Source: Secondary Assessment

Transcription

1 Source: Secondary Assessment

2 Introduction A & P Review Components Assessment Source:

3 Introduction Must understand normal before we can begin to understand abnormal Only accomplished through repetition Wide range of normal

4 Introduction Vital signs are a baseline measurement of function Respiration Circulation Perfusion Trends are more critical than just one set of vitals

5 Vital Signs Components Respirations Pulse Blood pressure Skin conditions Pupils O2 Saturation ETCO2 Source: Blood lactate

6 Every day in your clinical practice, you whip out your equipment and take someone s vital signs. But do you really understand what s going on behind the numbers?

7 Source: Respirations

8 Respirations Anatomy

9 Respirations Anatomy Source:

10 Respirations Physiology Source:

11 Respiration Physiology CSF ph Arterial PO2 Source:

12 Respirations Source:

13 Respirations Assess rate, depth, and effort Normal Rate = 30 seconds x 2 Adults breaths/minute Normal rates increase as age decreases Depth = adequate Effort = easy Inspiration is active Expiration is passive Table 20-3 on page 526 Abnormal Rate < or > normal for age Depth = shallow or deep Effort = looks like they are working to breathe Tripod Accessory muscle use Other abnormal findings Asymmetrical chest wall movement Abnormal lung sounds

14 Respirations Abnormal Patterns Kussmauls Cheyne stokes Biots Central Neurogenic Hyperventilation Apneustic Ataxic

15 Respirations Abnormal Patterns Source: what-when-how.com

16 Respirations Abnormal Patterns Source:

17 Source: Circulation

18 Circulation Anatomy Vascular system is comprised of soft, pliable, elastic walls With every heart contraction, a bolus of blood is ejected from the heart, either to the lungs (through the pulmonary arteries), or to the body (through the aorta) Bolus of blood (stroke volume) is typically 70 cc Palpable pulse is felt whenever that bolus of blood passes by a pulse point

19 Circulation Frank-Starling s Mechanism Muscle contracts more forcefully and efficiently when stretched Passive filling doesn t fill the ventricles enough to provide adequate cardiac output Atria act like primer pumps Atrial contractions force a little bit of extra blood, under pressure, into the ventricles Overfills and stretches the muscles located in the ventricles Allows for maximal contraction

20 Circulation Assess rate, rhythm, strength Locations to assess Normal Rate (only if regular) = 15 seconds x 4 Adults beats per minute Influenced by age, physical condition, pregnancy Other factors?? Rhythm = regular Strength Technology versus pulse Abnormal Rate < or > normal for age Rhythm = irregular Strength Weak Bounding Other abnormal findings Mismatch between technology and pulse Table 20-3 on page 526

21 Kwik Kwestion When assessing subjective findings, why would it be beneficial to have the same person do the subsequent assessments?

22 Source: Perfusion

23 Perfusion Adequate delivery of oxygen and nutrients AND the adequate removal of carbon dioxide and waste products

24 Fick Principle Adequate intake of oxygen Adequate oxygenation of RBCs Adequate transport of the RBCs to the target cells Adequate oxygenation of the target cells

25 Perfusion Physiology Venous return Occurs when the blood that s pumped in at one end of a closed system pushes the fluid ahead of it around the system, eventually making its way back to the heart

26 Perfusion Physiology Venous return (cont.) Eventually, when the returning fluid causes enough pressure to open the AV valves, the valves open, and blood rushes intro the ventricles Most blood that enters the ventricles do so during this phase

27 Hypoperfusion Often the result of decreased cardiac output and can lead to: Shock (prolonged state of hypoperfusion) Multiple organ dysfunction syndrome (MODS) Other disease states associated with with impaired cellular metabolism

28 Cardiac Output Total amount of blood pumped by the ventricles per minute CO=SV*HR Dependent on: Strength of contraction Rate of contraction Amount of venous return (preload) Decrease in cardiac output usually associated with decrease in: Blood pressure Tissue perfusion Cellular metabolism

29 Cardiac Output Hierarchy of perfusion Heart Brain Liver/GI/Spleen Kidneys Everything else Source:

30 Perfusion Blood Pressure Systolic Pressure exerted against arterial wall during contraction (systole) Ventricles pumping Should be less than 120 mmhg in all age groups First sound or pulsation Diastolic Pressure exerted against arterial wall during relaxation (diastole) Ventricles filling Should be less than 80 mmhg in all age groups When sound changes in quality or becomes muffled Can also be affected by physical conditions or diseases

31 Perfusion Blood Pressure Helpful Hints Proper size cuff Position patient properly Place lower end of cuff 2 inches above AC space Inflate cuff to about 30 mmhg above the point where the brachial pulse disappears with palpation Stethoscope over brachial artery (which side to use?) Deflate cuff slowly (2-3 mmhg per second) Auscultation preferred over palpation Alternate sites

