1. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Chapter 26 Vital Signs

2. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Vital Signs Temperature (T) Pulse (P) Respiratory rate (R) Blood pressure (BP)

3. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiological Function Thermoregulation –Body’s function of heat regulation –Goal: Maintain constant internal body temperature –Heat production –Heat loss –Behavioral control of body temperature (continued)

4. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiological Function Respiration –Act of breathing External respiration Internal respiration Inspiration Expiration Vital capacity (continued)

5. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Physiological Function Hemodynamic regulation –Function of blood circulating –Goal: Maintain appropriate environment in tissue fluids –Pulse –Blood pressure

6. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Factors Influencing Vital Signs Age Gender Heredity Race Lifestyle Environment Medications Pain Other factors: –Exercise –Anxiety and stress –Postural changes –Daily variations

7. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Measuring Vital Signs Equipment: –Thermometer –Stethoscope –Aneroid manometer (continued)

8. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Measuring Vital Signs Height and weight –Nursing considerations: Documentation

9. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Vital Signs and the Nursing Process Monitoring vital signs –Critical nursing intervention System of measurements based on nursing vocabularies and taxonomies

10. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Thermoregulation and the Nursing Process Assessment –Temperature scales –Sites: Oral Rectal Axillary (continued)

11. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Thermoregulation and the Nursing Process Diagnosis –Risk for imbalanced body temperature –Hyperthermia –Hypothermia –Ineffective thermoregulation (continued)

12. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Thermoregulation and the Nursing Process Planning and outcome identification –Involve client and/or family –Base on professional standards –Use best practices (continued)

13. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Thermoregulation and the Nursing Process Implementation –Delegation Assess and document competency of individuals performing vital signs –Client teaching –Documentation (continued)

14. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Thermoregulation and the Nursing Process Evaluation –Determine client’s response –Compare with desired outcome –Make necessary revisions

15. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pulse Sites: –Temporal –Carotid –Apical –Brachial –Radial (continued)

16. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pulse Sites: –Ulnar –Femoral –Posterior tibial –Dorsalis pedis (continued)

17. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pulse Assessing –Indirect measure of cardiac output –Characteristics: Quality Rate Rhythm Volume (continued)

18. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Pulse Nursing considerations: –Reporting of new abnormalities –Teaching of self-monitoring of pulse –Documentation

19. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Respirations Sites: –Chest wall, thorax –Nose, mouth (continued)

20. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Respirations Assessing –Movement of diaphragm –Characteristics of normal and abnormal breath sounds Eupnea, bradypnea, hypoventilation, tachypnea, and hyperventilation (continued)

21. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Respirations Nursing considerations: –Skin color –Level of consciousness –Advanced monitoring Oximeter Apnea monitor –Documentation

22. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Blood Pressure Sites: –Arm over brachial artery –Forearm –Leg sites (continued)

23. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Blood Pressure Assessing –Auscultation –Palpation –Hypotension Orthostatic hypotension –Hypertension (continued)

24. Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED. Blood Pressure Nursing considerations: –Documentation Systolic pressure Diastolic pressure Teaching Compliance with medications