] um the the uh the gradings so zero means absent one equals weak and thirty two is normal and three is bounding if peripheral pulses are absent or weak it may be because circulation is crap is compromised in those extremities you'll have you'll see cyanosis which is bluish or greatness discolorations resulting from from lack of oxygen in the blood you may also see parallel or paleness of the skin and the areas being compromised for example if if the circulation impairment is to the lower extremities then you will the feet will appear pale and you'll feel cool to touch also the dorsal posterior tibial pulses may be weak or absent let's talk about respirations respirations is the exchange of oxygen and carbon dioxide in the body the mechanical aspect involves the active movement of air in and out of the respiratory system chemical includes external respiration gas transport and internal respirations we're going to focus more on the mechanical aspect the mechanical aspect is also known as pulmonary ventilation are simply breathing external respiration is the exchange of oxygen and carbon dioxide between the alveoli and the pulmonary blood supply gas transporter is get the transport of gases throughout the body internal is the exchange of gases between the capillaries and body tissue cells what is a normal respiratory rate the normal respiratory weight rate is 12 to 20. however it varies with age exertion emotions and other factors this is a caveat because people can't control their breathing you should count their respirations when they are unaware do not let them know you are counting their respirations because they will hold their breath speed up their breads um they just do things and sometimes patients just do it to be funny but they don't realize how important it is or why you counting your respiration so try to do it without having a person be aware another caveat the primary stimulus for breathing is the level of carbon dioxide tension in the blood there are Central chemoreceptors that are sensitive to CO2 and hydrogen concentrations a minor increase in either one stimulates respiration there are peripheral chemoreceptors in the Carotid and aortic bodies the partial pressure of oxygen in the arterial blood which is the pao2 and it is normally 80 to 100 if it falls below the normal range peripherals chemo receptors will stimulate respirations breathing is usually involuntary and requires little or no effort however it is possible like I said to exert conscious control over your respirations so again the counter respirations without having the patient be aware what are the what are the mechanism of breathing inspiration which is during inspiration the diaphragm contracts and during expiration the diagram relaxes inspiration impulses a sin from the respiratory Center along the phrenic nerve the thoracic muscles and causes the diaphragm to contract the ribs move up the diaphragm moves down and out and the abdominal organs move down and forward which causes the thorax to expand in all directions as the thorax expands it causes airway pressure to decrease below asthmatic pressure and allows air to move into and expand the lungs expiration it is the diaphragm in the thoracic muscle relaxes and the chest cavity decreases in size the lungs recoil which forces air out of the lungs until the lungs reach asthmatic pressure causing expulsion of air from the lungs what factors influence respirations developmental level respirations decreases slightly in older adults a higher rate a rate rate higher than 27 is predictive of Adverse Events in older adults accurate measurement of respiratory rate is an essential component of the assessment especially of older adults so yeah they their respirations May decrease slightly as they age however if they're not feeling well or something is causing them to breathe a little bit more rapidly you might see that but any time their respirations is higher than 27 it is serious and it is considered an adverse event exercise temporarily increases your rate and the depth in in the depth to increase oxygen availability to the tissues to rid the body or blow off carbon dioxide pain increases the rate yet it decreases the debt because when a person is in print in pain they don't usually take those deep breaths especially if they're having any kind of pain in the thoracic area stress anxiety or fear causes an increase due to the sympathetic stimulation smoking of course smoking um causes an increase in respiratory [Music] um due to changes in the airway compliance due to the it um changes the elasticity of the respiratory system so that causes people to have trouble breathing fever increases for every degree the temperature rises the respiratory rate increases up to four beats per minute so like I was saying with the older adult yeah they respirations might decrease when they get older but let's say they have a fever it's going to increase right hemoglobin the respiratory rate in the depth increases due to anemia sickle cell anemia and high altitudes when hemoglobin is decreased the rate and depth increases to maintain tissue oxygenation high altitude inhibits The Binding of oxygen to hemoglobin and triggers compensation disease we have various diseases May either cause an increase or a decrease in respiratory in the respiratory rate medications you have your central nervous system um depressants such as morphine or general anesthesia which can cause slow breathing then you have caffeine and atropine which can cause shallow fast breathing position standing maximizes your depth and lying flat reduces it that's why a lot of people cannot tolerate lying down especially those who are already respiratory compromised leaning forward prevents chest expansion and increased breathing some people can't be bend over um because it