Vital Signs

Megan Sary, MSN,RN Merritt College

Vital Signs

Temperature, pulse, respirations, blood pressure. (TPR & BP) Pain & Pulse oximetry(SaO2) (5th & 6th). Most frequent measurements. Quick & efficient assessment. Tells a lot about clients usual state of health. Tells a lot about clients current status. Baseline Basis for evaluating nursing interventions Part of a complete/partial assessment.

Monitoring Vitals

When Do We Take Vital Signs?

On admission to any HC facility. To assess a clients condition. To establish a baseline. Based on policy of facility

Routine schedule & according to MD order. Before & after a surgical procedure. Before & after an invasive diagnostic procedure. Before, during, & after administration of medications that affect pulse, BP, RR, & temp. When physical condition changes (LOC, pain.) Client reports nonspecific s/s of physical distress. Example: I feel funny..

RN Should Take Vital Signs..

Whenever the nurse feels that she/he should take them to assess the patient.

Who Can We Delegate To?

Depends on HC facility policy Usually CNA when appropriate. -not in ER, critical care units, postop, or in OR RN assesses/evaluates vs whenever she/he feels it is needed. RN initiated intervention- clinical judgment Can be MD initiated- frequency RN determines when to report vitals to MD Knowledge of factors influencing vital signs helps to determine measurement frequency. Measure when client inactive/environment controlled for comfort.

Normal Range of Vital Signs for Healthy Adults

Oral temperature- 37C, 96.8F-100.4F Pulse 60-100/min (average 80/min) Respirations 12-20 breaths/min BP- 120/80-130/85

Maintenance of Body Temperature

Hypothalamus- thermoregulatory system regulates temperature. Center receives messages from cold & warm receptors in the body. Center initiates response to produce or conserve body heat or increase heat loss.

Thermoregulation

How the body maintains body temp. Neurological & cardiovascular mechanisms. Nerve cells in ant. hypothalamus become heated beyond set point---impulses sent to decrease body temp. Mechanisms of heat loss---sweating, vasodilatation of blood vessels/inhibition of heat production. Nerve cells in post. hypothalamus sense body temp is lower than set pointimpulses sent for heat conservation. Mechs of heat conservationvasoconstriction of blood vessels to reduce blood flow to skin & extremities. Voluntary shivering.

Heat Production-{byproduct of metabolism}

Primary source of metabolism in the body. Hormones, muscle movement, & exercise increase metabolism. Energy production decreases & heat production increases. Body Temp= heat produced minus heat lost.

Sources of Heat Loss

Skin-primary source Evaporation of sweat Warming & humidifying inspired air Elimination of urine & feces

Mechanisms of Heat Transfer to External Environment

Radiation- heat transfer from surface to surface w/out direct contact. (removing blanket) Conduction- transfer of heat from one object to another by direct contact; solids, liquids, gases.(body transfer heat to ice pack-ice melts) Convection- transfer of heat by air movement (increases when wet skin has contact with air) Evaporation- transfer of heat: liquid to gas; (perspiration)

Factors Affecting Body Temperature

Circadian Rhythms- temp lowest bet. 0100-0400 rises steadily during day until max at 1800. Age & Gender Environmental Temperatures

Average Normal Temperatures for Healthy Adults

Oral- 96.8-100.4F (36-38F) Core temp- deep in tissue- relatively constant Measured by rectal, tympanic membrane, temporal artery, esophagus, pulmonary artery, urinary bladder.
Charting temp:

Basal Metabolism Rate (BMR)

Accounts for heat produced by body at rest. Depends on body surface area. Controlled by thyroid.

Environmental Temperature

Fever (Pyrexia) T> 98.6F or 37C The client is febrile or afebrile

Environmental temps affect infants & older adults more oftenless efficient regulation.

Temperature Ranges
Pg. 505

Acceptable Ranges of Temperature

Newborn 35.5-37.5C (95.9-99.5F) Careful! Heat loss in newborns! Temp regulation is unstable until puberty. Older adult has narrower range than younger adult. Normal temp drops as approach older. 35C (95F) not unusual in elderly in the cold. Ave. for older adult is 36C (96.8F)-100.4F No single temp is normal for all people.

