British Thoracic Society and Scottish Intercollegiate Guidelines Network. BTS/SIGN guideline for the management of asthma. SIGN 158. 2019. https://tinyurl.com/y6quo7so (accessed 6 December 2019) Show
Dougherty L, Lister S. The Royal Marsden manual of clinical nursing procedures, Student edition. 8th edn. Oxford: Wiley-Blackwell; 2011 Hartley J. Respiratory rate 2: anatomy and physiology of breathing. Nursing Times. 2018; 104:(6)43-44 Kelly C. Respiratory rate 1: why accurate measurement and recording are crucial. Nurs Times. 2018; 114:(4)23-24 Mok W, Wang W, Cooper S, Ang EN, Liaw SY. Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses. Int J Qual Health Care. 2015; 27:(3)207-13 https://doi.org/10.1093/intqhc/mzv019 National Clinical Guideline Centre. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update of CG12) (full original NICE guideline). 2010. https://tinyurl.com/txddga5 (accessed 6 December 2019)
National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline NG115. 2019a. https://www.nice.org.uk/guidance/NG115 (accessed 6 December 2019) National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management (CG191). Pneumonia in adults: diagnosis and management. 2019b. https://www.nice.org.uk/guidance/cg191 (accessed 6 December 2019) O'Driscoll BR, Howard LS, Earis J, Mak V British Thoracic Society Guideline for oxygen use in adults in healthcare and emergency settings. BMJ Open Respiratory Research. 2017; 4 https://doi.org/10.1136/bmjresp-2016-000170 Subbe CP, Davies RG, Williams E, Rutherford P, Gemmell L. Effect of introducing the Modified Early Warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions. Anaesthesia. 2003; 58:(8)797-802 https://doi.org/10.1046/j.1365-2044.2003.03258.x In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of the changes and abnormailities in vital signs in order to:
Assessing and Responding to Changes/Abnormalities in Vital SignsThe vital signs include the assessment of the pulse, body temperature, respirations, blood pressure and oxygen saturation, which is the newest of all the vital signs. Vital signs are considered vital to the rapid assessment of the client when it is necessary to determine major changes in the client's basic physiological functioning. Baseline vital signs are taken prior to many procedures and treatments including upon admission to an acute care facility, prior to the administration of medications, prior to the administration of a blood transfusion, and prior to surgery and other invasive procedures These baseline vital signs are taken because they are vitally important for comparison to those vital signs that are taken during and after a treatment, a procedure or a significant change in the client. Vital signs are highly responsive to client abnormalities and changes. For example, a significant drop in blood pressure may indicate the presence of hemorrhage and bleeding, a drop in terms of a client's oxygen saturation can indicate the early stages of hypoxia, and a rise in the client's temperature can indicate the presence of infection. The sensitivity of vital signs to even subtle changes in the client's condition is so effective that vital signs are routinely taken for all acute care clients on a regular and ongoing basis. Physiologically, the vital signs reflect the adequacy or inadequacy of basic bodily functions. For example, the blood pressure reflects the cardiac output and the systemic vascular resistance. Respirations and the respiratory rate are reflective of a number of factors including the functioning of the chemoreceptors or baroreceptors in the brain stem, the aorta and the carotid arteries; and the bodily pulses are the physiological functioning of the parasympathetic nervous system, the autonomic nervous system and the cardiovascular system functioning. All significant changes in terms of vital signs must be reported and documented. Many facilities use a graphic flow chart for their patients' vital signs. Applying the Knowledge Needed to Perform Related Nursing Procedures and Psychomotor Skills When Assessing Vital SignsTemperatureBodily temperature results from the differences between heat production and heat losses. The normal bodily temperature is 98.6 degrees F, or 36.7 to 37 degrees centigrade, with some small, minor and normal variations among children, and also as impacted by stress, one's circadian rhythm, female hormonal changes and the external environment. Temperature can be taken at a number of sites including the mouth, rectum, ear, axillae, the temporal area and the forehead depending on the type of thermometer that is used. Oral temperatures are contraindicated among neonates, infants, young children and those adult clients adversely affected with confusion, agitation and a decreased level of consciousness; and rectal temperatures are contraindicated when a client is has a seizure disorder, heart disease or a rectal disorder. RespirationsRespirations are assessed and monitored using inspection for the rise and fall of the chest or abdomen or by gently placing your hand on the chest or abdomen to monitor and assess the rate, regularity, depth and quality of the client's respirations. A decreased respiratory rate can indicate and signal a number of disorders such as central nervous system depression secondary to opioids or central nervous system damage, a coma, planned sedation and sedation as a side effect to a medication and alkalosis; increased respiratory rates can occur secondary to a fever, pain, acidosis and anxiety. The normal respiratory rates along the life span are as follows:
