Vital Signs

1
Vital Signs

• Unit II

2
Vital Signs

• Temperature
• Pulse
• Respirations
• Blood Pressure
• Pain Assessment

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Terms to Know

• Hypothermia
• Hyperthermia
• Pulse oximetry
• Hypertension
• Hypotension
• Bradycardia
• Tachycardia
• Dysrythmia

• Systolic
• Diastolic
• Othostatic (postural hypotension)
• Apnea
• Eupnea
• tachypnea

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Guidelines

• Nurses responsibility- delegation
• Equipment
• Knowledge of clients range
• Knowledge of clients hx and current status
• Environmental factors
• Systematic approach

• Approach with client
• Frequency of assessment
• Assessment for medications
• Analysis and verification of results
• Communication of results
• Teaching

5
Temperature

• Physiology
• Neural and vascular control
• Heat production
• BMR
• Shivering
• Nonshivering
• Heat loss
• Radiation
• Conduction
• Convection
• Evaporation
• Skin and temperature regulation
• Behavioral control

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Factors Affecting Temperature

• Age
• Exercise
• Hormone level
• Circadian rhythm
• Stress
• Environment

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Temperature Alterations

• Pyrexia
• Hyperthermia
• Heatstroke
• Heat exhaustion
• Hypothermia
• Frostbite

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Temperature and the Nursing Process

• Assessment
• Sites
• Thermometers
• Normal range
• 36 to 38 C
• (96.8 to 100.4F)

• Nursing Diagnoses
• Risk for imbalanced body temperature
• Hyperthermia
• Hypothermia
• Ineffective thermoregulation

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Temperature and the Nursing Process

• Planning
• Goals and outcomes
• Afebrile
• Temperature decreased by one degree in 24 hours
• Priorities
• Continuity of Care

• Implementation
• Prevention of alterations
• Interventions for fever
• Interventions for hyperthermia
• Interventions for hypothermia
• Evaluation
• Change in body temperature

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Pulse

• Physiology and regulation
• Stroke volume
• Cardiac output
• Mechanical, neural and chemical factors

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Pulse and the Nursing Process

• Assessment
• Sites
• Use of stethoscope
• Character of pulse
• Rate
• Rhythm
• Strength
• equality
• Normal range
• 60 100 beats/min

• Nursing Diagnoses
• Activity intolerance
• Decreased cardiac output
• Ineffective tissue perfusion

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Apical Pulse Site
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Pulse Sites

• Peripheral
• Indicator of circulatory status

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Respirations

• Physiological control
• Oxygen
• Carbon dioxide
• Mechanics of breathing
• Inspiration
• Expiration
• Tidal volume

15
Respirations and the Nursing Process

• Assessment
• Rate
• Ventilatory depth
• Ventilatory rhythm
• Arterial oxygen saturation
• Normal range
• 12-16 breaths/min

• Nursing Diagnoses
• Activity intolerance
• Ineffective airway clearance
• Ineffective breathing pattern
• Impaired gas exchange
• Ineffective tissue perfusion

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Blood Pressure

• Physiology
• Cardiac output
• Peripheral resistance
• Blood volume
• Viscosity
• Elasticity
• Normal range
• lt120/80 mm Hg

• Influencing factors
• Age
• Stress
• Ethnicity
• Gender
• Diurinal variation
• Medications
• Other

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Blood Pressure

• 118/72
• Systolic 118
• Diastolic 72
• Pulse Pressure 46

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Blood Pressure

• Measurement
• Equipment
• Manual and automatic
• Auscultation
• Palpation
• Sites
• Children
• Self-measurement

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Blood Pressure

• Nursing Diagnoses
• Anxiety
• Decreased cardiac output
• Deficient/excess fluid volume
• Risk for injury
• Acute pain
• Ineffective tissue perfusion

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Blood Pressure Alterations

• Hypertension
• Hypotension
• Orthostatic (postural) hypotension

21
Additional Nursing Interventions

• Client teaching
• Reporting and recording