Shivering

Shivering- involuntary response Can increase heat production 4-5 Xs Used to equalize body temp.

Diaphoresis

Visible perspiration- beads of sweat, wetness. Mainly forehead, upper thorax Can be seen elsewhere on body Occurs: Pain, after anti-pyretic (Break a fever), exercise, warm, hot flashes.

Factors Affecting Body Temperature

Age Exercise Hormone level Circadian Rhythm (lowest 0100-0400) Max 1800 Stress Environment Temperature Alterations Fever (Pyrexia (fever) Client is febrile or afebrile.

Fever (Febrile)

Excess heat production Not harmful below 39C (102.2F) Fever is based on several temperature readings at different times of day. Need to know clients baseline.
Dehydration serious for elderly & children. As approaching death- fever increases significantly.

Fever of Unknown Origin (FUO)

Unknown etiology of fever. Fever causes cellular metabolism to increase. Oxygen consumption rises. Pulse & RR increase to meet metabolic needs for nutrients. Increased metabolism causes increased energy use that makes more heat. Stress of fever (for cardiac, resp clients) can weaken. Myocardial hypoxia = angina (chest pain) Cerebral hypoxia = confusion

Fever

Oxygen therapy needed. Diaphoresis = water loss Risk for fluid volume deficit Dehydration serious for elderly & children. Hyperthermia- elevated body temp r/t bodys inability to promote heat loss.

Malignant hyperthermia- hereditary; uncontrolled heat production (produced by certain anesthetics)

Heatstroke

Prolonged sun/heat exposure. Medical emergency- elderly/young at risk. High mortality rate. S/S- confusion, delirium, excess thirst, nausea, muscle cramps. Hot, dry skin- key No sweat (e- imbalance) Temp can be 45C /113F!!!

Heat Exhaustion

Profuse diaphoresis causes excess water & eloss. Hypothermia- Prolonged cold exposure < 35C/95F = shivering, memory loss <34.4C/94F = HR, RR, BP fall, cyanotic skin Cardiac dysrhythmias, LOC, no response to painful stimuli. Frostbite- over exposure to subnormal temp

Measuring Temperature/Assessment

Equipment Electronic or disposable single use Mercury Glass- almost obsolete Temporal Artery Thermometer- captures heat emitted over temporal artery. Automated monitoring devices

Conversions: Fahrenheit to Celsius: C= (F-32) X 5/9 Celsius to Fahrenheit: F= (9/5 X C) + 32

Sites for Assessing Temperature

Tympanic Membrane (ear)-core Oral (sublingual) Rectal-core; very accurate; but avoid for pt comfort. Axillary (underarm)

Electronic/Disposable Thermometer

Skill 31-1: Step 6C(7). Thermometer tip in

axilla. View

Advantages of Sites

Oral- accessible, comfortable, no position change, accurate, shows rapid changes, Tympanic Membrane- accessible, core reading, rapid, no need to wake pt., unaffected by oral intake, use for tachypneic pts., newborns, cerumen not big problem. Axilla- safe & noninvasive. Rectum- most reliable when oral not used, core.

Disadvantages of Sites

Oral- Affected by ingestion of fluids, foods, smoke, oxygen. Not for infants, trauma, oral surgery, shivering, epilepsy, unconscious, risk of fluid exposure. Axilla- long time to measure, continuous positioning by nurse, not for fever detection in infants/young children, does not rapidly show fever.

What about Glass Thermometers?

Not used today. Do not touch if spilled. Remove client. Home-rubber gloves, moisten towel, plastic bag. Notify environmental agency. Hospital-isolate spill, call housekeeping. Follow MSDS.

Disadvantages

Tympanic- variability of accuracy, due to placement, not with ear surgery, expensive, disposable probe.

Rectum- Not for clients with diarrhea, rectal surgery, more inaccessible, promotes anxiety, embarrassment, need lubricate, risk of body fluid exposure.