PulsesPulses are assessed with both palpation and auscultation. Peripheral pulses are assessed with palpation, often bilaterally. These peripheral pulses include the radial pulse, the femoral pulse, the brachial pulse, the popliteal pulse, the dorsalis pedis pulse of the foot and the posterior tibial pulse near the ankle. During the palpation of the pulse the index finger and/or the middle finger is used to count the number of beats and to assess other characteristics of the pulse such as its regularity, fullness or volume, and other characteristics. At times, a Doppler is used for difficult to palpate and assess peripheral pulses. The apical pulse is assessed with auscultation and the point of maximum intensity for the adult is on the left side of the chest at the fifth intercostal space. This point differs somewhat along the lifespan until adolescence and during later years secondary to an enlarged heart. The normal parameters for pulse rates along the life span are:
Blood PressureBlood pressure results from the pressure of the blood flow as it moves through the arteries. The blood pressure is what it is as the result of a combination of the blood volume, the peripheral vascular resistance, the pumping action of the heart and the thickness, or viscosity, of the blood. Systolic blood pressures reflect the pressure that occurs with the heart's contraction and diastolic blood pressure reflects the pressure that is exerted when the heart is at rest. Blood pressures are measured most commonly over the brachial artery just above the client's antecubital space. The normal blood pressures along the life span are:
Applying a Knowledge of Client Pathophysiology When Measuring Vital SignsNurses apply a knowledge of the client's pathophysiology when they are assessing vital signs. As stated above, temperatures are a function of bodily heat losses and bodily heat production. Among other things, bodily temperatures gains and abnormal body temperatures can result from pathophysiological changes of the brain, the central nervous system, pathologies of the hypothalamus, the inflammatory process, endocrine hormones, and external environmental temperatures such as extremes of hot or cold which can cause hyperthermia and hypothermia, respectively. Pathophysiologically, alterations and abnormalities of the cardiovascular system, the parasympathetic nervous system and the autonomic nervous system can lead to an abnormal pulse in terms of number of beats per minute, the regularity of the pulse, the volume of the pulse, and other characteristics of the pulse. Pathophysiological alterations affecting the brain stem and the baroreceptors in the carotid arteries, and the aorta, as well as pathophysiology of the respiratory system can lead to alterations in terms of the client's respirations. Similarly, pathophysiological changes in terms of cardiac rate, systemic vascular resistance, and venous return can lead to alterations in terms of the client's blood pressure. Evaluating Invasive Monitoring DataIn addition to monitoring noninvasive data like vital signs, registered nurses also monitor and evaluate invasive monitoring data such as increased intracranial pressure, pulmonary artery pressure and other hemodynamic monitoring data. Increased Intracranial PressureThe pressure within the cranial cavity or skull is known as intracranial pressure (ICP). The normal contents of the skull include the brain, cerebrospinal fluid and blood. Because the skull, after infancy, is a boney and rigid structure without any ability to expand and contract when necessary, increased intracranial pressure in the skull will lead to impaired cerebral perfusion, hypoxia, and the compression of the cerebral arteries. Increased intracranial pressure can be a life threatening situation when it is not treated and reversed. Increased intracranial pressure can increase when many neurological insults including a closed head injury, a cerebral tumor, an epidural hematoma, a subdural hematoma, a subarachnoid hematoma, spina bifida, infections and abscesses, hydrocephalus, a cerebral infarct, and status epilepticus. The normal range for intracranial pressure ranges from 5 to 15 mmHg. Increased ICP occurs when the volume of the cranial cavity increases. Under normal circumstances, the pressure that is necessary to adequately perfuse the brain is known as cerebral perfusion pressure which can be mathematically calculated by subtracting the actual intracranial pressure from the mean arterial blood pressure, as shown below. Cerebral perfusion pressure = The mean arterial pressure – The intracranial pressure The normal cerebral perfusion pressure, under normal circumstances, should range from 60 to 100 mm Hg. Brain herniation occurs when intracranial pressure increases to the point where the boney, rigid skull can no longer accommodate for this increased pressure without successful treatment. The types of brain herniation that can occur are a downward, lateral, and medial displacements, which are referred to as central transtentorial, transtentorial, and cingulated herniation, respectively. Some of the signs and symptoms of increased intracranial pressure include:
