1. When do you do Vital signs
    • *When emitted somewhere new
    • *Change in health status
    • *odd symptoms-pain, weak, hot
    • *Before and After surgery
    • *Before and After medications
  2. Vital signs consist of ?
    • *Temperature
    • *Pulse
    • *Respirations
    • *Blood Pressure
    • *Oxygen saturation -(Pulse ox)
    • *Pain
  3. Temperature
    • Control mechanisms of human beings keep the body's core temperature or temperature of deep tissues relatively constant.
    • *Acceptable Temp ranges ( 96.4-100.4)
  4. Body Temperature Regulation
    • *Neural and vascular control
    • *Heat production
    • *Heat loss
    • *Behavioral control
  5. Neural and Vascular Control
    • *Hypothalamus controls body's SET POINT
    • *Vasodilation & Sweating
    • *Shivering & Vasoconstriction (tighter body has to work harder
  6. Heat Production
    • Heat is produced as a by-product of metabolism
    • *Muscular activity
    • *Shivering
    • *Non-shivering Thermogenesis (neonates-brown fat)
  7. Basal Metabolic Rate
    Heat produced by body at rest
  8. Frostbite
    • more externam, icy covering (nose, earlobes) but tissue break down
    • *White waxy skin color
    • *Graduate loss of sensation
    • *Warm extremities slowly
    • * Can not pronounce dead until warmed up b/c easier to bring a cold temp to high and come back to life.
  9. Heat Loss
    • *Radiation
    • *Conduction
    • *Convention
    • *Evaporation
  10. Radiation
    Heat transferred from one service to another on its own (standing to fetal position)
  11. Conduction
    Transfer of heat with direct contact
  12. Convention
    Heat loss by circulation
  13. Evaporation
    Liquid loss 600-900 mL a day
  14. Diaphoresis
    visual perspiration on forehead and upper thorax reduces body temperature (fever, dehydration)
  15. Factors that affect body temperature
    • *Age
    • *Exercise
    • *Hormone Level
    • *Circadian Rhythms
    • *Stress Environment
  16. Fever
    • Heat loss unable to keep pace with excess heat production
    • *results from alteration of hypothalamic set point caused by pyrogens that stimulate the immune system
    • *Stimulates WBC production, suppresses growth of bacteria, and fights viral substances through production of interferon.
  17. Hyperthermia
    • Malignant Hyperthermia
    • Heat stroke
    • *Body's too Hot
  18. Malignant Hyperthermia
    Bodys reaction to anasethic reaction (high fever, seizer, then death)
  19. Mild Hypothermia
    93.2-96.8 F
  20. Moderate Hypothermia
    86-93.2 F
  21. Severe Hypothermia
    • Less than 86 F
    • *shivering, loss of memory, depression and poor judgement (below 34 C heart/respiratory rate &BP drop)
  22. Heat exaustion
    Skin is wet, sweating, woozy, dry mouth
  23. Heat Stroke
    skin is warm and dry, patient gets giddy(confused, weak, muscle cramp, visual change)
  24. Chill Phase
    shiver, feverish
  25. Plateu Phase
    body plays catch up, body warm and dry, things that go w/fever, chills go away
  26. Febrial Phase
    • having a fever, diaphretic (heavy sweating)
    • *Intervention: fever breaks
  27. Temperature Measurement
    • *Tympanic Membrane
    • *Rectal
    • *Oral
    • *Axilla
    • *Skin
  28. Tympanic Membrane
    Ear, thermometers vary in use, same thermometer on same patient
  29. Rectal
    Should not take temp who is bleeding, rectal surgery, instead you can use regular thermometer
  30. Oral
    Bucal mucosa- all the way in the back, capable of keeping mouth closed, least invasive, use sheath
  31. Axilla
    Under arm, cant be extremely skinny, runs 2 degrees below normal
  32. Skin Temperature
    • *Skin damage prior to taking temp
    • *Temporal location
    • * 2 degrees below normal
  33. Pulse
    • Measures the pressure in the arteries (the left ventricle pumping out to body)
    • *the # of pulsing sensations occurring in 1 min. is the pulse rate
    • *Adult: 60-100
    • *children have a higher, faster metabolism and are growing
  34. The Different Pulses
    • Radial(underneath thumb) and carotid (neck) are commonly used because they are easily palpated
    • *Temporal- Head
    • *Brachial- Mid arm (elbow)
    • *Ulnar
    • *Femoral-half way through the leg
    • *Popliteal-Knee
    • *Posterior tibial-inside of ankle
