Fundamental Nursing Skills and Concepts

1
Fundamental Nursing Skills and Concepts

• Chapter 11 page 137

2
Vital Signs

• Body temperature
• Pulse rate
• Respiratory rate
• Blood pressure
• Vital signs are objective data that indicate how
  well or how poorly the body is functioning. These
  signs are measureable.

3
Body Temperature

• Refers to the warmth of the human body and is
  produced primarily by exercise and the metabolism
  of food.
• Bodys shell, (skin surface), temperature is
  lower than the core, (at the center of the body),
  temperature
• Measured in the Fahrenheit or Centigrade scale.
  Box 11-2, top 139a. Need to know.
• Normal body temperature 96.6 to 99.3 Fahrenheit
  or 35.8 to 37.4 Centigrade, for shell temps.
• For core temps 97.5-100.4 F , or 36.4 -37.3 C

4
Body Temperature

• The hypothalmus- (structure within the brain)-
  acts as the center for temp. regulation.
• Temps higher than 105.8 F (41C) or lower than
  93.2F or (34C) show the hypothalmus is
  impaired.
• 110F or higher or lower than 84F is not
  compatible with life.

5
Body Temperature

• Lost from the skin, lungs and body waste products
  through the process of radiation, conduction,
  convection, and evaporation.
• Table 11-1 page 138

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Factors Affecting Body Temperature

• Food intake-affects thermogenesis,(heat
  production), both the amount and type eaten
  affect body temp. because the body requires
  energy to digest, absorb, transport, metabolize
  and store nutrients. Restrictions on diet can
  help decrease body heat, because of reduced
  processing of nutrients.
• Age- infants and older adults have limited body
  fat which helps to maintain body temp.
  regulation. Fat provides insulation to prevent
  heat loss. The ability to shiver and perspire may
  also be inadequate, putting them at risk for
  increase body temps. .
• Climate
• Gender-may see slight rise when ovulating due to
  hormonal changes.

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Factors Affecting Body Temperature

• Exercise and activity-involves muscle contraction
  which produces body heat. To provide energy,
  metabolic rate goes up leading to combustion of
  calories, and increases heat production.
• Circadian rhythm
• Emotions
• Illness or injury
• Medications

8
Assessment Sites

• Thermistor catheter (heat sensing device at the
  tip of internally placed tube)
• Oral site- mouth, oral cavity
• Rectal site-rectum
• Axillary site-axilla
• Ear-tympanic
• Document site temp. was obtained. Page 141a

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Oral site

• Area under the tongue rear sublingual pocket
  most accurate. Picture top page 141
• Patient needs to be informed, cooperative, keep
  mouth closed, and breathe at a normal rate.
• Avoid oral route if uncooperative, very young,
  unconscious, seizure risks, oral surgery patient,
  mouth breathers, and those that are talkative.
• Avoid if patient has been chewing gum, has smoked
  or has had something cold or hot to drink.
  Assessment should take place after 30 minutes,
  for a more accurate temp. reading.

10
Assessment sites and time

• Oral site-leave in place, mercury thermometer, 3
  minutes to 5 minutes if feverish.
• Rectal site-most accurate site. May be
  embarrassing. For glass mercury thermometers
  leave in place 2 minutes.
• Axillary site-underarm site, generally 1 lower
  than oral measurement. Infants and small children
  can be injured rectally so the axillary is the
  preferred method. It is safe, readily accessible,
  less disturbing, but longest assessment time, 5
  minutes or longer. Make sure contact is made for
  good transference of heat.

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Assessment sites and time

• The ear-also known as tympanic. This measurement
  has the closest correlation to core temperature.
  Considered more reliable, the electronic
  thermometer will beep when ready.

12
Thermometers used to measure body temps.

• Glass- slender or rounded bulbs-
• Slender, for oral use, (Blue tip)
• Rounded, for rectal placement, (Red tip)
• For rectal temps 1.5 adult, 1 child, .5
  infant.
• Mercury is used in the stem, it heats up and the
  highest point the mercury reaches in the stem is
  the reading of body temp.
• To clean them is located on page 144, 11-1.

13
Thermometers used to measure body temps.

• Electronic thermometers- temperature sensative
  probe covered with a disposable sheath. They are
  portable and rechargeable. Oral and axillary
  probe may be utilized, which is the blue probe,
  rectal probe is the red probe.
• The probe is connected to an electronic unit that
  senses the temp. . Temp. is reached. A signal is
  emitted to indicate the end. No specific time
  interval, usually 30-60 seconds. Remove probe -
  eject cover read display.