impedes their breathing sometimes the doctor will restrict the person from bending over there they'll have you know like no bending or something like that um if they're a respiratory status is compromised already what equipment do you need you need to watch with a second hand a stethoscope many electronic thermometers have counter displays and signals that indicate 15 30 or 60 second time intervals for counting respirations um now they have all kind of fancy stethoscopes and all kind of stuff that can do it it's uh so much out there nowadays but anyway um you must take an accurate uh assess respiratory rate uh accurately and try to do so when the person is unaware um what data should you obtain remember the rate the depth the Rhythm the effort and others with the rate of course that's the number of times a person breed within a full minute the depth it is subjective and is how much or how little the chest Rises during respirations with deep breaths you take a large volume of air and fully expand the chest or the abdomen with shallow the chest barely Rises and it's difficult to observe with normal breathing it's between deep and shallow the effort it refers to the degree of work required to breed normally people breathing this effortlessly some diseases cause a patient to work harder to breathe such as with asthma and pneumonia then we have dyspnea which is an increased effort or labor breathing then we have orthopnea that's difficulty or inability to breathe lying down such as with patients with cardiac or respiratory conditions and then you have others you have reason reason is a high pitch con continuous musical sound and is usually caused by narrowing of the airway on expiration and it can often be heard without a stethoscope sometimes you don't have to even put the stethoscope to hear somebody wheezing then you have ronkai ronkai is a low pitch continuous gurgling sounds caused by secretions and usually clears when a person coughs so sometimes you hear that you just tell a person to take a good cough and then you listen again you must once you have them to take that cough you must also take those lung sounds again then you have crackles which is discontinuous usually heard on inspiration they may be heard throughout the respiratory cycle they may be high pitched popping or low pitch bubbling sounds then you have structure this is labored breathing that produces a snoring sound and is common with mouth breathers or due to nasal congestion uh I think with people with adenoids as well and then they also call it the death rattle when somebody is um dying let me make sure that I tell you guys this refer to table 20-5 for terminology to describe these respiratory rhythms they have a description of each of these and it also has a picture that shows the the wavelengths of the breathing and everything very very very good table please refer to it um chest and abdominal movement respiratory patterns are usually normal and rise with inspiration and thought with exploration however the pattern changes when a person is having difficulty breathing for example when the patient has to use additional effort to breathe with intercostal breathing you have visible sinking around the around in between the ribs you can actually see the rib thick then you have substernal retraction tissues are drawn in beneath the sternum and that's right up under your breastbone yeah um sub ER internal retractions that's when the tissues are drawn in above the clavicles that's when you'll see the sinking down right above the clavicles while they try struggling to breathe Associated clinical signs always assess for clinical signs of oxygenation you have hypoxia which is you'll see Palace cyanosis restlessness apprehension confusion dizziness fatigue decreased level of Consciousness tachycardia tachypnea and changes in blood pressure um you have coughs coughs may be symptoms of allergic reactions lung disease respiratory infection or heart condition you have different types of cough if someone is coughing up something that is called a productive cough if they're coughing and nothing's coming up that's called the dry cough and if they have a series of coughs dry coughs that's called hacking cough and then they if they have a sudden periodic cough with a whooping sound at the end that's called a whooping cough okay ulterior oxygenation saturation abg's directly measure the partial pressure of oxygen and carbon dioxide and pH in the blood which requires arterial puncture and lab testing it is invasive it is painful and it's time consuming and expensive pulse ox however that's a little probe that you put on a person's finger it is non-invasive method and of measuring oxygen saturation it is the safest and it is the most one the one that's most oftenly used remember your normal range for oxygen saturation is 95 to 100 percent foreign blood pressure blood pressure is divine defined as the pressure of the blood as it is forced against arterials arterial walls during cardiac contraction systolic pressures when the ventricles contract and eject blood diastolic is between contractions when the heart is resting pulse pressure is the difference between the systolic and the diastolic pressure it is an indication of volume output of the left ventricle it should not be greater than one-third of the systolic pressure how a blood pressure reading is categorized please please please please refer to table 20-1 on page 413 of volume 1. how does the body regulate blood pressure blood pressure is influenced by cardiac function peripheral vascular resistance and blood volume cardiac function cardiac output is the volume of blood pumped by the heart per minute and it reflects the functioning of the heart an increase in cardiac output causes an increase in blood pressure a decrease in cardiac output