Nursing Diagnoses-pg 517

Risk for Imbalanced body temperature Hyperthermia Hypothermia Ineffective thermoregulation

Planning-pg 517

Goals & Outcomes Long term (obtaining appropriate clothes to wear in cold weather). Short term (regaining normal body temp) Example: Client with diaphoresis: Client intake and output (I/O) will be equal for the next 24 hours.

Implementation-pg 518

Health Promotion: Nurse teaches client to avoid strenuous exercise in hot weather; drink plenty of fluids before, during and after exercise; wear light, loosefitting clothing. Acute Care: Assess temp q2-4 hrs; Administer antipyretics as ordered for elevated temp; give Abx as ordered, replace fluids as needed. Apply cooling blanket or Bear hugger as ordered.

Evaluation

Determine if temp returns to normal range. Palpation of skin Assessment of pulse and RR.

Pulse

Palpable bounding of blood flow felt at various points in body. 60-70mls of blood enter the aorta with each ventricular contraction (stroke volume). Pulse wave reaching a peripheral artery can be palpated. Arteries are deeper than veins; close to bone. Number of pulse waves in a minute is the pulse rate. Characteristics: rate, quality, rhythm,volume of blood ejected per beat. (stroke volume)

Sites for Assessing Pulses

Palpating peripheral arteries

Auscultation of apical pulse with stethoscope

Assessing apical-radial pulse

Pulse Assessment

Cardiac Output

Volume of blood pumped by heart during one minute. Pulse rate X Stroke Volume = Cardiac Output 70 beats/min X 85 mls/beat= 5.1 L/min Adult: C.O. is usually ~ 5L/min. Normal Adult pulse: Regular, 60-100 beats/min Tachycardia= Pulse Rate 100-180/min Bradycardia= Pulse Rate < 60/min (sleep, men, sleep).

Pulse Assessment

Radial & Carotid arteries most accessible. Apical pulse (assess for pt. taking heart meds, & when pulse is irregular) Full one minute for apical

Assessment of Pulse

Brachial or apical for infants or young child. For adult: radial or apical best sites. Other sites like popliteal, pedal- for complete physical assessment. Carotid pulse for code blue situation.

Use Of Stethoscope Earpiece Binaurals Tubing Chestpiece (bell/diaphragm)

Use of Doppler Ultrasound Stethoscope to Assess Pulse

Assessing Radial Pulse

Locate radial pulse. Need second hand. If regular, count for 30 secs and multiply by 2. Irregular- count apical pulse for full minute. Assess pulse amplitude, quality,rhythm.

Assessing Apical Pulse

Critical Decision Point: If pulse is irregular, or weak do apical/radial pulse assessment. Pulse deficit exists if greater than 2 beats difference (means not all beats not reaching peripheral
arteries).

If radial pulse is irregular, or weak apical pulse. To assess heart tones (sounds). Before giving heart med: Digoxin (Lanoxin) Apical pulse needs to be 60/min.

Locate PMI (Point of Maximal Impulse)

Find PMI- on left chest 5th intercostal space at midclavicular line Where pulse is loudest Apex of heart

Angle of Louis

Heart Tones/Sounds APT-M

Assessing Apical Pulse

Place diaphragm of stethoscope over PMI Auscultate for S1 & S2 Lub-Dub sound (one heart sound) Filling & Contracting of Ventricles For regular: Count for 30secs X 2. For irregular: Count full 1 minute.

Assess Pulse

Rate Regular Strength Bounding +4 Strong +3 Weak +2 Thready +1 Absent 0

Acceptable Ranges for HR

Newborn to 1 mo 1mo-12mos 12mos-2yrs 2-6yrs 6-12 yrs Adolescent-Adult

120-160 beats/min 80-140 80-130 75-120 75-110 60-100

Factors Influencing Pulse Rate

Exercise Temperature Emotion Drugs Hemorrhage Postural Changes Pulmonary Conditions

Two Common Abnormalities

Tachycardia- HR > 100/min Bradycardia- HR < 60/min

Pulse Deficit- inefficient contraction of

heart fails to transmit pulse wave to peripheral pulse- if a difference in apical/radial= cardiac output decrease

Rhythm

Dysrhytmia (Arrhythmia)- early or late beat. Threatens hearts ability to provide adequate cardiac output. 12-lead EKG to document. Children often have sinus arrhythmiairregular HR that speeds up with inspiration and slows with exhalation.