14
Thermometers used to measure body temps.

• Infrared (Tympanic) thermometers-hand held
  covered probe- inserted into ear canal, detects
  warmth through sensor from the eardrum converted
  to temp. measurement in 2-5 seconds.
• Contraindicated for children younger than 2, due
  to small ear canals.

15
Thermometers used to measure body temps.

• Chemical thermometers- heat sensitive tapes, or
  patches can be reused before being discarded,
  placed on forehead or abdomen.
• Changes color according to body temp., easily
  read. Other varieties of strips are held in the
  mouth and dots change color to indicate temp..
  One use and discard.
• Page 145 bottom has some examples.

16
Thermometers used to measure body temps.

• Automated monitoring devices-allows, B/P, temp.,
  and pulse to be taken at same time. Usually
  rolled from room to room.
• Be careful of ??????????
• Continuous monitoring device- usually in
  critical care areas. Probes placed within the
  esophagus of anesthetized pts. Or a sensor
  attached to a pulmonary artery catheter.
• Skill 11-1 assessing body temp. pg 164.

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Fever

• Body temp is elevated _at_99.3F or above.
• Fever pyrexia
• Febrile, with fever
• Afebrile, with out fever, no fever
• Hyperthermia, high core temp. , usually exceeding
  105.8F or 40.6C at risk for brain damage or
  death due to high metabolic demands.
• Symptoms- restless, flushed, irritable, poor
  appetite, glassy eyes, increased perspiration,
  headache, increased pulse resp. rate.

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Fever cont.

• May be disoriented, confused and have fever
  blisters.
• A fever of less than 102.F may be a good thing
  to fight off infection, bodys own defenses,
  fighting microbes.
• Provide lots of fluids and or rest.
• Fever of 102-104F, antipyretics may need to be
  used. Aspirin(ASA), or acetaminophen.
• See nursing care plan guidelines for pts. with a
  fever, pg.148

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Hypothermia

• Core body temp. less than 95F, or 35C. , best
  taken with a tympanic thermometer. Why????
• What will you be seeing in a pt. that is
  hypothermic?
• What will you do for a hypothermic pt. ?
• Nursing guidelines 11-2 page 149.

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Phases of a Fever

• Prodromal Phase The client has nonspecific
  symptoms just before the temperature rises.
• Onset or Invasion Phase Obvious mechanism for
  increasing body temperature, such as shivering
  develops.
• Stationary phase The fever is sustained.
• Resolution or defervescence phase Temperature
  returns to normal
• Fig 11.11 page 147

21
Subnormal Temperature

• Hypothermia-core temperature less than 95 degrees
• Mild hypothermia-temperature 95 to 93.2 degrees
• Moderate hypothermia-93 to 86 degrees
• Severe hypothermia-below 86 degrees

22
Pulse

• A wavelike sensation that can be palpated in a
  peripheral artery, produced by the movement of
  blood during the hearts contraction.
• Normal heart rate is 60-100 beats per minute at
  rest, table 11.5 page 149
• Pulse rate (number of peripheral pulsations
  palpated in 1 minute) is counted by compressing a
  superficial artery against an underlying bone
  with the tips of the fingers, never, never the
  thumb.

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Factors Affecting Pulse and Heart Rates

• Age
• Circadian Rhythm (lower in am)
• Gender
• Body build
• Exercise and activity
• Stress and emotions

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Factors Affecting Pulse and Heart Rates

• Body temperature--- for 1F temp. elevation the
  heart and pulse rate increases 10 BPM.
• Blood volume---excessive blood loss causes heart
  rate to increase. Why??? ( task is to deliver O?
  to cells, so speeds up the action, due to lower
  circulating volume).
• Drugs---some slow, some speed up rate. Very
  important to know what meds do that you are
  giving.

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Alterations in Pulse Rate

• Tachycardia-100-150 bpm---heart is overworked,
  cells may not get the O? they need. Monitor
  closely, report document according to agency
  policy.
• Palpitation-Awareness of ones heart contraction
  without having to feel the pulse.
• Bradycardia-lt60 bpm---warrants monitoring,
  reporting documenting.
• Arrhythmia or dysrhythmia-irregular pattern of
  heartbeats, need to report promptly.

