Vital signs / Terminology #1 Temperature Aural (ear) AxillaCelsiusFahrenheit

Vital Signs / Terminology #2 FebrileMetabolismMucosaPyrexia

Vital Signs / Terminology #3 PulseApicalBrachialCarotidRadialarrhythmia

Vital Signs / Terminology #4 BradycardiaTachycardiaBounding Pulse deficit thready

Vital Signs / Terminology #5 RespirationApneaCheyne-StokesOrthopnea Shallow breathing Kussmaul’s respiration

Vital Signs / Terminology #6 HyperventilationCyanosisDiaphragmdyspnea

Vital Signs / Terminology #7 Blood pressure Aneroid manometer DiastolicHypertensionHypotensiondiaphragm

Vital Signs / Terminology #8 SphygmomanometerStethoscopeSystolicbell

Vital Signs / Purposes Temperature,pulse,respiration and blood pressure Assess functioning of vital organs Signify changes in the body

Vital Signs / Observations Color and temperature of the skin How is the patient acting What does the patient tell you about the way he/she feels

Temperature Balance between heat gained and heat lost The hypothalamus is the regulation center

Heat production Heat is produced by cellular activity, food metabolism, muscle activity, and some hormones Infection Brain injury External factors

Heat loss Heat is lost from the body through the skin, the lungs in breathing, and by elimination Sweating Increased respiratory rate Increased flow of blood to skin

Heat conservation Reducing perspiration Decreasing the flow of blood to the skin Shivering

Nursing measures to raise the temperature Increase the temperature in the room Add coverings to the body Provide hot liquids to drink Give warm baths or soaks

Nursing measures to lower the temperature Decrease the temperature in the room Remove coverings from the body Offer cool liquids to drink Provide cool bath or sponging Direct fan toward body

Major Pulse sites Major Pulse sites CarotidApicalBrachialRadialFemoralPopliteal Dorasalis pedis

Factors that increase pulse Exercise Strong emotions FeverPainShockHemorrhageAnemia

Factors that decrease pulse RestDepressionDrugs Respiratory center depression

Qualities of pulse RateRhythmStrength

Respiration Respiration is defined as the exchange of oxygen and carbon dioxide in the lungs It is regulated in the brain by the medulla

Factors that increase respiratory rate Exercise Strong emotion Infection Increased body temperature Increased metabolism

Factors that decrease respiratory rate Rest / Sleep Depression Respiratory center depression

Qualities of Respiration RateRhythmDepthEffortDiscomfortPositionSoundsColor

Abnormal breathing patterns LaboredOrthopneaStertorousAbdominalShallowDyspneaTachypneaBradypnea

Blood pressure Pressure exerted against walls of blood vessels Systolic pressure Diastolic pressure Thumping sounds Sounds correspond to numbers First sound heard is systolic pressure Last sound heard is diastolic pressure

Factors that raise blood pressure Strong emotion ExerciseExcitementPain Decrease of blood vessel size Digestion Cuff that is too narrow or too loose Cuff below heart level

Factors that lower blood pressure Rest/Sleep Lying down DepressionShockHemorrhage Cuff that is too wide Cuff above the heart level

Equipment needed to measure blood pressure ManometerCuffStethoscope

Guidelines to take blood pressure Is commonly measured at the brachial artery Do not use arm that is injured, has an intravenous infusion, or is in a cast Patient should be at rest Apply blood pressure cuff to bare arm Use appropriate sized cuff

Charting vital signs Report abnormal TPR and blood pressure to nurse Record on hospital flow sheets, graphic records, and nurse assistant notes Write the blood pressure as a fraction: systolic/diastolic e.g., 120/80 Note location,e.g., 150/90, thigh