Nursing Diagnoses for Altered Pulse

Activity Intolerance Anxiety Decreased Cardiac Output Fear Deficient/excess fluid volume Impaired gas exchange Hyperthermia Hypothermia Acute pain Ineffective tissue perfusion

Respiration

Terminology

Ventilation- breathing; movement of air in/out of lungs. Inspiration- breathing in Expiration- breathing out

Respirations- vital sign nurse measures

Breathing

Passive Process Brain stem regulates: Medulla Oblongata Adults: 12-20/min Ventilation regulation by CO2, O2, H+ (pH) in blood.

Normally: Level of CO2 in arterial blood drives ventilation!!

Hypoxemia {Low levels of arterial blood}

Elevated Co2 levels = increased RR. Removal of hi CO2 (Hypercarbia) Chronic lung disease (emphysema) Respond to low O2 levels Due to ongoing hypercarbia Chronic lungers increase RR due to hypoxemia High oxygen levels can be fatal!!

Breathing Mechanics

Breathing is passive Inspiration is active Brain sends impulse to phrenic nerve on diaphragm to make it contract & abdominal organs move upward & forward, air moves in-inspiration. Diaphragm relaxes, abdominal organs return, air move outexpiration. Tidal Volume: normal breath 500 mls air

Assessment: Ventilation

RR accessible. Easy to miscalculate. After taking pulse, keep fingers on radial pulse and watch and count movement of chest rising and falling. RR declines throughout lifespan. Depth Rhythm: regular, even, irregular, labored

RR < 12 or > 20 requires further assessment!!!!

Assessing RR

Assess RR in position of greatest comfort. - Pregnant (sidelying) - CHF (High Fowlers) - Ascites (fluid accumulation in abdomen-liver cirrhosis)

Critical Point: Irregular RR or periods of apnea; {cessation or Respiration for several secs.} are symptoms of underlying disease in the adult. *Must be reported to MD or RN in charge stat!

Unexpected Outcomes

Abnormal RR, depth, or states is SOB. Observe for related factors: -Abnormal breath sounds -productive cough -restlessness, confusion, irritability, anxiety Position- semi-Fowlers or High Fowlers Remove respiratory irritants: plants, perfume, smoke etc.

What Affects Character of Respirations? Rate, Depth, Movements

Age (neonate 30-60/min; adult 12-20/min) Gender (men more diaphragmatic) Acid-base balance Brain Lesion Increased Altitude Respiratory Disease Anemia (Hgb) Acute Pain Anxiety Smoking Body Position Medications-narcotics, sedatives

Acceptable Ranges

Newborn: Infant (6 mos) Toddler (2 yr) Child Adolescent Adult

30-60/min 30-50 25-32 20-30 16-19 12-20

Arterial Blood Gases (ABGs) {Direct Measurement of O2 Saturation}

Normal Ranges pH 7.35-7.45 PaCO2 35-45 mmHg PaO2 80-100 mmHg SaO2 95-100% Acceptable- (90-100%) OK for certain dxs (85-89%)(ie:COPD) ***Not OK = < 85% !!!!!

Assessing Diffusion & Perfusion

Oxygen Saturation of the blood Percent of saturation of Hgb (SaO2) Normal = 95-100%

CBC Complete Blood Count Hemoglobin 14-18 g/100 ml (M) 12-16 g/100 ml (F) Hematacrit 40-54% (M) 38-47% (F) RBCs 4.7-6.1 m/ml (M) 4.2-5.4 (F) Establishes O2 carrying capacity

Alterations in Breathing Patterns

Eupnea- normal breathing- evenly spaced Dyspnea- difficult & labored breathing Bradypnea (<12/min) Tachypnea (>20/min) Apnea Hyperventilation Hypoventilation Cheyne-Stokes- (apnea/hyperventilation) Kussmauls respiration (deep reg, increased rate) Biots respiration( shallow then irregular)

Portable Pulse Oximetry-6th vital sign

Indirectly measures oxygen saturation. Light waves absorbed differently by deoxygenated Hgb and oxygenated Hgb.

