Vital Signs

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Vital Signs
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Vital Signs

• Baseline data
• Guidelines for taking VS
• When to take VS

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Guidelines For Taking VS

• Know the patient
• Check equipment
• Know normal range
• Control environment
• Have a system
• Take as often as necessary
• Analyze
• Be aware of your communication
• Verify
• Report!!!

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When Do I take VS???

• On admission
• Routine
• Before and after any invasive procedure
• When conditions change
• Before and after nursing intervention
• Any complaints of non specific symptoms

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Regulation of Body Temp

• Neural control
• Heat production
• Skins role
• Heat loss
• Radiation
• Conduction
• Convection
• Evaporation
• Behavioral control

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Factors Affecting Body Temperature

• Factors affecting body temperature
• Age
• Exercise
• Hormones
• Circadian rhythms
• Stress
• Environment

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Temp. Alterations

• Fever
• Causes
• Treatment Issues
• Children

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Nursing Process for Fever

• Assessment
• Nursing Dx
• Plan and Implementation
• Evaluation

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Assessment of Body Temp

• Sites
• Mouth
• Rectum
• Axilla
• Tympanic
• Forehead

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Thermometers

• Mercury
• Electronic
• Disposable
• Digital

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Pulse

• Indicator of circulatory status
• Assess by palpating or using a stethoscope

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Pulse Assessment

• Radial and carotid pulse
• Apical Pulse
• Use first two fingers
• Use stethoscope

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Characteristics

• Rate
• Newborn 100-180
• 1 week-3 months 100-220
• 3 months-2 years 80-150
• 2 years-10 years 70-100
• 10 years-adult 55-90

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• Regular pulse
• Count for 15 seconds and multiply by 4
• Irregular pulse
• Count for full minute

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Factors influencing pulse

• Exercise
• Fever
• Heat
• Acute pain
• Anxiety
• Unrelieved severe and chronic pain
• Medication
• Hemorrhage
• Postural changes

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Apical Pulse

• Every heart beat has 2 sounds
• S1 lubb
• S2 dubb
• PMI
• Point of maximal impulse

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Variations in Heart Rate

• Tachycardia
• Bradycardia
• Always assess apical pulse if you suspect one of
  these!!

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Rhythm

• Normal
• Dysrhythmia
• Count an irregular pulse for 1 FULL minute
• Pulse deficit

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Strength and Equality

• Normal
• Bounding
• Weak
• Should be equal on both sides!!

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Respirations

• Generally a passive process
• CO2 is the most important factor
• Chemoreceptors
• Rising CO2 levels

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• Mechanics of Breathing
• Inspiration
• Expiration

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Assessment

• Always at rest
• Prior to taking temp in children
• Immediately following pulse in adults
• Inspect chest
• Intercostal spaces
• Use of accessory muscles

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Rate

• Newborn 35-40
• 2 years 25-32
• 8 years 20-30
• 12 years 16-19
• Adult 12-20
• Tachypnea in adult gt 24
• Bradypnea in adult lt 10

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Alterations in Respirations

• Hyperventilation
• Cheyne Stokes
• Apnea
• Hypoventilation
• Kussmaul
• Dyspnea
• Sighing
• Orthopnea
• Stertor
• Stidor
• Biots

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Oxygen Saturation

• Pulse oximetry
• Above 90
• Pay attention to your PATIENT not just the
  monitor!!!