Vital SignsVital Signs

Vital SignsVital Signs

Baseline dataBaseline data Guidelines for taking VSGuidelines for taking VS When to take VSWhen to take VS

Guidelines For Taking VSGuidelines For Taking VS

Know the patientKnow the patient Check equipmentCheck equipment Know normal rangeKnow normal range Control environmentControl environment Have a systemHave a system Take as often as necessaryTake as often as necessary AnalyzeAnalyze Be aware of your communicationBe aware of your communication VerifyVerify Report!!! Report!!!

When Do I take VS???When Do I take VS???

On admissionOn admission RoutineRoutine Before and after any invasive procedureBefore and after any invasive procedure When conditions changeWhen conditions change Before and after nursing interventionBefore and after nursing intervention Any complaints of non specific symptomsAny complaints of non specific symptoms

Regulation of Body TempRegulation of Body Temp

Neural controlNeural control Heat productionHeat production Skin’s roleSkin’s role Heat lossHeat loss

RadiationRadiation ConductionConduction ConvectionConvection EvaporationEvaporation Behavioral controlBehavioral control

Factors Affecting Body Factors Affecting Body TemperatureTemperature

Factors affecting body temperatureFactors affecting body temperature AgeAge ExerciseExercise HormonesHormones Circadian rhythmsCircadian rhythms StressStress EnvironmentEnvironment

Temp. AlterationsTemp. Alterations

FeverFever CausesCauses Treatment IssuesTreatment Issues

ChildrenChildren

Nursing Process for FeverNursing Process for Fever

AssessmentAssessment Nursing DxNursing Dx Plan and ImplementationPlan and Implementation EvaluationEvaluation

Assessment of Body Assessment of Body TempTemp

SitesSites MouthMouth RectumRectum AxillaAxilla TympanicTympanic ForeheadForehead

ThermometersThermometers

MercuryMercury ElectronicElectronic DisposableDisposable DigitalDigital

PulsePulse

Indicator of circulatory statusIndicator of circulatory status Assess by palpating or using a Assess by palpating or using a

stethoscopestethoscope

Pulse AssessmentPulse Assessment

Radial and carotid pulseRadial and carotid pulse Apical PulseApical Pulse Use first two fingersUse first two fingers Use stethoscopeUse stethoscope

CharacteristicsCharacteristics

RateRate Newborn 100-180Newborn 100-180 1 week-3 months 100-2201 week-3 months 100-220 3 months-2 years 80-1503 months-2 years 80-150 2 years-10 years 70-1002 years-10 years 70-100 10 years-adult 55-9010 years-adult 55-90

Regular pulseRegular pulse Count for 15 seconds and multiply by 4Count for 15 seconds and multiply by 4

Irregular pulseIrregular pulse Count for full minuteCount for full minute

Factors influencing pulseFactors influencing pulse

ExerciseExercise FeverFever HeatHeat Acute painAcute pain AnxietyAnxiety Unrelieved severe and chronic painUnrelieved severe and chronic pain MedicationMedication HemorrhageHemorrhage Postural changesPostural changes

Apical PulseApical Pulse

Every heart beat has 2 soundsEvery heart beat has 2 sounds S1 – lubbS1 – lubb S2 – dubbS2 – dubb

PMIPMI Point of maximal impulsePoint of maximal impulse

Variations in Heart RateVariations in Heart Rate

TachycardiaTachycardia BradycardiaBradycardia Always assess apical pulse if you Always assess apical pulse if you

suspect one of these!!suspect one of these!!

RhythmRhythm

NormalNormal DysrhythmiaDysrhythmia Count an irregular pulse for 1 FULL Count an irregular pulse for 1 FULL

minuteminute Pulse deficitPulse deficit

Strength and EqualityStrength and Equality

NormalNormal BoundingBounding WeakWeak Should be equal on both sides!!Should be equal on both sides!!

RespirationsRespirations

Generally a passive processGenerally a passive process CO2 is the most important factor CO2 is the most important factor

ChemoreceptorsChemoreceptors Rising CO2 levelsRising CO2 levels

Mechanics of BreathingMechanics of Breathing InspirationInspiration ExpirationExpiration

AssessmentAssessment

Always at restAlways at rest Prior to taking temp in childrenPrior to taking temp in children Immediately following pulse in adultsImmediately following pulse in adults Inspect chestInspect chest Intercostal spacesIntercostal spaces Use of accessory musclesUse of accessory muscles

RateRate

Newborn 35-40Newborn 35-40 2 years 25-322 years 25-32 8 years 20-308 years 20-30 12 years 16-1912 years 16-19 Adult 12-20Adult 12-20 Tachypnea in adult > 24Tachypnea in adult > 24 Bradypnea in adult < 10Bradypnea in adult < 10

Alterations in Alterations in RespirationsRespirations

HyperventilationHyperventilation Cheyne StokesCheyne Stokes ApneaApnea HypoventilationHypoventilation KussmaulKussmaul DyspneaDyspnea SighingSighing OrthopneaOrthopnea StertorStertor StidorStidor Biot’sBiot’s

Oxygen SaturationOxygen Saturation

Pulse oximetryPulse oximetry Above 90%Above 90% Pay attention to your PATIENT not just Pay attention to your PATIENT not just

the monitor!!!the monitor!!!