Guidelines for Measuring Vital Signs Establish a baseline for future assessmentsEstablish a baseline for future assessments Be able to understand and interpret valuesBe able to understand and interpret values Appropriately delegate measurementAppropriately delegate measurement Communicate findingsCommunicate findings Ensure equipment is in working orderEnsure equipment is in working order Document findings accuratelyDocument findings accurately © 2009 Elsevier Australia1 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Factors Affecting Body Temperature AgeExercise Hormonal level Circadian rhythm Environment Temperature alterations © 2009 Elsevier Australia2 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Temperature Range Temperature sites:Temperature sites: –Oral, rectal, axillae, tympanic membrane, oesophageal, urinary bladder, pulmonary artery © 2009 Elsevier Australia3 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Assessment of Pulse SitesSites Use of stethoscopeUse of stethoscope Character of pulse:Character of pulse: –Rate –Rhythm –Strength –Equality © 2009 Elsevier Australia4 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Assessment of Pulse © 2009 Elsevier Australia5 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Respiration © 2009 Elsevier Australia6 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Assessment of Ventilation Respiratory rateRespiratory rate Ventilatory depthVentilatory depth Ventilatory rhythmVentilatory rhythm Ventilatory soundVentilatory sound Assessment of diffusion and perfusionAssessment of diffusion and perfusion –Arterial oxygen saturation © 2009 Elsevier Australia7 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Assessment of Ventilation Respiratory rateRespiratory rate © 2009 Elsevier Australia8 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Nursing Process and Respiratory Vital Signs Measurements include:Measurements include: –Respiratory rate, pattern, depth, SpO 2 These measurements provide information about ventilation, diffusion and perfusionThese measurements provide information about ventilation, diffusion and perfusion Nursing diagnosisNursing diagnosis InterventionsInterventions PlanningPlanning EvaluationEvaluation © 2009 Elsevier Australia9 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Blood Pressure: Physiology Force exerted on walls of an arteryForce exerted on walls of an artery Systolic blood pressureSystolic blood pressure –Peak pressure during cardiac contraction Diastolic blood pressureDiastolic blood pressure –Pressure in the arteries with ventricular relaxation © 2009 Elsevier Australia10 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Blood Pressure: Physiology Cardiac outputCardiac output –Blood pressure depends on cardiac output Peripheral resistancePeripheral resistance –Tone of vasculature and diameter of blood vessels Blood volumeBlood volume –Amount of blood circulating in vasculature ViscosityViscosity –Thickness of blood (cells to fluid ratio) ElasticityElasticity –Amount of elastic and distensibility of arteries © 2009 Elsevier Australia11 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Blood Pressure: Physiology Haemodynamic factors to control blood pressure © 2009 Elsevier Australia12 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Factors Influencing Blood Pressure AgeAge StressStress MedicationsMedications Daily VariationDaily Variation GenderGender © 2009 Elsevier Australia13 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Hypertension and Hypotension Hypertension Hypertension – More common than hypotension – Thickening of walls – Loss of elasticity – Family history – Risk factors Hypotension Hypotension – SBP < 90 mm Hg – Dilation of arteries – Loss of blood volume – Decrease of blood flow to vital organs – Orthostatic/postural © 2009 Elsevier Australia14 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Measurement of Blood Pressure EquipmentEquipment AuscultationAuscultation Assessment in childrenAssessment in children Ultrasonic stethoscopeUltrasonic stethoscope PalpationPalpation Lower extremityLower extremity Automatic blood pressure devicesAutomatic blood pressure devices © 2009 Elsevier Australia15 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Measurement of Blood Pressure Auscultation (Korotkoff sounds): 1.onset of the sound (systolic pressure) 2.murmur or swishing sound occurs as the cuff deflates 3.crisper and more intense tapping 4.muffled and low-pitched as the cuff is further deflated 5.absence of sound (diastolic pressure) © 2009 Elsevier Australia19 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Measurement of Blood Pressure Korotkoff sounds © 2009 Elsevier Australia20 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p

Nursing Process and Blood Pressure Determination Assessment of blood pressure and pulse evaluates the general state of cardiovascular healthAssessment of blood pressure and pulse evaluates the general state of cardiovascular health Hypertension, hypotension, orthostatic hypotension or narrow / wide pulse pressures define nursing diagnosesHypertension, hypotension, orthostatic hypotension or narrow / wide pulse pressures define nursing diagnoses © 2009 Elsevier Australia22 Wotton, K.. (2009) ‘Vital Signs’ in eds J. Crisp & C. Taylor, Potter and Perry's Fundamentals of Nursing, 3rd edn, Elsevier, Sydney, p