32 Perfusion Hypertension 140/90 (per AHA) Diastolic number is important Constant pressure within system Hypotension SBP < 90 mmhg

33 Did You Know? Almost 1/3 of hypertension diagnoses can be attributed to white coat syndrome Source:

34 Oh No! Your BP cuff is not available, how can you quickly assess perfusion status? If carotid pulse present, SBP > 60 If femoral pulse present, SBP > 70 If radial pulse present, SBP > 80

35 Perfusion Orthostatic Blood Pressure The body s response to changes in posture requires normal function of the CV and autonomic nervous systems Standing results in blood pooling of approximately 500 to 1,000 ml in the lower extremities and splanchnic circulation This initiates an increase in sympathetic outflow, which increases PVR, venous return, and CO, thereby limiting the decrease in blood pressure Positive orthostats may result if there is inadequate intravascular volume, autonomic nervous system dysfunction, decreased venous return, or inability to increase CO in response to postural changes CPP decreases, thereby producing the neurologic symptoms of orthostatic hypotension. Source:

36 Perfusion Orthostatic Blood Pressures Obtain HR and BP while patient is laying, sitting/dangling, and standing Positive findings (within 3 minutes of standing) SBP decreases by 20mmHg DBP decreases by 10mmHg HR increases by mmhg Decreased SBP with dizziness Info Source: Source:

37 Perfusion Orthostatic Blood Pressures Obtain orthostats in patients with a history of: GI bleeding Abdominal pain Syncopal events (especially unexplained events) History of N/V/D Positive findings are an indicator for possible fluid replacement and/or further evaluation Source:

38 Perfusion Pulse Pressure Difference between SBP and DBP More sensitive to changes in perfusion than either the SBP or the DBP Widening = head injury Narrow = shock, cardiac tamponade

39 Perfusion Mean Arterial Pressure (MAP) Function of total cardiac output and total peripheral resistance Represents average pressure in the vascular system Reflects relative time spent in each portion of the cardiac cycle Often, treatment guidelines attempt to maintain a MAP of at least 60 mmhg Typical MAP runs mmHg

40 Perfusion Calculating MAP MAP = DBP+(pulse pressure/3) Pt has a BP of 120/80 MAP = 80 + (40/3) MAP = MAP = 93

41 Perfusion Factors affecting MAP MAP = CO x TPR (total peripheral resistance)

42 Perfusion Factors affecting MAP MAP Cardiac Output Systemic Vascular Resistance

43 Perfusion Factors affecting MAP MAP Cardiac Output Systemic Vascular Resistance??????

44 Perfusion Factors affecting MAP MAP Stroke Volume Cardiac Output Heart Rate Systemic Vascular Resistance Temperature Chemical Factors Medications Hormones Neural Factors Autonomic Nervous System

45 Perfusion Factors affecting MAP MAP Stroke Volume Cardiac Output Systemic Vascular Resistance Heart Rate Left Ventricular Diastolic Filling Systolic Ejection

46 Perfusion Factors affecting MAP MAP Cardiac Output Stroke Volume Systemic Vascular Resistance Heart Rate Left Ventricular Diastolic Filling Systolic Ejection Venous Return Gravity

47 Perfusion Factors affecting MAP MAP Cardiac Output Stroke Volume Systemic Vascular Resistance Heart Rate Left Ventricular Diastolic Filling Systolic Ejection Venous Return Gravity Fiber Length (Starling s Law) Contractility Autonomic Nervous System Medications/Hormones

48 Perfusion Factors affecting MAP MAP Stroke Volume Cardiac Output Systemic Vascular Resistance Heart Rate Left Ventricular Diastolic Filling Systolic Ejection

49 Perfusion Factors affecting MAP MAP Cardiac Output Systemic Vascular Resistance Blood Viscosity Blood Vessels

50 Perfusion Factors affecting MAP Cardiac Output Temperature Decrease temperature = Increased viscosity MAP Systemic Vascular Resistance Blood Viscosity Blood Vessels RBC Concentration Increased RBC concentration = Increased viscosity Plasma proteins & Other Factors

51 Perfusion Factors affecting MAP MAP Cardiac Output Blood Viscosity Systemic Vascular Resistance Blood Vessels Intrinsic Tone Decrease tone = Vasodilation Temperature Increase temperature = Vasodilation Chemical Factors Inflammatory response = Vasodilation Neural Factors Autonomic Nervous System

52 Perfusion Factors affecting MAP MAP Cardiac Output Systemic Vascular Resistance Blood Viscosity Blood Vessels Temperature Decrease temperature = Increased viscosity RBC Concentration Increased RBC % = Increased viscosity Plasma proteins & Other Factors Intrinsic Tone Decrease tone = Vasodilation Temperature Increase temperature = Vasodilation Chemical Factors Inflammatory response = Vasodilation Neural Factors Autonomic Nervous System