    • *Dorsalis Pedis- Top of foot (farthest away from heart)
  35. Apical Pulse
    provides a more accurate assessment of heart rate (on the chest)
  36. Factors influencing Pulse Rates
    • *Exercise
    • *Temperature
    • *Emotions
    • *Drugs
    • *Hemorrhage
    • *Postural changes
    • *Pulmonary Changes
  37. Pulse Assessment
    • *Note Rhythm
    • *Pulse volume
    • full bounding
    • Weak febrile thready
  38. Signs and Symptoms of Pulse Rate
    • *Dyspnea
    • *Fatigue
    • *Pallor
    • *Cyanosis
    • *Palpitations
    • *Syncope
  39. Blood Pressure
    The force exerted on the walls of an artery created by the pulsing blood under pressure from the heart
  40. Systolic
    The peak of max. pressure when ejection occurs (SKY)
  41. Diastolic
    When the hear relaxes, the blood remaining in the arteries exerts a min. (Down)
  42. Physiology of Arterial BP
    BP reflects the interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.
  43. Prehypertension
    • 120/80
    • Systolic range : 120-139
    • Diastolic range: 80-89
  44. Stage 1 hypertension
    • Systolic range: 140-159
    • Diastolic range: 90-99
  45. Stage 2 hypertension
    • Systolic: greater than 160
    • Diastolic: greater than 100
  46. Influences on BP
    • *Age
    • *Stress
    • *Ethnicity
    • *Gender
    • *Daily variation
    • *Medications
    • *Activity and Weight
    • *Smoking
  47. Hypotension
    considered present when they systolic BP falls to 90 mmHg or below
  48. Orthostatc hypotension (postural)
    • symptomatic drop in BP with change in postion
    • *due to decreased systemic resistamce, low blood volume, anemia, dehydration etc.
  49. Auscultation of BP
    • indirect measurement based on basic principles or pressure
    • *blood flows freely through arteris until inflated cuff exerts pressure and causes artery to collapse
    • *When cuff pressure is released and blood flow returns=systolic BP
    • *When sound disappears=diastolic BP
  50. Common Mistakes in BP Assessment by Auscultation
    • *Cuff too wide
    • *Cuff too narrow
    • *Cuff wrapped improperly
    • *Repeating assessments too quickly
  51. Respiration
    the mechanism the body uses to exchange gases between the atmosphere and the blood and the cells
  52. Respiration involves 3 processes
    • Ventilation
    • Diffusion
    • Perfusion
  53. Ventilation
    the mechanical movement of gases in and out of the lungs
  54. Diffusion
    The movement of oxygen and carbon dioxide between the alveoli and the red blood cells
  55. Perfusion
    the distribution of RBC and from the pulmonary capillaries
  56. Measurement of Respiration
    • *rate and depth of breathing
    • *and the rhythm of ventilatory
  57. Respiratory Rate
    observe a full inspiration and expiration when counting ventilations or respiratory rate
  58. Bradypnea
    slow rate
  59. Tachypnea
    fast rate of breathing
  60. Hyperpnea
    Faster and deeper breathing
  61. Apnea
    • *sleep apnea
    • *swallowing
    • *chocking
    • *Medicaiton
  62. Hyperventilation
    • Fast and shallow
    • *Anxiety, body blows out
    • *too much CO2
  63. Hypoventilation
    sleepy, damage to medula build up
  64. Cheyne-Stokes
    • Respiratory rate/patter of death
    • *deep ventilation
  65. Kussmauls respirations
    • increase rate, fruity breath
    • *confuession
    • *change in mental status
    • *look drunk
  66. Respiratory Assessments
    • *depth of respirations is assessed by observing the degree of excursion or movement in the chest wall & regularity respiratory rhythm
    • *May also see associated diaphragmatic movement (babies not adults)
    • *Ventilatory movements may be described as deep, normal, or shallow
    • *Use of intercostal or accessory muscles and retractions
  67. Factors influencing Character of Respirations
    • *Exercise: increase
    • *Acute pain: Shallow
    • *Anxiety:increase
    • *Smoking:increase
    • *Body position
    • *Medications: increase and decrease
    • *Neurologic Injury: increase and decrease
    • *Hemoglobin Function: increase
  68. Measurement of Arterial Oxygen Satuation
    • *A pulse oximeter permits the indirect measurement of oxygen saturation
    • *Light sensor that distinguishes between oxygenated and deoxygenated hemoglobin molecules
