1. Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 32 Vital Signs NRS 102

2. 2 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. General Survey  Physical appearance  Age  Sex  Level of consciousness  Skin color  Facial features

3. 3 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. General Survey  Body structure  Stature  Nutrition  Symmetry  Posture  Position  Body build, contour  Mobility  Gait  Range of motion

4. 4 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. General Survey  Behavior  Facial expression  Mood and affect  Speech  Dress  Personal hygiene

5. 5 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Guidelines for Measuring Vital Signs  Establish a baseline for future assessments.  Be able to understand and interpret values.  Appropriately delegate measurement.  Communicate findings.  Ensure equipment is in working order.  Accurately document findings.

6. 6 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Body Temperature Physiology  Body temperature:  Heat produced  Heat lost  Temperature range:  98.6° F to 100.4° F or 36° C to 38° C  Temperature sites:  Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery

7. 7 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Body Temperature Regulation Neural and vascular control Heat production Heat loss Skin temperature regulation Behavioral control Thermoregulation

8. 8 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Affecting Body Temperature AgeExercise Hormonal level Circadian rhythm Environment Temperature alterations

9. 9 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Body Temp Hypothermia  Heat loss during prolonged exposure to cold  Classified by core temp (mild-severe)  May be intentional (surgery)  Early signs- uncontrolled shivering, loss of memory, poor judgment  Later signs- Cyanosis, decreased VS, cardiac dysrhythmias, loss of consciousness  Frostbite- body exposure to subnormal temps

10. 10 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Abnormal Body Temp Hyperthermia  Elevated body temp related to body’s inability to promote heat loss or reduce heat production  Heatstroke- prolonged exposure to sun or high environmental temp. Heat depresses hypothalamus function  Heat Exhaustion- profuse diaphoresis result in fluid & electrolyte loss

11. 11 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

12. 12 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process and Temperature  Assessment  Diagnosis  Planning  Implementation  Evaluation

14. 14 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Pulse, Physiology, and Regulation  The indicator of circulatory status  Electrical impulses originate from the sinoatrial (SA) node.  Cardiac output, heart rate, stroke volume  Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume.

15. 15 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of Pulse  Sites  Use of stethoscope  Character of pulse  Nursing process and pulse determination

16. 16 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

17. 17 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

18. 18 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Knowledge check! Which patient would be most likely to present with a pulse rate that is lower than normal? A.A 70-year-old telephone salesman presenting with dehydration. B.A 20-year-old runner who had surgery 4 days ago for a fractured leg. C.A 67-year-old who presented with an exacerbation of his COPD

19. 19 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Respiration  Ventilation  Diffusion  Perfusion  Physiological control  Mechanics of breathing

20. 20 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of Ventilation  Easy to assess  Respiratory rate  Ventilatory depth  Ventilatory rhythm  Diffusion and perfusion  Arterial oxygen saturation

21. 21 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Assessing Respirations  Assessing rate- observe full inspiration & expiration  Assess for full minute  Normal adult 12 –20 breaths/minute  Varies with age, rate declines throughout life  Apnea Monitor

22. 22 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Normal & Abnormal Respirations  Eupnea- normal respirations  Bradypnea- abnormally slow < 12  Tachypnea- abnormally fast >20  Hyperpnea- labored, after exercise  Hyperventilation/Hypoventilation  Cheyne-Stokes

23. 23 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process and Respiratory Vital Signs  Measurements include:  Respiratory rate, pattern, depth, SpO 2, ventilation, diffusion, perfusion  Nursing diagnosis  Interventions  Planning  Evaluation

24. 24 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Pressure and Physiology  Force exerted on walls of an artery  Systolic and diastolic  Cardiac output  Peripheral resistance  Blood volume  Viscosity  Elasticity

25. 25 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Influencing Blood Pressure  Age  Stress  Ethnicity  Gender  Daily Variation  Medications  Activity, weight  Smoking

26. 26 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Hypertension and Hypotension  Hypertension  More common than hypotension  Thickening of walls  Loss of elasticity  Family history  Risk factors  Hypotension  90 mm Hg  Dilation of arteries  Loss of blood volume  Decrease of blood flow to vital organs  Orthostatic/postural

27. 27 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Factors controlling Blood Pressure

28. 28 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Measurement of Blood Pressure

29. 29 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9-29  Blood pressure  Systolic pressure  Diastolic pressure  Pulse pressure  Mean arterial pressure Vital Signs

30. 30 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Measurement of Blood Pressure  Equipment  Auscultation  Children  Ultrasonic stethoscope  Palpation  Lower extremity  Electronic blood pressure

31. 31 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Process and Blood Pressure Determination  Assessment of blood pressure and pulse evaluates the general state of cardiovascular health.  Hypertension, hypotension, orthostatic hypotension, or narrow/wide pulse pressures define nursing diagnoses.

32. 32 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Knowledge check! Significant elevation in blood pressure measurements from one day to the next could be attributed to: A.A decrease in cuff size B.An increase in cuff size C.New onset of pain or anxiety D.A and C

33. 33 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Measurement of Arterial Oxygen Saturation  Pulse oximeter  Allows indirect measurement of oxygen saturation  SpO2 is a reliable estimate of SaO2  Measurement is affected if extremity is cold, edematous or if nail polish is present (interference with light transmission)

34. 34 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

35. 35 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9-35

36. 36 Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. Health Promotion and Vital Signs  Monitor vital signs.  Include age-related factors.  Include environmental and activity factors.