nrs204

• Four "cardinal" vital signs are:

  • Temperature
  • Pulse
  • Respirations
  • Blood Pressure
• Oxygen Saturation and Pain are often included with vital signs
• Maintaining equipment, measuring correctly, considering the environment, interpreting values, communicating findings, and intervening as needed require nurse-level training
• Core temperature is regulated by the hypothalamus, while peripheral temperature can be measured sublingually, rectally, axillary, temporally, or tympanically
• Rectal temperature readings are usually higher than oral readings, and axillary readings are usually lower than oral readings
• Hypothermia is when temperature is below 36.5°C, Normothermia is between 36.5 - 37.3°C, and Hyperthermia is above 37.3°C
• Heart rate can be assessed peripherally, centrally (femoral, carotid), or apically
• Pulse deficit measurement involves measuring apical and radial heart rates simultaneously
• Nurse documents rate, rhythm, and strength of the pulse
• Respiratory rate can be assessed visually without a stethoscope by counting inspirations or expirations
• Respiratory rate is subject to voluntary control, and the patient should be unaware during assessment
• Apnea is no breathing, Bradypnea is less than 12 breaths/min, Eupnea is 12-18 breaths/min, and Tachypnea is more than 18 breaths/min
• Blood pressure assessment involves limb choice, patient positioning, and cuff size
• Orthostatic vital signs compare blood pressure and heart rate in supine, sitting, and standing positions
• Hypotension is below 90/60, Normotension is 90/60 - 120/80, and Hypertension is above 120/80
• Oxygen saturation is influenced by heart and lung function, cellular oxygen need, and supplemental oxygen use
• Measurement errors in oxygen saturation are common and usually related to movement or decreased blood flow at the measurement site
• Desaturation is below 95% on room air, Normal saturation is 95-100% on room air, and High saturation is 100% for patients on supplemental oxygen
• Cardiac Output:

  • The amount of blood pumped by the heart in one minute
  • Dehydration can lead to low blood volume
  • Heart compensates for low blood volume by increasing cardiac output
  • Small children have limited ability to increase stroke volume
• Physical Assessment: Cardiovascular

  • Vital signs, heart exam, peripheral vascular exam
  • Inspect general appearance, skin color, scars, neck veins
  • Palpate point of maximal impulse, carotid arteries
  • Auscultate heart, carotids
  • Murmur: turbulent blood flow in the heart
  • Bruit: turbulent blood flow in an artery
  • Thrill: turbulent blood flow in the heart or arteries
  • Peripheral vascular exam includes peripheral pulses, skin turgor, edema, peripheral temperature, capillary refill
• History: Chest pain

  • Women have heart attacks as often as men but higher death rate
• Cardiovascular subjective and objective assessment data:

  Emergencies:

  • Chest pain
  • Shortness of breath
  • Irregular heartbeat
  • Pedal pulses that are unpalpable
  • Blood pressure 180/120
  • Cyanosis
• Associated Nursing Diagnoses:

  • Activity intolerance/Risk for activity intolerance
  • Decreased cardiac output/Risk for decreased cardiac output
  • Risk for unstable blood pressure
  • Risk for decreased cardiac tissue perfusion
  • Risk for ineffective cerebral tissue perfusion
  • Ineffective peripheral tissue perfusion/Risk for ineffective peripheral tissue perfusion
• Respiratory Assessment:

  • Vital signs, inspection, lung and chest exam
  • Breathing pattern assessment: regularity, chest movement, rate, retractions, accessory muscle use
  • Normal breathing patterns: Bradypnea, Tachypnea, Sighing, Apnea
  • Abnormal breathing patterns: Cheyne-Stokes, Kussmaul, Biot, Ataxic
• Physical assessment: Respiratory

  • Inspection for differences in photos
  • Normal and abnormal findings:
  • Clubbing of fingers
  • Crackles
  • Stridor
  • Cyanosis
  • Deep cough with green sputum
• Nursing interventions for Respiratory:

  • Atelectasis prevention through mobility, deep breaths, breathing exercises, coughing
  • Supplying extra oxygen: devices for higher oxygen concentration, monitoring vital signs
• Respiratory subjective and objective assessment data:

  • Assessment findings: normal, grey, abnormal, dangerous
  • Dangerous findings: Use of accessory muscles to breathe, Tachypnea, Shortness of breath, Dyspnea, Irregular breathing pattern, Cyanosis
• Associated Nursing Diagnoses:

  • Impaired Gas Exchange
  • Ineffective Breathing Pattern
  • Ineffective Airway Clearance
  • Decreased Cardiac Output
  • Activity intolerance/Risk for activity intolerance