Increased rate and depth (extreme exercise, fever)
Hypoventilation
Decreasedrate and depth (irregular, overdose of narcotics)
Cheyne-stokes
Alternating periods of deep, rapid breathing followed by periods of apnea (typically seen in dying patient, drug overdose, heart failure)
Dysrhythmia
Irregular pattern of heartbeats (must report immediately)
When to Assess Vital Signs
On admission
Based on policy
Any time change in patients condition/ loss of consciousness
Before/after surgical or invasive procedure
Before/after activity that may increase risk, such as ambulation after surgery
Before/after administration of meds that affect heart and respirations
Delegation
As nurse cannot delegate teaching of a patient
When delegating: must make sure person (UAP) knows skills
If patient is unstable or change in vitals- CANNOT delegate vitals
Nurse's responsibility to ensure accuracy or the data, and report abnormal findings
Medical diagnosis
What bringspatient to the hospital
Patients level of acuity
How sick patient actually is
Interventions for fever
1. Light clothing
2. Antipyretics (need order)
3. Increase fluids
Signs of fever
Shivering
Dehydration
Sweat
Body's natural response to reduce temperature
How does patient with fever present
Loss of appetite
Headache
Hot/ dry skin
Flushed in face
Thirst
Fatigue
Muscle aches
Increased respiration
Pulse rate
In older adult: delirium or delusion, confusion
In younger children: seizures
Vital Signs
Body Temperature 96.7-100.5
Pulse Rate 60-100 (newborns have higher pulse rate/ older adults have lower pulse rates)
Respirations 12-20
Blood Pressure 120/80
Pulse Ox 95-100%
Circadian rhythm
24hour sleep cycle, typically temperature is lowest in the morning
Body temperature in older adults
Maybe lower due to impaired thermoregulation response
Pulse amplitude
0 Absent
+1 Diminished, Weaker than expected
+2 Brisk, expected, normal
+3 Bounding
Sites for Pulses
Temporal
Carotid- Neck
Brachial-pinky side, elbow
Radial- thumb side
Femoral- groin
Popilteal- behind knees
Posterior tibial- inside ankle
Dorsalis pedis- on top of foot
Oral and rectal route
NOT preferred for child under 5/ older confused patient/ or someone who just had oral surgery
Rectal temperature
Thermometer probe into the anus about 1.5 in in an adult or no more than 1 in in a child
Oral temperature
Sublingual; use protective probe, make sure patient can hold probe under tongue, close lips [if patient had something to eat or drink; wait 15-30 minutes after]- AVOID glass thermometers
Axillary temperature
The armpit; place in middle of axilla - most common for neonates
Temporal temperature
Swiped over the skin; forehead and back of ear
Tympanic temperature
Ear; can be used on adults/children for child pull down and back… for adult pull up and back on pinna [large wax deposit/ smaller canal/ wrong position could affect accuracy of temperature]
Rhythm
Regular or irregular
Amplitude/ quality
Strong or weak
Apical pulse
Found on left mid clavicular line, fifth intercostal space, listen for 1 minute
Pulse deficit
Difference between apical and radial pulse; which indicates that all of the heartbeats are not reaching in the peripheral arteries or are too weak to be palpated [need 2 nurses] assess the apical and radial pulse together for 1 minute
Eupnea
Normal/ unlabored breathing
Listening Korotkoff sounds
Systolic (measurement of contraction of ventricles) typically 100-140- can be affected with emotional state
Diastolic (relaxation of ventricles) typically 60-90
Pulse pressure
Difference between systolic and diastolic pressure