1. Vital Signs

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

3. 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!!!

4. 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

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

6. Factors Affecting Body Temperature
Age
Exercise
Hormones
Circadian rhythms
Stress
Environment

7. Temp. Alterations
Fever
Causes
Treatment Issues
Children

8. Nursing Process for Fever
Assessment
Nursing Dx
Plan and Implementation
Evaluation

9. Assessment of Body Temp
Sites
Mouth
Rectum
Axilla
Tympanic
Forehead

10. Thermometers
Mercury
Electronic
Disposable
Digital

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

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

13. Characteristics Rate Newborn 100-180 1 week-3 months 100-220
3 months-2 years
2 years-10 years
10 years-adult 55-90

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

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

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

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

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

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

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

21. Mechanics of Breathing
Inspiration
Expiration

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

23. 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

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

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