Nursing Diagnosis: Depends on Defining Characteristics

Activity Intolerance Ineffective airway clearance Anxiety Ineffective breathing pattern Impaired gas exchange Acute pain Ineffective tissue perfusion

Blood Pressure

Blood Pressure

Force exerted on walls of artery by the pulsing blood under pressure from heart. BP = good indicator of CV status. Measurement of blood as flows thru arteries. Assessment of BP gives info about circulation; arterial wall elasticity, efficiency of heart as a pump, and volume of circulating blood.

BP=Blood Pressure

Systolic BP (SBP)-contraction of ventricles Diastolic BP (DBP)-relaxation of ventricles Adult normal = 120/80 mmHg SV=stroke volume= amount of blood forced out of LV with each contraction. CO=cardiac output= amount of blood pumped out of LV per min. CO= HR X SV BP= CO X R (PVR)

Arterial BP Physiology

Cardiac Output- amt of blood pumped out of LV per

minute; determines BP & perfusion.

Peripheral Resistance- resistance of arteries that

blood has to flow against. Main factors affecting BP

Blood Volume- amount

Viscosity- blood thickness

Compliance-elasticity of arteries

What Influences BP?

Age Circadian rhythm- lowest in arising in am Gender Food Intake Exercise Weight Stress Body Position Ethnicity- more prevalent & severe in African Americans Medications- oral contraceptives can cause mild increase Biofeedback- observe fish in a tank: Evidence Based Practice

Hypertension (HTN)

Silent killer Often asymptomatic Optimal BP= 120/80 BP > normal for at least two different times. Primary (essential HTN)= no known cause Secondary HTN= known cause Pre-HTN 120-139/80-89

Risk Factors

Obesity Cigarette Smoking Heavy Alcohol Use High Sodium Intake Sedentary lifestyle Constant stress exposure Incidence greatest in: Diabetics, elderly, African-Americans.

Hypertension

Major risk for stroke Myocardial Infarction (MI) Cardiovascular Disease is #1 cause of mortality in the U.S.

Anti-hypertensive Medications Categories

Diuretics (Lasix) Beta-adrenergics (beta-blockers) (Propanolol)

Vasodilators(Hydrazaline)
Calcium channel blockers (Verapamil) Angiotension- converting enzyme (ACE) inhibitor (Captopril)

What Can Nurse Do?

Screening Education Referrals

Terminology

Hypotension- Consistently low SBP 90-115 mmHg if symptomatic. May be normal in athletes, some people. Report stat! Tachycardia, increase sweating, confusion.

Orthostatic hypotension- low BP associated with weakness or fainting upon rising to supine or sitting. Etiology: prolonged bedrest, dehydration. Elderly at risk! Move/sit slowly; dangle at bedside first. Postural hypotension- change in BP when going from supine to sitting to standing. Sign of internal bleeding.

Measuring BP Sphygmomanometer

Common Mistakes in Taking BP

Wrong cuff size Cuff wrapped too loosely or unevenly Deflating cuff too slowly or quickly Arm not supported Inaccurate inflation level Arm below heart level Arm above heart level Pressing stethoscope too firmly

Do not take BP on arm with Intravenous Needles, Dialysis shunts, postmastectomy clients.Put sign above patients bed.

Correct Use

Width of BP cuff should be 40% of circumference of limb used. (hold cuff horizontally against arm)

Bladder inside cuff should enclose 2/3rds of limb used. (wrap bladder around limb)

Inappropriate Use of Dinamap

Irregular HR Seizures Shivering Excessive tremors Inability to cooperate BP < 90 mmHg

Palpating brachial artery

Noninvasive Portable Doppler

Where Can We Take BP?