    • *Accuracy dependent upon light transmission and adequate arterial pulsations
  69. Mobility
    • a person's ability to move around free in his or her envrornment
    • * serves many purposes
  70. Bed Rest
    an intervention in which the client is restricted to bed for therapeutic reasons
  71. Body Mechanics
    • coordinated efforts of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment
    • *used during lifting, bending, moving, and performing activities of daily living
    • *balance is achieved when a relatively low center of gravity is balanced over a wide base of support
  72. Principles of Body Mechanics
    • *Equilibrium maintained as long as center of gravity aligns with base of support
    • *Facing different of movement prevents abnormal twisting of the spine
    • *Balanced use of arms and legs reduced risk of back injury
    • *Leverage, rolling, turning and pivoting requires less work than lifting
    • *Less friction= less force needed to move object
    • *Alternating period of rest and activity helps to reduce fatigue and injury
  73. Musculoskeletal System (regulation of movement)
    • Bones, joints, ligaments, tendons, cartilage
    • *what is the function of the skeletal system
    • *what changes occur in bones as a person ages
  74. Skeletal Muscle (regulations of movement)
    • *facilitates movement
    • *determines body form and contour
  75. Nervous System (regulation of movement)
    • *regulation of movement and posture
    • *Requires neurotransmitter production, transmission of impulses from nerve to muscle and activation of muscle activity
  76. Pathological Influences on Mobility
    • *Congenital defects
    • *Disorders of bones, joints, and muscles
    • *CNS damage
    • *Musculoskeletal trauma
  77. Congenital defects
    Osteogenesis imperfecta, scollosis
  78. Disorders of bones, joints, and muscles
    Osteoporosis, arthritis, non-imflammatory joint disease
  79. CNS damage
    Damage to component that regulates voluntary movement
  80. Musculoskeletal trauma
    Bruises, contusions, sprains, and fractures
  81. Effects of Immobility
    • *Physiological effects
    • *Respiratory changes
    • *Changes in metabolic rate
    • *Changes in metabolism of carbohydrates, fats, and proteins
    • *Fluid and electrolyte balances
    • *Gastrointestinal changes
  82. Effects of Immobility (systems)
    • *Cardiovascular changes
    • *Musculoskeletal changes
    • *Integument changes
    • *Urinary elimination changes
    • *Psychosocial effects
    • *Developmental effects
  83. Assessment of Mobility
    • *Range of joint motion
    • *Gait
    • *Activity tolerance
    • *Body alignment
    • *Pain associated with activity
  84. Implementation
    Nursing interventions for the completely or partially immobilized client focus on health promotion and prevention of the hazards of immobility
  85. Nursing Interventions and Health Promotion
    • *Musculoskeletal system
    • *Skin integrity
    • *Elimination system
    • *Psychosocial problems
    • *Developmental changes
  86. Health Promotion
    Structured exercise programs for immobile clients can enhance their feelings of wellbeing, as well as their endurance, strength, and health
  87. Nursing Interventions in Acute Care
    • *Respiratory system
    • *Maintaining a patent airway
    • *Cardiovascular system
  88. Nursing Interventions
    • *Respiratory system
    • *Promoting expansion of the chest and lungs
    • *Preventing stasis of pulmonary secretions
    • *Metabolic system
    • *Cardiovascular system
  89. Therapeutic Positioning
    • Clients with impaired nervous or musculoskeletal system functioning; increased weakness, or restricted to bed rest benefit from therapeutic positioning
    • *Repositioning
    • -clients should be repositioned as needed
    • -at lease every 2 hours if they are in bed
    • - every 20 to 30 min. if they are sitting in a chair
  90. Fowler's
    HOB elevated, support and align hips and spine
  91. Supine
    Back lying, support with pillows, trochanter rolls, splints
  92. Prone
    Face down
  93. Sim's
    Semiprone on right or left side with weight placed on ilium, humerus, and clavicle
  94. Lateral
    Side lying with proper spine alignment
