Mosby items and derived items © 2005 by Mosby, Inc. Chapter 31 Vital Signs

Mosby items and derived items © 2005 by Mosby, Inc. Guidelines Nurse’s responsibility/delegation Equipment Knowledge of client’s range Knowledge of client’s history and current status Environmental factors Systematic approach

Mosby items and derived items © 2005 by Mosby, Inc. Guidelines (cont'd) Approach with the client Frequency of assessment Assessment for medications Analysis and verification of results Communication of results Teaching

Mosby items and derived items © 2005 by Mosby, Inc. Temperature Body temperature Physiology –Regulation: neural and vascular control –Heat production Basal metabolic rate Shivering Nonshivering thermogenesis

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Physiology –Heat loss Radiation Conduction Convection Evaporation

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Physiology –Skin and temperature regulation Behavioral control

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Factors affecting temperature –Age –Exercise –Hormone level –Circadian rhythm –Stress –Environment

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Temperature alterations –Pyrexia (fever) –Hyperthermia Heatstroke Heat exhaustion –Hypothermia Frostbite

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Assessment –Sites –Thermometers

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Nursing diagnoses –Risk for imbalanced body temperature –Hyperthermia –Hypothermia –Ineffective thermoregulation

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Planning –Goals and outcomes –Setting priorities –Continuity of care

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Implementation –Prevention of alterations –Interventions for fever –Interventions for hyperthermia –Interventions for hypothermia

Mosby items and derived items © 2005 by Mosby, Inc. Temperature (cont'd) Evaluation –Changes in body temperature

Mosby items and derived items © 2005 by Mosby, Inc. Pulse Physiology and regulation –Stroke volume –Cardiac output –Mechanical, neural, and chemical factors

Mosby items and derived items © 2005 by Mosby, Inc. Pulse (cont'd) Assessment –Sites Radial Apical Other peripheral sites –Use of a stethoscope

Mosby items and derived items © 2005 by Mosby, Inc. Pulse (cont'd) Character of the pulse –Rate –Rhythm –Strength –Equality

Mosby items and derived items © 2005 by Mosby, Inc. Pulse (cont'd) Nursing diagnoses –Activity intolerance –Decreased cardiac output –Ineffective tissue perfusion

Mosby items and derived items © 2005 by Mosby, Inc. Respiration Physiological control –Oxygen –Carbon dioxide Mechanics of breathing –Inspiration –Expiration –Tidal volume

Mosby items and derived items © 2005 by Mosby, Inc. Respiration (cont'd) Assessment –Rate –Ventilatory depth –Ventilatory rhythm –Arterial oxygen saturation

Mosby items and derived items © 2005 by Mosby, Inc. Respiration (cont'd) Nursing diagnoses –Activity intolerance –Ineffective airway clearance –Ineffective breathing pattern –Impaired gas exchange –Ineffective tissue perfusion

Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure Physiology –Cardiac output –Peripheral resistance –Blood volume –Viscosity –Elasticity

Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Influencing factors –Age –Stress –Ethnicity –Gender –Diurnal variation –Medications –Other

Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Alterations –Hypertension –Hypotension Orthostatic hypotension

Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Measurement –Equipment Manual and automatic –Auscultation –Palpation –Sites –Children –Self-measurement

Mosby items and derived items © 2005 by Mosby, Inc. Blood Pressure (cont'd) Nursing diagnoses –Anxiety –Decreased cardiac output –Deficient/Excess fluid volume –Risk for injury –Acute pain –Ineffective tissue perfusion

Mosby items and derived items © 2005 by Mosby, Inc. Additional Nursing Interventions Client teaching Reporting and recording