Estimating Systolic Pressure First

Purpose: ?
Allows for determination of approximate systolic reading. Wrap cuff on arm. While palpating brachial artery, pump up cuff until you can not feel beating. The point at which the pulse disappears provides an estimate of systolic pressure. You will know how high to pump cuff up when doing BP instead of blindly estimating. Pump the pressure 30mmHg above where estimated to ensure hearing the first sound. Record as eg 130/P or 130/-, palpated.

Assessing Blood Pressure

Listening for Korotkoff sounds with stethoscope. - First Korotkoff sound= clear, rhythmical tapping that gradually increases in intensity. - A blowing or swishing sound occurs as cuff continues to deflate= Second Korotkoff sound. - Third Korotkoff sound= crisper more intense tapping. - Fourth Korotkoff sound= Change or cessation of sound occurs-diastolic pressure

Brachial artery or popliteal artery are commonly used.

Korotkoff Sounds

Focus on Older Adults

Normal temp decreases with age. Infection may not cause increase in temp. Confusion, tachycardia, tachypnea, anorexia, falling, delirium, overall functional decline. Doppler prn for pulse. Pulse may be muffled. Decreases with age. BP may increase with age; but DO NOT consider normal. Allow to change position slowly to avoid postural hypotension. Decreasing lung fx causes increased RR 16-25. Limited ability to respond to hypoxia. Pulse oximeter probe may be difficult to assess: PVD decreased CO, cold-induced vasoconstriction, anemia.

Recording Vital Signs

Special graphic flow sheets. Abnormal vs are mentioned in narrative. What nursing interventions were done. Any evaluation later on.

Review Questions
A nurse is preparing to take vital signs on an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method to assess this clients body temperature? A. Oral B. Axillary C. Rectal D. Heat-sensitive tape

Question
A nursing change of shift report has indicated that a clients pulse amplitude is described as 1. The nurses first action after report is to do which of the following?
A. B. C. D.

Notify the MD Assess the client right away. Document the pulse amplitude is normal. Change the client's position.

Question
A client has an elevated temperature. The nurse assesses the client and finds the skin is flushed and very warm. The client is oriented to person, place, and time, and expresses severe fatigue. The most appropriate nursing action at this time would be to do which of the following? A. Place ice bags on the clients skin. B. Remove blankets and offer fluids. C. Increase the clients activity. D. Decrease the clients intake.

Question
A nurse obtained a clients pulse and found the rate to be above normal. How would the nurse document this finding?
A. B. C. D.

Tachypnea Hyperpyrexia Arrhythmia Tachycardia

Question
A client had oral surgery following a motor vehicle accident and the nurse assessing the client finds the skin flushed, warm, and diaphoretic. Which of the following would be the best method to assess the clients body temperature? A. Oral B. Axillary C. Arterial line D. Rectal

Question
The nurse is unable to palpate a clients pedal pulses in an edematous right lower extremity. Which of the following would be the best nursing action? A. Notify the MD of the inability to detect the pedal pulses. B. Check the temperature of the lower extremities. C. Use a Doppler to check for pedal pulses. D. Measure the right lower extremity and compare it to the left.

Oxygenation

Supplying the Body with Oxygen

Cardiac Structure & Function

Myocardial Pump-essential to oxygen delivery (Starlings Law) Myocardial Blood Flow= blood flow is unidirectional due to valves in heart. Coronary Artery Circulation Systemic Circulation

Terminology

Blood Flow Regulation Cardiac output= Stroke Volume X Heart Rate Stroke Volume Preload Afterload

Terminology

Cardiac Index- CO divided by BSA

Stroke Volume- amount of blood ejected from left ventricle with each contraction. Preload- end-diastolic volume Afterload- resistance to left ventricular ejection; the work heart has to overcome to fully eject blood from left ventricle.

