NURSING INTERVENTIONS VITAL SIGN MEASUREMENT

SJ/LAC FFPYEAR ONE - VITAL SIGNS2 VITAL SIGNS Vital signs are indicators of the body's: b Physiological status b Response to Physical stressors b Environmental stressors b Psychological stressors

SJ/LAC FFPYEAR ONE - VITAL SIGNS3 VITAL SIGNS Temperature, Pulse Blood Pressure & respiration rate can REVEAL the patients ability to: Temperature, Pulse Blood Pressure & respiration rate can REVEAL the patients ability to: b Maintain body temperature regulation b Maintain local & systemic blood flow b Maintain oxygenation of the tissues

SJ/LAC FFPYEAR ONE - VITAL SIGNS4 VITAL SIGNS Any difference between a clients NORMAL EXPECTED baseline measurement and the ACTUAL PRESENT vital sign is an indication for the nurse to PURSUE APPROPRIATE necessary care and INITIATE nursing action/therapies.

SJ/LAC FFPYEAR ONE - VITAL SIGNS5 VITAL SIGNS Temperature & Respiration b Vital sign changes may reveal sudden changes as well as progressive changes b raised temperature may indicate an infection; b raised pulse - ?bleeding; b lowered blood pressure - ?bleeding

SJ/LAC FFPYEAR ONE - VITAL SIGNS6 CONSIDERATIONS OF VITAL SIGN MEASUREMENT From a nursing viewpoint b Measurement provides information used to determine a patient / clients baseline data & response to medical./ nursing therapy b Vital sign recording is a quick, efficient way of monitoring a condition or identifying problems. Can be used as a basis for clinical problem solving b Vital sign measurement is incorporated into Practice for assessment & determining the need for intervention(s), Viewed as routine care measures

SJ/LAC FFPYEAR ONE - VITAL SIGNS7 TEMPERATURE b In health, tissues & cells function best within a relatively narrow range of temperature - controlled by the hypothalamus. b Body Core temperature is maintained within + or of a degree Celsius / centigrade. b Surface body temperature fluctuates according to environmental changes. b Skin temperature can range between 20 o - 40 o C without causing tissue damage.

SJ/LAC FFPYEAR ONE - VITAL SIGNS8 TEMPERATURE b Temperature range is balanced & regulated to allow for changes that result from Exercise, Activity and Rest. b Temperature regulatory mechanisms include: Vasodilatation, Vasoconstriction, Sweating & avoiding environmental extremes hot/cold. b For body temperature to stay constant HEAT PRODUCED must equal HEAT LOST to the environment. b When internal control mechanisms fail the nurse may initiate measures to  CONTROL the immediate environments  REMOVE or ADD coverings  GIVE MEDICATIONS - antipyretics

SJ/LAC FFPYEAR ONE - VITAL SIGNS9 Monitoring temperatures Types of thermometers b Glass with a mercury column; b Electronic; b Disposable;  Tympanic Thermometry.

SJ/LAC FFPYEAR ONE - VITAL SIGNS10 Factors influencing / affecting temperature b General - age; exercise; hormones; stress; environment; medications; daily fluctuation / time / gender b Specific - diagnosed infections; burns / open wounds; Low white cell count 12,000; immunosuppresive drug therapy; post operative state; hyperthermic therapy; hypothermic therapy; injury to the hypothalamus; infusion of blood products b Nurses asses for Fever or Hypothermia

SJ/LAC FFPYEAR ONE - VITAL SIGNS11 b Show Video on Genius thermometers

SJ/LAC FFPYEAR ONE - VITAL SIGNS12 RESPIRATIONS Human survival depends on the ability for Oxygen to reach the body cells and Carbon Dioxide to be removed from the cells. Human survival depends on the ability for Oxygen to reach the body cells and Carbon Dioxide to be removed from the cells. b Factors affecting character of respirations - Exercise; acute pain; anxiety; smoking; anaemia; body position; medications; brain stem injury.

SJ/LAC FFPYEAR ONE - VITAL SIGNS13 ASSESSMENT OF RESPIRATIONS b Easiest of all vital signs to measure but most often haphazardly recorded. b NEVER estimate a respiratory rate b Accurate measurement of the chest wall rising and falling is required. b Any change may be important b Respiration is tied to the function of numerous body systems, therefore the nurse must consider all variables when change occurs.

SJ/LAC FFPYEAR ONE - VITAL SIGNS14 MEASUREMENT b RATE - determined by a full inspiration and expiration, will vary with age b DEPTH - assessed by observing the degree of movement in the chest wall and is usually considered to be deep, normal or shallow. b RHYTHM - regular occurrence of respiration will depict a normal range. During assessment the nurse estimates the time interval; after each respiration cycle. Respiration is then either regular or irregular in rhythm

SJ/LAC FFPYEAR ONE - VITAL SIGNS15 ALTERATIONS IN BREATHING PATTERN b b Bradypnoea rate regular, but abnormally slow < 12 b/min b b Tachypnoea rate regular, but abnormally fast > 20 b/min b b Hyperpnoea laboured respirations, increased depth, increased rate > 20 breaths / minute b b Hyperventilation rate & depth increased b b Hypoventilation rate & depth abnormally low b b Cheyne-Stoke rate & depth irregular, alternating periods of apnoea and hyperventilation b b Kussmaul resp. abnormally deep, regular but increased in rate b b Biots resp. abnormally shallow for 2-3 breaths, followed by irregular periods of apnoea

SJ/LAC FFPYEAR ONE - VITAL SIGNS16 WHEN TO RECORD VITAL SIGNS b On clients admission to a health care facility b In hospital, on routine or schedule according to physicians order or hospital policy b During clients visit to clinic or physicians office b Before & after any surgical procedure b Before & after any invasive diagnostic procedure b Before & after administration of medications that affect cardiovascular, respiratory & temperature control function

SJ/LAC FFPYEAR ONE - VITAL SIGNS17 WHEN TO RECORD VITAL SIGNS b When the clients general physical condition changes - e.g. loss of consciousness or increased intensity of pain b Before & after nursing interventions influencing any one of the vital signs - e.g. before ambulating client previously on bed rest or before client performs range of movement exercises b Whenever client reports to nurse any non- specific symptoms of physical distress - e.g. "feeling funny or different"

SJ/LAC FFPYEAR ONE - VITAL SIGNS18 Patient at risk score. b PAR b Research completed in Swansea NHS trust. b Reduced observation of Respiratory recording. b Aim = Early indications of deteriation.

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SJ/LAC FFPYEAR ONE - VITAL SIGNS21 References: b Fundamentals of Nursing, Concepts, Process & Practice b Potter,A. Perry,A. (1997) Fundamentals of Nursing, Concepts, Process & Practice St Louis: MosbyCh 32 p 594 b Fundamentals of Nursing - The Art & Science of Nursing Care. b Taylor,C. Lillis,C. LeMonde,P. (1997) Fundamentals of Nursing - The Art & Science of Nursing Care. Philadelphia: LippincottCh25 p432