Intracranial pressure is assessed and monitored with invasive and noninvasive tests. A CT scan can diagnose and monitor intracranial pressure and invasive direct monitoring of the intracranial pressure can be done with a intraventricular catheter, also referred to as a ventriculostomy, which is placed into the lateral ventricle of the brain, a subarachnoid bolt and an epidural bolt. Some of these devices also drain excess intracranial fluid to relieve the pressure. The treatments of increased intracranial pressure are often dependent on the cause of the increase and the severity of the increased intracranial pressure. In addition to the identification and treatment of an underlying disorder when possible, some of the medications that are used include intravenous osmotic diuretics, like mannitol, to remove fluid, corticosteroids to reduce edema, and anticonvulsant medications to prevent seizures. At times, a barbiturate coma may be induced to preserve brain functioning by decreasing the metabolic demands of the brain. Life saving measures, including cardiopulmonary resuscitation and mechanical ventilation may be indicated. Decorticate posturing is abnormal rigid bodily posturing that is characterized with the tight clenching of the fists on the chest while the arms are turned inward; and decerebrate posturing is rigid and abnormal bodily posturing that is characterized with the extension and arching backward of the client's head while the arms and the legs are extended and the toes are point upward. These abnormal posturings can be unilateral or bilateral. Hemodynamic MonitoringHemodynamic monitoring provides health care providers with current data and information relating to the client's blood pressure, pulmonary artery pressures, pulmonary artery wedge pressure, central venous pressure, cardiac output, intra-arterial pressure, mixed venous oxygen saturation and other data. The normal values for hemodynamic monitoring measurements are as below:
Invasive hemodynamic monitoring systems include a pressure transducer, a monitor, pressure tubing, a pressure bag and a flush device. Some even permit access to draw arterial blood gases. For example, a pulmonary artery catheter consists of a proximal lumen which measures the central venous pressure and it can also be used for the administration of intravenous fluids and to draw venous blood samples, a distal lumen that measures the pulmonary wedge, the pulmonary artery systolic, and the pulmonary artery diastolic pressures, a thermistor that measures the cardiac output, and a balloon inflation port that measures the pulmonary artery wedge pressure when it is briefly inflated. RELATED CONTENT:
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Alene Burke, RN, MSN Alene Burke RN, MSN is a nationally recognized nursing educator. She began her work career as an elementary school teacher in New York City and later attended Queensborough Community College for her associate degree in nursing. She worked as a registered nurse in the critical care area of a local community hospital and, at this time, she was committed to become a nursing educator. She got her bachelor’s of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. She graduated Summa Cum Laude from Adelphi with a double masters degree in both Nursing Education and Nursing Administration and immediately began the PhD in nursing coursework at the same university. She has authored hundreds of courses for healthcare professionals including nurses, she serves as a nurse consultant for healthcare facilities and private corporations, she is also an approved provider of continuing education for nurses and other disciplines and has also served as a member of the American Nurses Association’s task force on competency and education for the nursing team members. Latest posts by Alene Burke, RN, MSN (see all) What type of breathing pattern is manifested with Hypercarbia?In contrast, hypercapnia triggers a breathing pattern of deep and slow breaths with a relatively more significant increase in tidal volume than respiratory rate.
Which degree of edema will result in a 6 mm deep indentation upon pressure application?Grade 3: Noticeably deep pit (6 mm) with the dependent extremity full and swollen that takes up to 30 seconds to rebound.
When assessing a client's respiratory rate the nurse should take which action?When assessing a client's respiratory rate, the nurse should take which action? -Count the number of respirations for 10 seconds. -Remind the client to breathe normally.
What part of the nursing process is the nurse using when assessing a patient who has been admitted with chest pain and shortness of breath?Subjective Assessment
The primary symptom to assess when a patient is experiencing decreased oxygenation is their level of dyspnea, the medical term for the subjective feeling of shortness of breath or difficulty breathing.
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