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Nursing Vital Signs

Fundamentals Vital Signs

QuestionAnswer
What are the 6 vital signs? Blood Pressure, Pulse, Temperature, Respiratory Rate, Oxygen Saturation, Pain
When are Vitals taken? On admission, on a routine schedule as orders by a Dr, Before and after surgery, or an invasive procedure, before and after some medications
When a patient reports nonspecific physical distress what happens? Vital signs may be taken. Vitals can also be taken at the nurses discretion
What is body temperature? heat production-heat loss= body temperature.
How is core temperature taken? From deep tissue, it regulated by temperature-control mechanism.
Where can a core temperature be taken? Rectum, typanic membrane, temporal artery, esophagus, pulmonary artery, urinary bladder
Temperature Regulation Neural and Vascular, Heat Production, Heat Loss,
What factors effect temperature? Age, Exercise, Hormone Level, Sleep Rhythm, Stress, Environment, Temperature alterations
What are temperature alterations? Pyrexia(fever); febrile> 102.2 Hyperthermia- Heat stroke, exhaustion Hypothermia- <93.2 - frost bite.
Sites to take a temperature Oral, tympanic membrane, rectum, axilla, skin, temporal artey
Types of thermometers Electric, disposable, Do not use glass/mercury
Nursing Diagnoses associated with temperature Risk for imbalanced Body Temperature Hyperthermia Hypothermia Ineffective Thermoregulation
Pulse Physiology and Regulation Cardiac output (Heart rate X Stroke Volume = CO) Mechanical, neural, and chemical factors
Pulse Sites Radial, brachial, ulnar Apical Carotid arteries, temporal Femoral, posterior tibial, dorsalis pedis Infant: brachial or apical
Pulse Characteristics Rate, Rhythm, Strength, Equality
Acceptable Pulse Ranges Infant: 120-160 Toddler 90-140 Preschooler 80-110 School-age Child 75-100 Adolescent 60-90 Adult 60-100
Factors influencing Heart Rate Exercise Temperature Emotions Drugs Hemorrhage Postural Changes Pulmonary Conditions
Nursing Diagnoses Associated with Pulse Activity intolerance Decreased cardiac output Ineffective tissue perfusion
What is Respiration? 3 Parts Ventilation, diffusion, Perfusion
What are the mechanics of respiration? inspiration, expiration, tidal volume
What do you assess with respiration? The Rate, and the ventilatory depth- whether deep or shallow Ventilatory rhythm Arterial oxygen saturation Unlabored effort Noises
What is normal Oxygen saturation? 95-100%
Factors that influence respiration? Pain,smoking, medications, neurological injury, hemaglobin.
Nursing Diagnoses Association with respiration Activity intolerance Ineffective airway clearance Ineffective breathing pattern Impaired gas exchange Ineffective tissue perfusion
Blood Pressure 2 Parts Systolic- top Diastolic- bottom
What is Systolic Blood Pressure? The peak of maximum pressure when ejection occurs
What is Diastolic Blood Pressure? Minimum pressure exerted by arteries after ventricles relax.
What is the physiology of the Blood Pressure? Cardiac Output Peripheral Resistance Blood Volume Viscosity Elasticity
Factors that influence Blood Pressure? Age Stress Ethnicity Gender Daily Variation Medications Activity and Weight Smoking
What is hypertension? Most common alteration Asymptomatic Thickening and loss of elasticity of arterial walls Peripheral vascular resisntace Heart, brain, and Kidney Family history, obesity, smoking, alcohol, high sodium intake, sedentary lifestyle and stress
What is Hypotension? Dilation of arteries, decrease blood volume (i.e. hemorrhage), heart failure (i.e. Myocardial Infarction) Systolic <90
How is Blood Pressure measured? Directly (invasive); arterial line Indirectly (noninvasive) Equipment: Manual or automatic Sphygmomanometer Stethoscope Auscultation or palpation
How do you assess Blood Pressure in children differently? Different arm size requires careful and appropriate cuff size May be difficult to obtain Stethescope placement Korotkoff sounds difficulty to hear; use bell of pediatric stethoscope
When do you not take an electronic Blood Pressure? Irregular heart rate Peripheral vascular obstruction (e.g., clots, narrowed vessels) Shivering Seizures Excessive tremors Inability to cooperate Blood pressure less than 90 mm Hg systolic
Nursing Diagnoses Associated with Blood Pressure Anxiety Decreased cardiac output Deficient/Excess fluid volume Risk for injury Acute pain Ineffective tissue perfusion
How do we record Vitals? Record values on electronic or paper graphic. Record in nurses’ notes any accompanying or precipitating symptoms. Document interventions initiated on the basis of vital sign measurement
How should you document a vital sign outside of expected range? If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action. In the nurse’s variance note, address possible causes of a fever
Safety Guidelines Clean devices between patients to decrease risk for infection. Rotating sites during repeated measurements decreases the risk for skin breakdown. Analyze trends for vital signs, and report abnormal findings.
Created by: dgreen158