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Alterations in Pulse Rate

• Palpitation- awareness of ones own heart
  contraction without having to feel the pulse.
• Pulse volume- table 11-6 page 150-quality of
  pulsation felt.
• Peripheral pulse sites-fig. 11-12---know these
• Assessing radial pulse---skill 11-2 page 172

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Alterations in Pulse Rate

• Fig. 11-13, page 151b. Apical heart rate point
  of maximum impulse. Point of maximum impulse,
  slightly below the left nipple in line with the
  middle of the clavicle.
• Listening to the apical, lub dub will be heard,
  this is equal to one beat.
• The lub will be heard louder than the dub if the
  stethoscope has been placed correctly.
• Taking a radial pulse this lub dub will come
  across as 1 beat.

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Pulse Assessment Sites

• Peripheral pulses-radial artery
• Apical heart rate-number of ventricular
  contractions per minute that occur.
• Apical-radial heart rate-number of sounds heard
  at the hearts apex and the rate of the radial
  pulse during the same period. 2 nurses, (1 nurse
  counts the apical beats, the other counts
  radial), 1 clock is used. They start counting at
  the same time. They should get the same total, if
  not the difference between is called the pulse
  deficit. Should be reported to charge nurse and
  doctor.

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DOPPLER

• Doppler ultrasound device- conductive jelly is
  used to hear very faint sounds. Document D, for
  doppler.
• Doppler is used when slight pressure occludes
  pulsation.
• Page 152 shows a doppler being used.

30
Pulse rate and respiratory rate

• Factors that influence the pulse rate usually
  affect the respiratory rate such as temp.,
  activity, anxiety, stress and fright.

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Respiration

• Exchange of oxygen and carbon dioxide
• External respiration- exchange between alveolar
  capillary membranes
• Internal or tissue respiration- exchange between
  blood body cells
• Ventilation-movement of air in and out of the
  chest
• Inhalation-breathing in
• Exhalation-breathing out
• Respiratory rate-number of ventilations per minute

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Respiration

• The medulla is the respiratory center in the
  brain and controls ventilation. It is sensitive
  to the CO?, (carbon dioxide), in the blood.
• Count the number of ventilations in one minute.
• Table 11-7 page 152need to know normal
  respiratory rates.
• Ratio of 4-5 heartbeats to 1 respiration is
  fairly normal.

33
Breathing Patterns and Abnormal Characteristics

• Cheyne-Stokes Respiration-Breathing pattern in
  which the depth of the respirations gradually
  increases followed by gradual decrease, and then
  a period when breathing stops before resuming
  again. Usually seen as death approaches.
• Hyperventilation-Rapid or deep breathing
• Hypoventilation-Diminished breathing
• Changes in ventilation may occur in clients with
  airway obstruction, pulmonary or neuromuscular
  disease.

34
Breathing Patterns and Abnormal Characteristics

• Dyspnea-Difficult or labored breathing. May see
  nostrils flare, or widen, pt. appears anxious, or
  worried. Fight for breath. Abdominal, and neck
  muscles used to breathe, seen in anxious pt.
  along with fast heart rate.
• Orthopnea-Breathing facilitated by sitting or
  standing up, page 412 shows the examples. The
  abdominal organs move away from the diaphram with
  gravity so breathing is easier.

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Breathing Patterns and Abnormal Characteristics

• Apnea-Absence of breathing. Lasts 4-6 minutes,
  life threatening. Prolonged apnea there will be
  brain damage. Skill 11-3, pg 174.
• Tachypnea-fast respiratory rate
• Bradypnea-slower than normal resp. rate. Drugs
  such as MS can slow rate so count 1 full minute.

36
Sounds to be aware of

• Stertorous breathing- noisy ventilation
• Stridor- harsh, hi-pitched sound heard on
  inspiration when there is a laryngeal
  obstruction. Children often have stridor with
  croup.
• Anterior and posterior lung assessments are well
  demonstrated on page 199, you will need to know
  these well.

37
Blood Pressure

• Force that the blood exerts within the arteries
• Circulating blood volume averages 4.5 to 5.5 L in
  adult men
• Contractility of the heart is influenced by the
  stretch of cardiac muscle fibers. If the muscle
  tissues are damaged and scar tissue happens, less
  stretch and reduced contractility occurs.
• Cardiac output-volume of blood ejected from the
  left ventricle per minute is approximately 5 to 6
  liters, average stroke volume in adults is 70 ml
  x heart rate x minute or time.