Normal EKG waveform

Heart is electrical & mechanical

Myocardial Blood Flow CO = SV X HR Conduction System

Respiratory Physiology Structure & Function

Work of Breathing Lung Volumes Pulmonary Circulation

Respiratory Gas Exchange

Diffusion Oxygen Transport Carbon Dioxide Transport

Factors Affecting Oxygenation

Physiological, developmental, lifestyle, environmental. Physiological Factors.. decreased oxygen-carry capacity (Co3 poisoning) decreased inpired oxygen concentration (hi altitudes, drug OD) Hypovolemia Increased metabolic rate

Conditions Affecting Chest Wall Movement

Pregnancy Obesity Musculoskeletal Abnormalities Trauma Neuromuscular Diseases CNS alterations CNS alterations Influences of Chronic Disease

Normal Sinus Rhythm

Atrial Fibrillation

Most common adult arrhythmia Irregular, chaotic atrial rhythm Can lead to embolus formation

Ventricular Fibrillation

Fatal if untreated stat! Ventricles not pumping blood at all Chaotic rhythm

12-Lead EKG (ECG)

Decreased Oxygenation to Heart

Angina Pectoris: myocardial ischemia

Myocardial Infarction

Acute Coronary Syndrome (ACS)

Developmental Factors Affecting Breathing

Infants/Toddlers- risk for URI School-age/Adolescents- exposure to resp infectionssmoking at early age? Young/Middle-age Adults (unhealthy diet, lack of exercise) Older Adults- decline/changes with aging process. Box 40-3 pg 917 look at.

Alterations in Respiratory Function

Goal of ventilation:
Maintain normal ABGs PaCo2: 35-45 mmHg PaO2: 95-100mmHg pH: 7.35-7.45 SaO2: 95-100% Hyperventilation Hypoventilation Atelectasis- collapse of alveoli causing hypoventilation. Hypoxia- inadequate cellular oxygenation Cyanosis- bluish skin or mucosa, nailbeds-LATE SIGN OF RESP FAILURE. Central cyanosis-tongue, eyeball, soft palate= hypoxemia Peripheral- extremities, nailbeds, earlobes=vasoconstriction and stagnant blood flow.

COPD

Respiratory is low oxygen levels. Keep nasal cannula at 1-3L/min

Nursing Process Assessment

Nursing Hx
Pain: Cardiac or pleuritic pain Fatigue Smoking Dyspnea- subjective feeling of SOB: clincial sign of hypoxia (pulmonary, CV, neuromuscular, anemia). Orthopnea uses several pillows when lying down. Hemoptysis- bloody sputum Wheezing- high-pitched musical sound

Assessment

Exposure to inhaled substances Cigarette smoke, carbon monoxide, radon. Asbestos, coal, cotton fibers, fumes,chemical irritants.

Respiratory Infections PNA- green or rust-colored sputum Mycoplasma PNA- HIV clients Pneumocystis carinii (PCP)- HIV Allergies Medications

Physical Assessment

Inspection Palpation Percussion Auscultation

Nursing Diagnoses

Activity Intolerance Risk for activity intolerance Ineffective airway clearance Anxiety Ineffective breathing Decreased cardiac output Ineffective tissue perfusion Fatigue Impaired spontaneous ventilation

Planning

Goals & Outcomes: -Clients lungs are clear to auscultation -Clients SaO2 are maintained at > 95% Setting Priorities- ie: Airway before smoking cessation program

Continuity of Care- collaboration with other HCW

Implementation

Health promotion & prevention behaviors Positioning Coughing techniques Oxygen therapy Lung inflation techniques Incentive spirometry Administration of medications Chest physiotherapy Suctioning

Evaluation

Review if expected outcomes have been met. Modify as needed.

Chest Tubes

Chest tube- catheter inserted into thorax to remove air & fluids in the pleural space. Pneumothorax

Hemothorax

Oxygen Equipment-Know pg 956,958,959

Nasal cannula- 1-6L/min: Add humidifier for 5L up. Simple face mask Venturi mask Nonbreather mask

Bipap and Ventilator

Airway Devices Nasal and Oral