Fundamentals Vital Signs
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| What are the 6 vital signs? | Blood Pressure, Pulse, Temperature, Respiratory Rate, Oxygen Saturation, Pain
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| 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
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| When a patient reports nonspecific physical distress what happens? | Vital signs may be taken. Vitals can also be taken at the nurses discretion
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| What is body temperature? | heat production-heat loss= body temperature.
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| How is core temperature taken? | From deep tissue, it regulated by temperature-control mechanism.
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| Where can a core temperature be taken? | Rectum, typanic membrane, temporal artery, esophagus, pulmonary artery, urinary bladder
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| Temperature Regulation | Neural and Vascular, Heat Production, Heat Loss,
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| What factors effect temperature? | Age, Exercise, Hormone Level, Sleep Rhythm, Stress, Environment, Temperature alterations
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| What are temperature alterations? | Pyrexia(fever); febrile> 102.2
Hyperthermia- Heat stroke, exhaustion
Hypothermia- <93.2 - frost bite.
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| Sites to take a temperature | Oral, tympanic membrane, rectum, axilla, skin, temporal artey
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| Types of thermometers | Electric, disposable, Do not use glass/mercury
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| Nursing Diagnoses associated with temperature | Risk for imbalanced Body Temperature
Hyperthermia
Hypothermia
Ineffective Thermoregulation
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| Pulse | Physiology and Regulation
Cardiac output (Heart rate X Stroke Volume = CO)
Mechanical, neural, and chemical factors
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| Pulse Sites | Radial, brachial, ulnar
Apical
Carotid arteries, temporal
Femoral, posterior tibial, dorsalis pedis
Infant: brachial or apical
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| Pulse Characteristics | Rate, Rhythm, Strength, Equality
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| Acceptable Pulse Ranges | Infant: 120-160
Toddler 90-140
Preschooler 80-110
School-age Child 75-100
Adolescent 60-90
Adult 60-100
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| Factors influencing Heart Rate | Exercise
Temperature
Emotions
Drugs
Hemorrhage
Postural Changes
Pulmonary Conditions
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| Nursing Diagnoses Associated with Pulse | Activity intolerance
Decreased cardiac output
Ineffective tissue perfusion
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| What is Respiration? 3 Parts | Ventilation, diffusion, Perfusion
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| What are the mechanics of respiration? | inspiration, expiration, tidal volume
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| What do you assess with respiration? | The Rate, and the ventilatory depth- whether deep or shallow Ventilatory rhythm
Arterial oxygen saturation
Unlabored effort
Noises
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| What is normal Oxygen saturation? | 95-100%
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| Factors that influence respiration? | Pain,smoking, medications, neurological injury, hemaglobin.
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| Nursing Diagnoses Association with respiration | Activity intolerance
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Ineffective tissue perfusion
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| Blood Pressure 2 Parts | Systolic- top Diastolic- bottom
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| What is Systolic Blood Pressure? | The peak of maximum pressure when ejection occurs
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| What is Diastolic Blood Pressure? | Minimum pressure exerted by arteries after ventricles relax.
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| What is the physiology of the Blood Pressure? | Cardiac Output
Peripheral Resistance
Blood Volume
Viscosity
Elasticity
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| Factors that influence Blood Pressure? | Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity and Weight
Smoking
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| 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
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| What is Hypotension? | Dilation of arteries, decrease blood volume (i.e. hemorrhage), heart failure (i.e. Myocardial Infarction)
Systolic <90
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| How is Blood Pressure measured? | Directly (invasive); arterial line
Indirectly (noninvasive)
Equipment:
Manual or automatic
Sphygmomanometer
Stethoscope
Auscultation or palpation
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| 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
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| 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
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| Nursing Diagnoses Associated with Blood Pressure | Anxiety
Decreased cardiac output
Deficient/Excess fluid volume
Risk for injury
Acute pain
Ineffective tissue perfusion
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| 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
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| 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
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| 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.
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Created by:
dgreen158
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