NR 302 Week 4 Edapt

NR 302 Week 4 Edapt

Student Name

Chamberlain University

NR-302: Health Assessment I

Prof. Name:

Date

Week 4 Edapt- NR 302 Vital Signs

Pulse Rate

Pulse rate typically varies with age, being faster in infancy and childhood and slowing down as one ages. In addition to age, gender also influences pulse rate. After puberty, females generally have a slightly faster pulse rate compared to males. In the event of abnormal vital sign readings, the apical pulse should first be assessed for a full minute to verify the result. Once verified, a focused assessment should be performed, and the findings documented. There is no need to contact the client’s family for additional information, as the electronic health record (EHR) provides the relevant data regarding the client’s previous heart rate and rhythm.

Abnormal Assessment Findings

Diastolic blood pressure reflects the pressure in the arteries when the ventricles are at rest, while systolic pressure occurs during heart contraction. The difference between the two readings is known as “pulse pressure.” Korotkoff sounds are used to assess blood pressure; phase 1 corresponds to the systolic reading, and the diastolic pressure is marked when the sound fades. An auscultatory gap, or absence of sound, indicates reduced peripheral blood flow. The normal temperature is 95.1 °F (35.1 °C) or higher, while a heart rate of 110 beats per minute is considered tachycardia. Similarly, respiratory rates and blood pressure measurements are crucial in identifying potential health issues.

When Should Vital Signs Be Taken?

Vital signs should be taken at various times, including upon admission, as ordered by a healthcare provider, before and after surgical or diagnostic procedures, and before and after certain medications. Monitoring is also necessary when there is a change in the client’s condition or after interventions such as ambulation or tracheal suctioning.

Table: Assessment of Vital Signs

Temperature

The hypothalamus, located in the brain, regulates body temperature, balancing heat production and heat loss. Temperature is documented in Fahrenheit or Celsius based on geographical location and facility policy.

Pulse

The pulse rate is a measure of the rhythmic expansion and contraction of arteries as a result of blood ejected by the left ventricle of the heart. Normal adult pulse rates range between 60 and 100 beats per minute, with the average being 80. Variations in pulse rate can result from factors such as age, gender, physical activity, and emotional state.

Pulse Variations

Conditions such as tachycardia (pulse > 100 beats/min) and bradycardia (pulse < 60 beats/min) can be influenced by factors like shock, hemorrhage, exercise, or medication. Irregular pulse rhythms, including dysrhythmia, should be noted, as well as irregularly irregular rhythms, which lack a repeating pattern.

Respirations

Respiratory rate is controlled by the medulla oblongata in the brain, with normal rates for adults ranging from 12 to 20 breaths per minute. The depth and rhythm of respiration are essential factors in assessment. Abnormal respiratory patterns, such as shortness of breath or irregular rhythms, should prompt further evaluation.

Blood Pressure

Blood pressure should not be measured in arms with casts, burns, or a previous mastectomy. Special care should be taken when assessing blood pressure in the presence of intravenous lines or dialysis shunts.

Oxygen Saturation

Oxygen saturation indicates the percentage of hemoglobin carrying oxygen, with normal values above 95%. Factors like nail polish or cold extremities can affect the accuracy of pulse oximeter readings.

Pain Assessment

Open-ended questions should be used to allow the client to describe their pain. After gathering information, the pain can be quantified using an appropriate scale. This helps in determining the severity and impact of pain on the client’s overall condition.

Impact of Vital Signs on Social Determinants of Health

Vital signs can be influenced by social determinants such as food and housing insecurity, financial limitations, and access to healthcare. These factors can exacerbate health conditions and should be considered in the assessment process.

Health Education Based on Vital Signs

Education should focus on the importance of monitoring vital signs regularly and how lifestyle changes can impact blood pressure control and overall health. Clients should be educated on proper techniques for taking their pulse or blood pressure, especially in home settings.

References

American Heart Association. (2020). Blood pressure and heart disease. https://www.heart.org

NR 302 Week 4 Edapt

National Heart, Lung, and Blood Institute. (2021). Vital signs. https://www.nhlbi.nih.gov