Interpreting Vital Signs in the Clinical Area

What do they mean?

Objectives Review vital sign assessment. Review abnormal vital signs and their implications in disease. Identify proper notification of vital signs to the physician. Identify chain of responsibility. Review legal issues surrounding reporting and documentation of vital signs.

Abnormal V.S. Assessment TPR & B/P Measure while patient is relaxed, sitting, or laying down Use appropriate cuff size for B/P assessment (most important for accuracy) On initial assessment complete orthostatic B/P’s and HR (lying, sitting, standing) Initially measure B/P in both arms

Abnormal V.S. What do they mean? Temperature: normal degrees F (36-38 degrees C) depending on the time of day. Physiology: body temp. is regulated by the hypothalamus balancing heat production and heat loss.

Abnormal V.S. What do they mean? Physiology cont..: 85% of body heat is lost through the skin and remainder through the lungs and fecal/urinary excretions.

Abnormal V.S. What does it mean? When temperature is elevated (fever/pyrexia) it can mean : menstruation cycle-ovulation to menses exercise infection stress dehydration In the Post-op pt hrs: may indicate an inflammatory response to surgery above 100.4: ? Lung congestion, wound infection, urinary infection, respiratory infection, phlebitis

Abnormal V.S. What does it mean? In the Post-op pt. Cont.: aerobic organisms spike fevers in the afternoon or evening and return to near normal in AM. Think about fevers 7-10 after surgery: UTI, thrombophlebitis (IV sites) ? Septicemia if pt has intermittent high fevers accompanied by shaking chills & diaphoresis.

Abnormal V.S. What does it mean? Elevated Temp. cont... any disease, injury or condition that triggers the body’s immune response crushing injuries, fractures, spinal cord injuries etc.

Abnormal V.S. Temps are a good thing? A fever may mean that there is something else going on in the body that is causing it. Fever helps the body fight infections by making the body's defense systems work more efficiently. Bacteria and viruses cannot live at higher temperatures and so are killed by fever.

Abnormal V.S. What does it mean? Critical levels dramatic change in temperature, report temperature above 101.5, report (38 degrees celcius) temperatures above 106 degrees F, can cause brain damage. Neutropenic fevers can be quite high as well. All abnormal temps even low, need to be reported to MD

Abnormal V.S. What does it mean ? Variation in temperatures: thyroid disorders cardiovascular: tachycardia, bradycardia, hypotension hypertension other endocrine related disorders hypothermia: effects of anesthesia and body heat loss in surgical exposure or cold exposure

Abnormal V.S. What does it mean? Heart Rate (pulse) Normal: be aware of patient’s own normal rate. Less than 50 and greater than 150 patient will have decreased perfusion.

Cardiac Deviations Bradycardia-heart rate less than 60

Abnormal V.S. What does it mean? Conditions affecting heart rate: hypervolemia and hypovolemia exercise autonomic nervous system: sympathetic nervous system demands (SNS) (fight or flight) increases HR parasympathetic lowers HR

Abnormal V.S. Conditions affecting heart rate: Mechanical problems with the heart, ex. valve diseases Medications OTC (over the counter) Prescriptions Recreational/street drugs Electrolyte imbalances Stress

Abnormal V.S. What does it mean? Respiratory Rate Normal 12-20/minute Conditions that affect respiratory rates: autonomic NS metabolic and respiratory acidosis and alkalosis anemia exercise pain fever sleeping disorders

Abnormal V.S. Respiratory Conditions COPD Influenza TB Pneumonia: Pseudomonis, Candida Bacterial or Viral pneumonia Pleural effusion atalectasis Pulmonary fibrosis Pulmonary hypertension PE Lung CA

Abnormal V.S. What does it mean? Blood Pressure important to note patient’s normal blood pressure range. SBP should be less than 140 DBP should be less than 90

Abnormal V.S. Blood pressure Blood pressure is affected more by systems: Ex. Neurological, cardiovascular, respiratory, endocrine, etc.

Abnormal V.S. Blood Pressure Primary/Essential Hypertension hereditary Unknown cause 90-95% of all hypertension Contributing Factors Increased SNS Hormones Vasoconstrictors Sodium Intake Obesity Diabetes Excessive Alcohol Intake

Abnormal V.S. Secondary Hypertension Specific cause that can be corrected: vascular narrowing renal disease endocrine neurological disorders sleep disorders medications toxemia

Abnormal V.S. Proper Notification of VS to Physician: Report change in condition/deviation from normal, promptly Notify primary care physician Notify consulting physicians as appropriate Chain of Accountability If you, the nurse, are not satisfied with the outcome of orders received, patient care management or have further questions notify in order: Attending MD Charge Nurse PCM/HS VP Patient Care Services/Administration

Abnormal V.S. Legal Responsibilities: Nurses are responsible to know and recognize: Deviations from normal values. Policy & procedures Nursing standards of care for each disease process Problems or risk to patient safety: Review P&P Communicate confidentially and appropriately Documentation needs patient care flow sheets nurses notes procedure flow sheet frequent VS flow sheet

Summary Recap: Reviewed vital sign assessment. Reviewed abnormal vital signs and their implications in disease. Identified proper notification of vital signs to the physician. Identified chain of responsibility. Reviewed legal issues surrounding reporting and documenting vital signs. One final note: Vital Signs are the hallmark of nurse surveillance. Accurately assessing deviations from normal directly effects the ability to rescue a patient.