38
Blood Pressure

• Preload volume of blood that fills the heart and
  stretches the heart muscle fibers during its
  resting phase.
• Afterload-force against which the heart pumps
  when ejecting blood. Resistance increases when
  valves of the heart and arterioles are narrowed
  or calcified. Afterload is decreased when
  arteries dilate.
• Systolic and diastolic are expressed as a
  fraction in millimeters of mercury, (abbreviated
  mmHg).
• Generally a B/P of 140/90 is considered the
  beginning of high B/P. Optimal B/P for adult
  120/80 mmHg.

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Factors Affecting Blood Pressure

• Age-tends to rise with age
• Circadian rhythm-lowest _at_ 12 to 4 or 5 a.m.
• Gender women tend to have lower B/P
• Exercise and activity
• Emotions and pain- B/P rises
• Arteriosclerosis-arteries loose elasticity
• Athersclerosis-narrowed arteries due to deposits
• Miscellaneous factors
• Drugs-heart stimulants-nicotine,caffiene,cocaine

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Pressure Measurements

• Systolic pressure-Pressure within the arterial
  system with the heart contracts. Is higher than
  the Diastolic pressure- Pressure within the
  arterial system when the heart relaxes and fills
  with blood
• Pulse pressure-Difference between systolic and
  diastolic pressure measurements
• A pulse pressure between 30-50 mmHg when
  diastolic is subtracted from systolic blood
  pressure is said to be in the normal range.

41
Assessment of the Blood Pressure

• Over the brachial artery at the inner aspect of
  the elbow is usually used. When there is a
  problem with taking it at this location, then the
  lower arm can be used, using the radial artery.
• Popliteal artery- behind the knee. Always
  document site used.
• Equipment for Measuring Blood Pressure
  Sphygomomanometer- mercury or aneroid
• Inflatable cuff that encircles at least 2/3 of
  the limb at mid point
• Stethoscope

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Assessment of the Blood Pressure

• Table 11-9 page 157 B/P assessment errors
• First time a B/P is measured it needs to be taken
  in each arm. Should not vary 5-10 mmHg. Doctors
  may request a lying, sitting and standing B/P.
• Too wide cuff will give a false low reading
• Too narrow cuff will give a false high reading
• Stethoscope ear tips need to be positioned
  downward and forward in ears. Tips need to be
  cleaned between uses. Best length of tubing for
  sound conduction 20 inches.

43
Measuring Blood Pressure

• Korotkoff Sounds-Sounds that result from the
  vibrations of blood within the arterial wall or
  changes in blood flow, fig 11-21, page 158
• Phase I-begins with the first faint but clear
  tapping sound that follows a period of silence as
  pressure is released from the cuff. This is the
  systolic pressure measurement. Note the placement
  of the gauge mark.
• Auscultatory gap-Period during which sound
  dissappears
• Phase II-is characterized by a change form
  tapping sounds to swishing sounds
• Phase III-is characterized by change to loud and
  distinct sounds, described as crisp knocking
  sounds

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Measuring Blood Pressure

• Phase IV-sounds are muffled and have a blowing
  quality
• Phase V-Last sound is heard, this is the
  diastolic pressure reading.
• Palpating the B/P- instead of using a stethoscope
  use fingers over the artery, when the first
  palpation is felt after the release of the cuff
  pressure, this is the systolic B/P. No diastolic
  is perceptible. Document systolic B/P palpated
  and the number.
• Doppler stethoscope used, please document D.

45
Abnormal Pressure Measurements

• Hypertension-High blood pressure-140/90 or above
  for adults 18 or over for sustained amount of
  time is considered HTN. HTN often associated
  with anxiety, obesity, vascular diseases, stroke,
  heart failure, kidney disease.
• Whitecoat Hypertension-Condition in which the
  blood pressure is elevated when taken by a health
  care worker, but normal other times.
• A sudden rise or fall of 20-30 mmHg is
  significant- take B/P on both arms and report it
  to your charge nurse.

46
Abnormal Pressure Measurements

• Hypotension-Low blood pressure- may indicate
  shock, hemorrhage, drugs, orthostatic hypotension
  or postural hypotension, which is a sudden but
  temporary drop in B/P when rising from a
  reclining position. Commonly seen in patients
  with circulatory problems, dehydration, patients
  on diuretics. Patient will present with
  dizziness, going weak, and fainting. Postural or
  orthostatic hypotension-Sudden temporary drop in
  blood pressure when rising from a reclining
  position.
• Report any abnormal vital signs!!!!
• Skill 11-4 assessing the B/P page 176
• Please look over general gerontologic
  considerations