53 MAP Too Little vs Too Much Source: Source:

54 Helpful Hint LISTEN to what a patient tells you; then compare it to what you see

55 Source: Skin Condition

56 Vital Signs Skin Condition Very useful, yet often overlooked tool Assess color/condition, temperature, and moisture Source:

57 Vital Signs Skin Color/Condition Normal Color = pink Condition Free of bruises, lesions, and/or rashes Abnormal Color Pale/pallor Yellow Red Blue Grey Mottled Conditions Bruises, lesions, or rashes present

58 Vital Signs Skin Temperature Normal Warm Abnormal Hot Cold How can we quickly estimate skin temperature?

59 Vital Signs Body Temperature Normal body temperature is 37 C (98.6 F) Oral Age > 6 years Affected by many things Crying, eating, drinking Smoking O2 administration by mask Neb treatment Position in mouth Axillary Age < 6 years Add 1 to get core temperature

60 Vital Signs Body Temperature Normal body temperature is 37 C (98.6 F) Tympanic Age >3 years Reading is taken close to hypothalamus, so when done correctly can be very accurate Affected by hx of ear surgery/infection, excessive earwax, recently exercised, air movement

61 Vital Signs Body Temperature Normal body temperature is 37 C (98.6 F) Rectal Any age Young children Patient with ALOC Risk of perforation Insert no more than ½ to 1 inch

62 Vital Signs Skin Moisture Normal Dry Abnormal Wet (clammy, diaphoretic)

63 Source: Pupils

64 Window to the Brain Source:

65 Pupils Eye Anatomy Source:

66 Pupils Eye Anatomy Conjunctiva Source:

67 Pupils Optic Nerve Anatomy Cranial Nerve 2 (sensory) Cranial Nerve 3 (motor)

68 Pupils Physiology

69 Vital Signs Pupils Assess for PERRL Pupils are Equal, Round, and Reactive to Light Source:

70 Pupils Equal? A difference of less than 1mm is still considered equal Source: Source: This condition, present in about 20% of the general population, is typically physiologic, but can be pathologic.what is it? Anisocoria

71 Kwik Kwestion Can you identify this wellknown British celebrity who just happens to have anisocoria?? Source:

72 Kwik Kwestion Can you identify this wellknown British celebrity who just happens to have anisocoria?? Musician, singer, songwriter especially popular in the 1970 s and 1980 s Source:

73 Kwik Kwestion Can you identify this wellknown British celebrity who just happens to have anisocoria?? Musician, singer, songwriter especially popular in the 1970 s and 1980 s Ziggy Stardust Under Pressure Album Let s Dance Source:

74 Kwik Kwestion Can you identify this wellknown British celebrity who just happens to have anisocoria?? Musician, singer, songwriter especially popular in the 1970 s and 1980 s Ziggy Stardust Under Pressure Album Let s Dance Source:

75 Kwik Kwestion Can you identify this wellknown British celebrity who just happens to have anisocoria?? David Bowie Musician, singer, songwriter especially popular in the 1970 s and 1980 s Ziggy Stardust Under Pressure Album Let s Dance Source:

76 Pupils Round? Source: Pupils Round? Source: Source: Source: Source: Ruptured Globe

77 Pupils Reactive? Consensual response CN2 responds to light stimulus CN3 responds in the other eye Process Look at distant object (focusing near causes constriction) Dim environment Source:

78 Pupils Reactive? Source:

79 Source: Other Vital Signs

80 Other Vital Signs Ventilation versus Oxygenation Ventilation Movement of air Inhale O2, exhale CO2 Oxygenation How we get O2 to the tissues Measured with O2 capnography saturation

81 Other Vital Signs Source: Source:

82 Other Vital Signs O2 Saturation Indicator of percentage of Hgb saturated at time of measurement Cannot differentiate between oxygen and CO molecules Tissue oxygenation is NOT reflected Slow to respond to changes in perfusion Affected by numerous patient variables: Hgb level Blood flow Temperature Amount of ambient light Normal values (per AHA) > 94% SpO2

83 Other Vital Signs O2 Saturation Source:

84 Other Vital Signs ETCO2 Provides immediate feedback of patient condition Provides direct measurement of ventilation in lungs Indirectly measures metabolism and circulation Increased metabolism = increased CO2 = increased ETCO2 Decreased CO = decreased CO2 = decreased ETCO2 Normal values = mmhg

85 Other Vital Signs ETCO2 Source:

86 Technology is wonderful, but it is only a part of your assessment TREAT YOUR PATIENT, NOT THE TECHNOLOGY

87 The Final Vital Sign? Source:

88 Summary Vital Signs Respiration Circulation Perfusion Other Practice, practice, practice Treat your patient, not the machine

89 Questions?