Clinical nursing

• An accurate assessment is crucial to the nursing process as it identifies the patient's problems and determines appropriate interventions to improve the patient's health.
• Vital signs are essential physiological measurements that indicate the functioning of vital organs and body systems
• The four primary vital signs commonly monitored in clinical settings are:

  • Heart Rate (Pulse): The number of times the heart beats per minute, typically measured by palpating peripheral arteries or using electronic devices
  • Respiratory Rate: The number of breaths taken per minute, indicating the efficiency of the respiratory system
  • Blood Pressure: The force exerted by circulating blood against the walls of the arteries, measured as systolic pressure over diastolic pressure in millimeters of mercury (mmHg)
• • Body Temperature: The degree of heat in the body, usually measured in degrees Celsius (°C) or Fahrenheit (°F)
• Monitoring vital signs provides crucial information about a person's overall health, helps detect abnormalities or changes in physiological status, and guides medical interventions and assessments
• Body temperature is the result of the difference between the heat generated by the body through metabolic processes and the heat present in the surrounding environment
• Body temperature is typically expressed in degrees Celsius, with the normal range fluctuating between 35.5°C and 38°C
• Two types of body temperature measurements:

  • Internal: rectal, oral
  • External: skin (tympanic, temporal artery, underarm)
• The nurse should monitor changes in body temperature and document them in the records
• Oral temperature:

  • Document previous temperature measurements
  • Confirm intact cognitive function
  • Ensure the patient can close their lips around the thermometer
  • Inquire about recent smoking, gum chewing, or food/drink consumption before measurement
  • Keep the thermometer continuously under the tongue (sublingual)
• Underarm temperature:

  • Ensure the patient can keep their arm close to their body
• Tympanic temperature:

  • Use the other ear if a patient experiences pain in one ear
  • Assess secretions or scars on the tympanic membrane
  • Measure the temperature from the opposite ear if the patient has been sleeping with their head turned to one side
• Rectal temperature:

  • Not recommended in patients with diarrhea or rectal issues
  • May not be recommended in patients with certain heart diseases or surgeries
  • Readings are about 1° higher than other methods
• The hypothalamus controls body temperature and maintains a set point at a specific value (37°C in humans)
• Fever:

  • Substances inducing fever are called pyrogens
  • Fever is described by a curve influenced by underlying causes
  • Different types of fever include continuous, remitting, intermittent, waving, and low-grade fever
• Treatment goals for fever include reducing the hypothalamic threshold and facilitating heat dissipation
• Heart Rate:

  • The heart is a muscle in the center of the chest, above the diaphragm
  • It consists of 4 chambers separated by septums
  • The heart pumps blood through arteries and receives blood from veins
• The heart is composed of the myocardium and has different chambers: atrium and ventricle
• Blood is received by the heart from the superior and inferior vena cava and the right and left pulmonary veins
• The heart pushes blood out through arteries such as the right and left pulmonary arteries and the aorta
• The heart has one-way valves that guide blood flow, including atrioventricular valves and semilunar valves
• The coronary circulation supplies oxygen and nourishment to the heart muscles through the right and left coronary arteries
• The heart's conduction system involves the sinoatrial node, atrioventricular node, and the medulla oblongata
• Cardiac output is the amount of blood pumped per minute and varies based on factors like heart rate and stroke volume
• Blood circulation occurs through closed blood vessels, including capillaries, veins, and arteries
• Oxygen is transported by red blood cells and exchanged at the tissue level
• Pulse is a term describing the heartbeat's rate, pace, and force, and can be felt at different peripheral arteries
• Heart rate can be affected by various factors like physical activity, age, and medications
• Tachycardia and bradycardia are conditions characterized by increased or decreased heart rate, respectively
• The quality and breadth of the pulse describe the force of contraction of the left ventricle
• Pulse rhythm can be regular or irregular, with irregular rhythms indicating arrhythmias
• Taking the apical pulse involves auscultation above the apex of the heart to listen to heart sounds
• Taking the peripheral pulse by palpation involves feeling the pulse over an artery and counting the heartbeats
• When the pulse is irregular or difficult to detect, additional measures like using a Doppler ultrasound may be necessary
• Peripheral pulse may be difficult to detect due to irregularity, feebleness, or excessive rapidity
• Doppler Ultrasound is used to detect pulses that are difficult to palpate or listen to
• For an adult or adolescent patient and a child over two years of age, the radial site is the most common for taking the pulse
• The apical site is preferred for taking the pulse in infants and children less than two years of age
• Factors that could affect pulse characteristics include patient age, exercise intensity, fluid balance, and medication use
• Simultaneous measurement to ascertain apical and radial pulse rates simultaneously