causes a decrease in blood pressure a change in either stroke volume or heart rate Alters your cardiac output increased stroke volume are caused by increased blood volume such as with pregnancy during exercise when more forceful contractions are with more forceful contractions of the ventricles decreased stroke volume is caused by conditions such as dehydration active bleeding damage to the heart such as with the Mi or a heart attack a very rapid heart rate a very rapid heart rate limits the time allotted for the ventricles to fill which results in decreased stroke volume and ultimately decreased cardiac output peripheral resistance refers to arterial and capillary to blood flow as a result of friction between blood and the vessel walls increase peripheral resistance creates a temporary increase in blood pressure blood viscosity influences the ease which with which blood flows through the vessels and it is determined by the hematocrit if a hematocrit is high it increases the blood pressure such as with dehydration a low hematocrit May reduce blood pressure such as with anemia arterial size the sympathetic nervous system controls vasoconstriction and vasodilation the smaller the radius in the blood vessel the more resistant the blood flow is so construct constricted arteries subsequently increases blood pressure dilated arteries increases blood flow arterial compliance arteries with good elasticity can distance and recall easily and adequately when changes in arterial structure causes a loss of elasticity there you have it peripheral resistance and possibly blood pressure increasing arteriosclerosis is a common contributor to increased blood pressure in middle aged and older adults blood volume is about five liters and it looks and a significant loss of blood as with hemorrhaging it reduces vascular volume and blood pressure Falls and vice versa increase a vascular volume increased over the norm as with renal failure of fluid retention blood pressure does what increases okay laughs what factors influence blood pressure developmental blood pressure increases with age as a result of decreased arterial compliance and changes in the left ventricle walls these normal aging processes process changes can lead to cardiovascular instability sex blood pressure slightly high in men blood pressure increases with menopause possibly due to decreasing estrogen family history most likely a person is um likely to develop hypertension if it's a family if it's if they have a familiar history of it lifestyle your sodium alcohol and smoking has been shown to elevate blood pressure caffeine raises it for a short time after digestion but it usually doesn't last long um and it usually has no effect no long-term effect on your blood pressure exercise muscular exertion temporarily increases your blood pressure due to increased heart rate and cardiac output physical fitness reduces blood pressure so if a person has been exercised you want to wait 30 minutes before assassinate blood pressure body position blood pressure is higher when standing than when sitting a lion higher if taken with patient's arm above the Heart level or if arms is unsupported at the patient's side you always want to take a blood pressure with the with the arm at the level of the heart remember blood pressure is taken with the arm at the level of the heart the blood pressure is also higher when feet are dangling instead of resting on the floor or if a person's legs across so you always want to make sure your patient is sitting in a chair with their feet on the floor or they if they you know if they're in the chair with their feet on the floor and their legs are not crossed and if they lying in bed you want to have them to uncross their legs I usually have them uncross their legs and wait a minute or two before I take blood pressure um stress if a person is um worried or fearful about something are they excited the sympathetic nervous system causes the blood pressure to rise if if it's constant if they constantly um dealing with stress and having a blood pressure increase treatment may be indicated pain often causes an increase in blood pressure prolonged pain can cause a decrease in blood pressure African Americans have a higher rate of hypertension or higher incidences of complications and hypertension related deaths than do European Americans obesity increases blood pressure due to the additional vascular Supply that is required for perfusion to a larger body mass and it increases in an increase in peripheral resistance that urinal variations a person's daily scheduling routines sometimes it depends on what the person is uh with their daily activities are most of the time people's blood pressure is low when they're sleeping end up on awaken and it rises during the day and then it starts to decrease again during bit when it gets close to that bedtime then you have medications medications alter blood pressures sometimes it is an intended effect that a medicine medication such as with your antihypertensives or it's unattended such as what your pain meds um diseases diseases that affect the circulatory system or any other major organ such as the kidneys then you have genetic variations now genes research shows a link between genetic factors and hypertension what equipment do you need you need a stethoscope a blood pressure cuff a Despicable momentum or an electric blood pressure monitor to assess BP electronic monitoring is gradually replacing the stethoscope and the speak no sphygmoman nanometer and patient care settings so a lot of times you'll hear people saying they're using Dynamat when BP is weak ultrasonic stethoscopes are useful for magnifying sound waves occurring during systole using the Bell enables you to hear the blood pressure sounds more accurately especially at diastolic