Vital Signs

Vital Signs Baseline data Guidelines for taking VS When to take VS

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!!!

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

Regulation of Body Temp Neural control Heat production Skin’s role Heat loss Radiation Conduction Convection Evaporation Behavioral control

Factors Affecting Body Temperature Age Exercise Hormones Circadian rhythms Stress Environment

Temp. Alterations Fever Causes Treatment Issues Children

Nursing Process for Fever Assessment Nursing Dx Plan and Implementation Evaluation

Assessment of Body Temp Sites Mouth Rectum Axilla Tympanic Forehead

Thermometers Mercury Electronic Disposable Digital

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

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

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

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

Factors influencing pulse Exercise Fever Heat Acute pain Anxiety Unrelieved severe and chronic pain Medication Hemorrhage Postural changes

Apical Pulse Every heart beat has 2 sounds PMI S1 – lubb S2 – dubb Point of maximal impulse

Variations in Heart Rate Tachycardia Bradycardia Always assess apical pulse if you suspect one of these!!

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

Strength and Equality Normal Bounding Weak Should be equal on both sides!!

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

Mechanics of Breathing Inspiration Expiration

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

Rate Newborn 35-40 2 years 25-32 8 years 20-30 12 years 16-19 Adult 12-20 Tachypnea in adult > 24 Bradypnea in adult < 10

Alterations in Respirations Hyperventilation Cheyne Stokes Apnea Hypoventilation Kussmaul Dyspnea Sighing Orthopnea Stertor Stidor Biot’s

Oxygen Saturation Pulse oximetry Above 90% Pay attention to your PATIENT not just the monitor!!!