Vital signs are vital Sample lecture notes: Module II – Objectives 1-7

Rationale – signs of life  Guides course of actions  Detects changes in health status  Accuracy is “vital”  Part of nursing assessment  Viewed in relation to other data

Documentation and reporting  Responsibility of nurse  “Abnormals” MUST be dealt with  Methods and formats vary Computer Written Charts

Temperature  Reflect Infection & inflammation  Show balance in thermoregulation (or imbalance)  Measuring Scale “C” or “F”

Tools for temp measuring  Glass  Electronic  Tympanic  Disposable strips

Routes  Oral  Rectal  Axillary  Core

Pulse  Reflects Heart contractions  Defined by rate, rhythm, and strength  Normal adult: <60 = bradycardia >100 = tachycardia

Characteristics  Variable measuring locations Brachial Radial Apical Total nine locations

Pulse specifics  Rate – changes with stress  Rhythm – normal is “regular”  Quality – strong or weak Important to note if changed  (remember – vital signs are analyzed in relation with other data)

Respirations  Body must receive oxygen and release carbon dioxide  Primarily an involuntary act  Normal is a quiet easy respiration

Tools  Stealth  Stethoscope  Visual  Occasionally tactile  Environment

Blood pressure  Relates information about the client’s cardiovascular system Blood volume Peripheral vascular resistance

Tools  Sphygmomanometer  Stethoscope  Doppler

Guides to measuring  Usually brachial artery  Under constant conditions  Millimeters of mercury (mmHG)  Right size  Right place  Right use of equipment  Right environment

Hints  Palpate first  Wait 30 – 60 sec  If changing position, wait 2 minutes for circulation to equalize

The sounds of pressure  Korotkoff sounds (5)  Systolic  Diastolic  Know normals  Chart according to policy (2 or 3)

Review  Vital signs are valuable in assessing life Know “normal”  Look for relationships  Document findings and report changes  Select right tools for accurate collection  Delegate with follow-up

Conclusion Questions ? Concerns? Confusion? THE END