pressures most hair care providers use the diaphragm because it is easily placed and some don't even have a bell but make sure you use a high quality stethoscope with shark tubing to get a more accurate blood pressure Android manometers and electronic blood pressure monitors using the microphones to sense sounds or sensors that detect pressure waves as blood flows through arteries can be said at time intervals we use um we um like in the emergency room or in your specialty areas they can put the blood pressure cuff on the patient and set the monitor or set it to take their um vital signs not just their blood pressure but their heart rate and stuff at intervals automatically um and it doesn't require a stethoscope they measure systolic diastolic amine ulterior pressure like I said it's mostly used in your pressure in your specialty areas and it's useful for frequent monitoring and um that's why they use it what cup size should you use you should use the stethoscope that covers two-thirds the length of the upper arm for adults and the entire arm for a child alternatively the cuff width should be 40 of the on circumference and the length of the bladder should cover 80 of the length of the arm in adults cuffs come in various sizes however it depends on your facility trust me every facility is not going to have the exact size you need however please it is better to use one that is too large than to use one that is too small also record the cuff size with the blood pressure reading C figure 20-10 on page 443 and table 20 day seven on page 444. which size should you use avoid assessing blood pressure and on with an IV or dialysis fistula skin graft extensive trauma cast or dressing paralyzed or if they had breast cancer or shoulder surgery alternatively you can use the forearm the thigh or the calf but keep in mind systolic pressure could be 20 to 30 millimeters of mercury higher in the lower extremities see um 20-6 on pages 216 through 220 in volume 2. auscultating blood pressure blood pressure can be measured indirectly by auscultation which is the prepared it which is the preferred and most commonly used are by palpation there are five sounds that you're gonna hear in the blood pressure but you may not hear all five of them in some of your patients and those are your systolic your turbulence your rhythmic tapping muffled and diastolic you do not need to worry about describing all five of those just putting it out there but remember you may not hear all five in some patients okay then we have palpation when it's difficult to hear you can use the palpation method alone you and then you can use palpation with auscultation using the two techniques together helps ensure the accuracy of your readings with the hypertensive patient you may lose the sound for as much as 30 millimeters of mercury as you deflate the cuff and then when as you deflate the cuff it returns this is called an oscillatory Gap palpating first then auscultating ensures you do not miss the isolated first sound refer to procedure 20-6 on pages 217 through 218 and volume 2 when doing so pay close attention to number six where we using the radial artery and number eight where you inflate 30 millimeters of mercury higher or above then follow through to number 11. remember your NEX instructor will elaborate on this procedure and also they'll demonstrate it and have you to practice it the first time you measure a patient's blood pressure you may not know what the systolic blood pressure is or how how high to inflate the cuff if you over inflate it it can be very uncomfortable for the patient but if you underinflate it you may miss the first sound and that is why we go we um palpate while we inflate the cup first and then when we stop feeling it we go up another 30 that gives us an indication as to how high to pump the uh cuff up okay also this is a caveat if you fail to recognize an oscillatory Gap it can result in a serious misreading of a person's systolic blood pressure now let's talk about our example problems hypotension it is diagnosed when the systolic blood pressure is 90 millimeters of mercury or lower order diastolic is 60 or lower theoretical diagnose uh is usually not a problem unless it causes symptoms dizziness fatigue concentration problems activity intolerance shortness of breath risk factors are low um some risk factors are low hematocrit hypothyroidism diabetes heart failure and chronic chest pain orthostatic that is postural hypotension and that's when you have a sudden drop of 10 millimeters of mercury are greater within two to five minutes of moving from line to sitting and from sitting to standing risk factors are older adults pregnancy prolonged bed rest decreased blood volume such as with dehydration or recent blood loss some causes can be changing positions dehydration Hemorrhage medications such as your antihypertensive than your diuretics assessment you might see a change in blood pressure you might see orthostatic hypotension activity and tolerance shortness of breath pale skin complain of dizziness fatigue problems concentrating assess for the ideology or the cause and the risk factors analysis and diagnosis risk for Falls related to dizziness secondary to postural hypertension fear of falling related to fainting secondary to postural hypertension unstable blood pressure related to cardiac arrhythmia and decreased output what are the outcomes you want to see for this patient it depends on the nursing diagnosis for blood pressure 100 over 70 you want to see an increase in circulatory volume you want them to be absent of dizziness you want them to not have weakness and you want to see resilient skin Target no Falls while walking could also be an outcome what are your interventions it depends on the nursing diagnosis right so a lot of times you want to monitor