Changes/Abnormalities in Vital Signs (Nursing)

00:01 Hi! I'm Joanna Jackson, and this lesson is about changes and abnormalities in vital signs.

00:07 Vital signs measure the bodies functions. They provide medical staff with a picture of what's going on inside of a person's body. Let's start with pulse.

00:17 The expected range for pulse of an adult is 60 to 100 beats per minute at rest.

00:24 For infants, the expected pulse is 120 to 160 beats per minute.

00:30 The average pulse for 12 to 14-year-old child is 80 to 90 beats per minute. In addition to the rate, the nurse should assess the rhythm and strength of the pulse. As with all vital signs, there's no exact normal. Every patient will have a different and unique baseline to be used as a measure for comparison.

00:52 Let's talk about abnormalities with pulse. We'll begin with bradycardia.

00:59 This means an abnormally low pulse rate. Usually slower than 60 beats per minute.

01:04 Nursing interventions include, assessing the patient for injury, positioning, chronic pain, or medications that may have decreased the pulse. As always, if you get an abnormal pulse, recheck it just to be sure. Then we have tachycardia. This is an abnormally high body pulse rate. Average is higher than 100 beats per minute. Nursing interventions include assessing the patient for injury, pain, an allergic reaction, positioning, or medications that might increase the pulse. Assess and monitor all vital signs. Notify the provider and document any findings. Next let's talk about dysrhythmia. This is an irregular heart rhythm. Sometimes this is found while assessing a radial pulse or while using a stethoscope. Assess the patient for injury, assess and monitor all vital signs, administer appropriate medications in order to maintain a proper heart rhythm, and notify the provider as soon as possible, and document your findings. Next we'll talk about temperature. An oral temperature should remain within the range of 96.8 to 100.4. The average is 98.6. Rectal temperatures are usually about 0.5 to 0.8 higher than the oral temperature.

02:29 Axillary and tympanic temperatures are usually 0.5 to 0.9 lower than oral temperatures.

02:34 Please remember as with all vital signs, there is no exact normal. Every patient will have a different and unique baseline. Now let's talk about abnormalities with temperature. Hypothermia refers to an abnormally low body temperature.

02:50 Nursing interventions include create a warm environment, provide blankets, oral and IV fluids, and assess the vital signs regularly. Be prepared for life-saving measures and notify the provider and document the findings.

03:06 Hyperthermia refers to an abnormally high body temperature.

03:12 Nursing interventions include provide oral and IV fluids, administer fever reducing medications like acetaminophen, as ordered, keep linens and clothing dry, prevent shivering but do not warm the patient, notify the provider, and document your findings. A fever alone is typically not harmful in adults unless it exceeds 102 degrees Fahrenheit. Now we will review respirations. The expected rate for adults is 12 to 20 respirations per minute.

03:45 Newborns have rates of 30 to 60 respirations per minute. And it's normal for them to have brief periods of apnea. School-age children have respiration rates of 20 to 30 respirations per minute. Altered depths are described as deep or shallow. A regular rhythm is expected in adults. Occasional changes in rhythm are not abnormal. Oxygen saturation is typically between 90% and 100%, but may vary due to illnesses like COPD. Again, with all vital signs, there is no exact normal. Every patient will have a different and unique baseline to use for comparison. One abnormality related to respirations is hypoxemia. This is an abnormally low oxygen in the blood. In hypoxemia, oxygen saturation is usually below 90%. Nursing interventions include confirming the vital sign by retaking it, just to be sure it's correct and not a malfunction of the equipment.

04:46 Assess the patient's positioning, oxygen equipment, and surrounding environmental factors. Now we will review blood pressure. Normal blood pressure is 120 over 80. Infant's blood pressure is much lower but increases with age. Again, with all vital signs, every patient will be different and unique.

05:08 One abnormality related to blood pressure is hypotension. This is an abnormally low blood pressure.

05:14 Nursing interventions include confirm the vital sign as abnormal and not an equipment error, assess the patient's positioning, assess for related symptoms and abnormal vital signs, and educate the patient about calling for assistance to avoid falling and assist them with ambulation.

05:31 Now let's review hypertension. This is an abnormally high blood pressure.

05:36 Nursing interventions include confirming the vital sign is actually abnormal and not an equipment error, assessing the patient's positioning, administering medications as ordered, and educating the patient on lifestyle, diet changes, and stress as those are related to hypertension. Here are some important tips to help you obtain the proper vital sign. Gather all your equipment before beginning. Know which abnormal vital signs are an emergency, and which require further monitoring.

06:07 Always, always document your findings. Recheck abnormal vital signs to ensure the abnormal results. Here are some quick ways to remember this content. Say the information out loud.

06:19 Practice talking to friends or in the mirror as if you were the nurse explaining a procedure to a patient. Make up funnier quirky acronyms about medications or processes that will help you remember them. For example, the nursing process can be remembered as ADPIE. Assess, diagnose, plan, implement, and evaluate. Visualize the information. In the example ADPIE, visualize an apple pie with the letters AD on it. The NCLEX will be as easy as pie.

06:51 Here are some quick tips for success. When in doubt, assess, diagnose, plan, and then implement. Always assess before taking any action. If two answers feel correct, do your best to pick the one that is most correct. And remember, opposites attract.

07:10 If two answers are complete opposites, one of the answers is probably correct.