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Vital signs are vital Sample lecture notes: Module II – Objectives 1-7
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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
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Documentation and reporting Responsibility of nurse “Abnormals” MUST be dealt with Methods and formats vary Computer Written Charts
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Temperature Reflect Infection & inflammation Show balance in thermoregulation (or imbalance) Measuring Scale “C” or “F”
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Tools for temp measuring Glass Electronic Tympanic Disposable strips
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Routes Oral Rectal Axillary Core
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Pulse Reflects Heart contractions Defined by rate, rhythm, and strength Normal adult: <60 = bradycardia >100 = tachycardia
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Characteristics Variable measuring locations Brachial Radial Apical Total nine locations
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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)
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Respirations Body must receive oxygen and release carbon dioxide Primarily an involuntary act Normal is a quiet easy respiration
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Tools Stealth Stethoscope Visual Occasionally tactile Environment
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Blood pressure Relates information about the client’s cardiovascular system Blood volume Peripheral vascular resistance
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Tools Sphygmomanometer Stethoscope Doppler
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Guides to measuring Usually brachial artery Under constant conditions Millimeters of mercury (mmHG) Right size Right place Right use of equipment Right environment
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Hints Palpate first Wait 30 – 60 sec If changing position, wait 2 minutes for circulation to equalize
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The sounds of pressure Korotkoff sounds (5) Systolic Diastolic Know normals Chart according to policy (2 or 3)
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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
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Conclusion Questions ? Concerns? Confusion? THE END
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