Vital Signs

temperature, pulse, respirations & blood pressure

pain level or comfort level

identify nursing diagnoses, to implement planned interventions, and to evaluate success when vital signs have returned to acceptable values

your judgment of the need, the patient's condition and physician orders

graphic flow sheets

98.6 F (37 C)

regulates body temperature/ located in the brain, forming the floor and part of the lateral wall of the third ventricle/ helps maintain a balance between heat lost and heat produced by body

core temperature & surface temperature

temperature of the deep tissues of the body

the temperature of the skin

above-normal body temperature

above-normal body temperature

above-normal body temperature

age/ excercise/ hormonal influences/ diurnal (daily) variations/ stress/ environment/ ingestion of hot & cold liquids/ smoking

thirst/ anorexia/ flushed, warm skin/ irritability/ glassy eyes or photophobia (sensitivity to light)/ headache/ elevated pulse & respiratory rates/ restlessness or excessive sleepiness/ increased perspiration/ disorientation, progessing to convulsions in infants & children

remains elevated consistently and fluctuate very little

rise and fall; for example, temp. is normal or subnormal in the morning and spikes in the afternoon

similar to intermittent fevers except the temp. does not return to normal at all until the pt becomes well

abnormally low body temp.

oral/ rectal/ axilla/ tympanic/ temporal artery

an instrument that is placed against the pt's chest or back to hear heart and lung sounds

to listen for sounds within the body to evaluate the condition of heart, lungs, pleura, intestines, or other organs or to detect fetal heart tones

a rhythmic beating or vibrating movement; in the body it signifies the regular, recurrent expansion and contraction of an artery produced by the waves of pressure that are caused by the ejection of blood from the left ventricle of the heart as it contracts

between 60 and 100 beats per minute; approximate average being 80

abnormally fast pulse rate; faster than 100 beats per minute

pulse rate slower than 60 beats per minute

shock, hemorrhage leading to hypovolemia (an abnormally low circulating blood volume), exercise, fever, medication or substance abuse, and acute pain

age/ exercise/ fever, heat/ acute pain, anxiety/ unrelieved severe pain, chronic pain/ medications/ hemorrhage/ postural changes/ metabolism/ pulmonary conditions

unrelieved severe pain/ some drugs (beta blockers)/ resting in a supine position/ cardiac condition called heart block

any disturbance or abnormality in a normal rhythmic pattern, specifically, irregularity in the normal rhythm of the heart

refers to apex of the heart

represents the actual beating of the heart/ used when taking the pulse rate of an infant

a difference between the radial and apical pulse rates

the taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing, i.e. inhaling & exhaling

refers to the exchange of gas at the tissue level caused by the process of cellular oxidation, as well as the gas exchange that occurs in the alveoli of the lungs

breathing movements of the pt that you can observe

1: inspiration-inhaling air with oxygen into the lungs; 2: expiration- exhaling air with carbon dioxide out of the lungs

medulla oblongata in the brain

rapid respiratory rate

a slow respiratory rate ( below 10 per minute)

disease or illness/ stress/ fever/ age/ sex/ body position/ medications/ exercise/ acute pain/ smoking/ brainstem injury/ hemoglobin function

breathing with difficulty

abnormal pattern of respiation characterized by alternating periods of apnea and deep, rapid breathing

not breathing

when the rate of ventilation exceeds normal metabolic requirements for exchange of respiratory gases, such as during emotional trauma/ volume and depth of respirations increase

occurs when the rate of ventilation entering the lungs is insufficient for metabolic needs/ respiratory rate is below normal and depth of ventilation is depressed/ ex: after open cholecystectomy is performed, when deep breathing results in discomfort

when counting a radial or an apical pulse

the pressure exerted by the circulating volume of blood on the arterial walls, the veins, and the chambers of the heart

millimeters of mercury (mm Hg)

systolic pressure is the higher number and represents the ventricles contracting, forcing blood into the aorta and the pulmonary arteries/ indicated by the first sound heard on auscultation

lower number of the bp reading, represents the pressure within the artery between beats, that when blood enters the relaxed chambers from the systemic circulation and the lungs

difference between systolic and diastolic readings (a reading of 120/80 mm Hg reveals a pulse pressure of 40)

age/ anxiety, fear, pain, & emotional stress/ medications/ hormones/ diurnal (happening daily) variations/ race/ sex

occurs when the elevated pressure is sustained above 140/90 mm Hg

values of 120-139/80-89 mm Hg

family history of hypertension/ obesity/ smoking/ heavy alcohol consumption/ elevated blood cholestrol level/ continued exposure to stress

below normal blood pressure

a drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when a person moves from a lying to a sitting or from a sitting to a standing position/ occurs when a person rises too quickly, usually from a supine position & frequently feels lightheaded and unstable

a device for measuring the arterial blood pressure

first sounds heard while taking BP using sphygmomanometer and stethoscope