your eye nose your vital signs you want to assist the person in lying down if they get dizzy you want to have safety surveillance for your older adults your pregnant women those on prolonged bed rest decrease blood volume increase or so if they have decreased blood volume on an increase over oral fluids if possible have them to eat small low carb meals to minimize the drop in blood pressure that occurs after meals but orthostatic take pulse and blood pressure with the patient lying sitting and then standing with one to three minutes after each position change notify the provider if changes in of any changes in the measurements we're collaborating you want hemodynamic regulation IV fluids treating the underlying cause and administer medications as prescribed for transient elevations [Music] um I mean I'm sorry for hypertension transient elevations are normal to confirm hypertension using average based on two readings obtained on two or more occasions c table 20-day six on page 4 and 39. elevated systolic blood pressure of actually I'm not going to go through this because it's um the table is in the book the characteristics of the excuse me elevated hypertension stage one stage two and all that is in the book um on that page um 439 I think it is some colleges could be um physiologically hypertension is related to thickening of ulterior walls and decreased the elasticity of the arteries as blood pressure Rises peripheral resistance increases over time the heart is unable to compensate and cardiac output declines essential hypertension has no known cause secondary secondary hypertension is caused by from renal and endocrine disorders prescription and non-prescription drugs oral contraceptives some decongestants adrenal steroid hormones nicotine illicit drug use like a cocaine amphetamines and stressful lifestyles you want to assess for risk factors possible causes they may have symptoms so assess for complaints of early morning sub-app sub occipital headaches fatigue and visual changes analysis and diagnosis could be a risk for decreased cardiac output risk for unstable blood pressure your outcomes could be that we want the cardiac pump to be effective we want to see vital signs within normal range or close to Baseline the person will have systolic blood pressure and diastolic blood pressure of not more than 15 over the Baseline interventions depend on the nursing diagnosis such as smoking cessation cardiac risk management monitor or Vital Signs activity to determine activity and tolerance um collect iron observed for edema weight gain assess attitude and beliefs about taking meds making Lifestyle Changes monitor for adherence to medication and those like that's Lifestyle Changes collaborating you want to test your B unit in creatinine electrolytes hemoglobin hematocrine and lipid levels treat the underlying cause administered medications or anti-hypertension that's prescribed the American College of Physicians and the American Ecology of the American Academy of Physicians recommend initiation of medications in adults 60 and greater to achieve a Target systolic blood pressure of less than 150. teaching the patient you want to teach them the need for Lifestyle Changes teach them a balanced diet balance weight loss diet you want to encourage them to decrease alcohol consumption Stress Management relaxation techniques self-monitoring of blood pressure and compliance with medication and therapeutic regimens avoid diuretics at night in caring you want to if the patient does any little bitty um life change or show any kind of signs of com trying to comply You Want To Praise them um when they show any kind of signs of trying to do the right thing you want to continue to provide encouragement and realistic expectations okay now we're going to pull it all together in the hospital setting you will usually take a complete set of vital signs at regular intervals in the in the ambulatory setting varies according to the chief complaint always use your clinical judgment about which Vital sign to measure and how often evaluating bioscience when you want to evaluate you want to evaluate according to your knowledge of known Norms on the patient's particular trends when noting a deviation evaluate in the context of the medication diagnosis procedures environment activity Etc to understand the basis for the change further assess the patient for other clinical signs to determine the course of action remember we can't just go by one thing we have to look at the whole picture we have to go into that chart and look at those Trends we have to know what the person's person's deadline or Baseline is we have to know what medications they're on we have to know what kind of activities they're involved in we pretty much have to know everything about that patient when we are evaluating vital signs delegating by the signs by the signs are commonly obtained by the unlicensed assisted Personnel however the nurses always responsible for reviewing and interpreting by Design Trends and making decisions based on abnormal vital signings as a student if you are unsure of how to interpret Vital Signs discuss the findings with your instructor not the staff nurse not the staff unlicensed assistive personnel with your instructor and or the assigned staff nurse if your instructor has given you permission to do so the assigned nurse maintains the responsibility to oversee the patient do we have any questions if you have questions please please please please place them in the discussion board so that everyone has access to the information also could you please go in and do a duty evaluation for the course if you has if you have watched this recorded lecture That's all folks thank you very much for your time I truly appreciate it and again my name is Mrs Murdoch and it has been a pleasure