What do they assess? What can they tell you? Why are they important? Are they objective or subjective? Think about how they can help you ANTICIPATE a patient’s outcome?

 TEMPERATURE  PULSE  RESPIRATION  BLOOD PRESSURE  PULSE OXIMETER T P R BP PULSE OX  VS are taken as an assessment, whenever ordered, or to help clarify a diagnosis.  VS are NEVER routine; you are recording measurements which reflect a patients well being and possible impending trouble with their vital organs.

 Measurement of body heat. It is the balance between heat produced and heat lost. It is:  Fairly constant  Lower the closer to the body surface it is measured  Less stable in children  Affected by:  illness, medication, age, infection, pregnancy and dehydrations

 Hyperthermia-  Hypothermia-

Measured in 1 of 5 areas: 1. Rectal 2. Oral 3. Tympanic 4. Axillary 5. Temporal Scanner

 ORAL  Normal: 98.6F/37 C  Range:    RECTAL  Normal: 99.6/37.9  Range:  

BATTERY OPERATED/IVACS

 Pressure of blood felt against wall of an artery as heart contracts/relaxes.  Measured to assess how well the cardiovascular system is meeting body’s needs.  Look at:  RATE ??  RHYTHM ??  FORCE ??

 Where are the pulse sites in your body? (HAND OUT)  Temporal  Carotid  Brachial  Apical  Radial  Femoral  Popiteal  Posterior Tibial (Pedal)

Count for 60 sec Count for 30 sec and multiply X2  Shorter time counts = inaccurate data

 Radial pulse- taken at wrist with 2 fingers over radial artery site

 Pulse taken over apical site. Using your stethoscope you count the heart sounds FOR 1 FULL MINUTE.

TACHYCARDIA Too Fast! Greater than 100 BRADYCARDIA Too Slow….Lower than 50

Birth- one year Childhood Adult 65-80

PULSE DEFICIT Difference between the apical and radial pulse

Count for 60 sec Count for 30 sec and multiply X2 Respiration- 1 inspiration/1 expiration Normals: Adults: Children: Infants: 30-60

 Types of Respirations  1. Stertorous-  2. Tachypnea-  3. Shallow-  4. Cheyne-Stokes-  5. Dyspnea-  6. Apnea-

1. Regular 2. Irregular 3. Shallow 4. Deep 5. Labored

To count respirations, watch or feel the patient’s chest rise and fall. Try to observe WITHOUT patient’s awareness to prevent a change in the normal rate.

 Fever  Exercise  Stress  Disease  Medications

 Blood pressure- the force of blood exerted on inner walls of arteries as blood circulates  There is ALWAYS a certain amount of pressure in arteries because as the heart is pumping blood, it is constantly forcing it to circulate  Blood pressure depends on:  Volume: amount of blood in circulatory system  Force of heart beat  Condition of arteries (elasticity)

 Your heart is an AMAZING pump. It works reliably for decades, and it safely pumps blood around. Your blood vessels are the pipes. They take the output from the pump (heart) and distribute it though out the body. A blood pressure gauge is simply a way to measure the performance of the pump and pipes.

 Systolic:  Pressure exerted on artery walls when the heart is contracting  Top number  Always higher  120

 Diastolic: Pressure exerted on artery walls when heart is relaxing Bottom number Always lower ___ 80

 Normal Blood Pressure  120  80 Hypotension- low blood pressure Systolic less than 80 Hypertension- high blood pressure Systolic higher than 140 Diastolic higher than 90 Pulse Pressure- difference between systolic and diastolic pressure

 When the cuff is pumped up, the blood flow is actually cut off as the pressure is exerted by the cuff. As the pressure in the cuff is released, blood starts flowing again and you can hear the flow in the stethoscope. The number at which blood starts flowing (120) is the measure of the maximum output pressure of the heart (systolic). You continue releasing the pressure on the cuff and listen until there is no sound. That number (80) indicates the pressure in the system when the heart is relaxed (diastolic).

 Aneroid:  Mercury:

 Possibly considered the 5 th vital sign. It is a rough measurement of the oxygen saturation of the blood. It allows nurses to get a good idea of how well the patient is breathing and oxygenating his blood. No nail polish! Why??

 Pages in your textbook Pulse oximeter measures the level of saturation of the patient’s hemoglobin with oxygen. Hemoglobin is the part of the blood that carries oxygen to the cells to nourish them. It measures how full the hemoglobin molecules are with oxygen.

 Automatic vital sign machines

It is tempting to view VS as a routine & static piece of data but…  VS are fluid, dynamic, & ever- changing, just like our patients!

 Be accurate!  Be gentle!  Be observant!