  95. Range-of-Motion Exercises
    • *the easiest intervention to maintain or improve joint mobility for clients is the use of range of motion exercies
    • *active range of motion exercises
    • -the client is able to move his or her joints
    • *passive range of motion exercises
    • - the nurse moves the client's joints
  96. Assisting with Ambulation
    • *Clients with hemiplegia/hemiparesis
    • -use of gait belt
    • -support affected side
    • *Clients feeling dizziness or faint during ambulation
    • -return to closest bed or chair
    • -gently lower client to floor to prevent injury if necessary
  97. The Skin's Function
    • *protection
    • *secretion
    • *excretion
    • *temperature regulation
    • *sensation
  98. Skin's 3 Layers
    • Epidermis: shields underlying tissue
    • Dermis: contains nerves, vessels, and glands
    • Subcutaneous tissue: insulates and cushions skin
  99. Feet and Nails
    • *Require special attention
    • *Discomfort causes stress and pain
    • *The normal nail is transparent, smooth, and convex, with a pink nail bed and white tip
    • *Changes in shape, thickness, and curvature can occur
  100. Nursing Knowledge Base
    • *Personal preferences for hygiene
    • *Hygiene care is never routine
    • *During hygiene
    • -assess physical status and limitations
    • - assess client's readiness to learn
    • -provide privacy
    • -foster physical well being
  101. Tub or shower
    More thorough than bed bath
  102. Complete Bed Bath
    for clients who are dependent and require total hygienic care
  103. Partial bed bath
    involves bathing only those parts that would cause discomfort odor if left unbathed
  104. Perineal Care
    • *part of bed bath
    • *clients most in need are those with secretions or Foley catheters and following rectal surgery or childbirth
    • *be alert to discharge, skin irritation, and odors
    • *good perineal care prevents skin irritation and breakdown
  105. Foot and Nail Care
    • *soak and soften cuticles
    • *cleanse and dry the feet thoroughly
    • *trim nails straight across (check agency policy regarding trimming of nails)
    • *inspect for lesions, dryness, and signs of infection
    • *clients with DM or PVD are at risk for impaired circulation
  106. Temperature tells us
    infection and inflammation
  107. What is the minimum time length for checking pain level??
    4 hours min
  108. Core temperature
    within deep tissues

    *** Rectal
  109. Hypothalamus controls the body's ???
    "Set Point"

    ¨Vasodilation & Sweating

    ¨Shivering & Vasoconstriction
  110. Disease or trauma to the hypothalamus or spinal cord (which carries hypothamic messages) does what????
    decreases body’s ability to control body temperature
  111. Heat is produced as a by-product of
  112. Basal Metabolic Rate
    heat produced by body at rest
  113. Why cant newborns shiver??
    Non-shivering Thermogenesis (neonates- brown fat)

    Newborns can not shiver they have a layer of brown fat
  114. BMR decreases with???
    with age and they have a hard time maintaining heat
  115. Pulse is the ...???
    measurement of Circulation through the pts body
  116. Apical pulse is where the
    the Left ventricle and right ventricle are squezing
  117. 5L a minute of what???
    blood is circulating in you body
  118. PMI
    -point of maximal intensity (apical pulse) pointy part of the heart lies closest to the skin. 5th intercostal midclavicular
  119. The Pulse measures..???
    • Rate(speed)
    • Force(strength)
    • Rhythm (regularity) if irregular auscultate or palpate for one min
  120. Radial and carotid arteries are commonly used
    because they are easily palpated
  121. Apical pulse provides a more
    accurate assessment of heart rate.
  122. Strength and amplitude of a pulse reflects
    volume & pressure of blood ejected against arterial wall with each contraction & condition of vasculature leading to pulse site
  123. Normal Pulse for newborns
    • 120-160 infants because they are growing and their basal metabolic is faster and Lower blood pressure. Not normal for an infant to have a pulse rate lower
    • than 100
  124. Normal Adult Pulse
  125. Bounding Pulse
    we don’t want it to be like that all the time, body is working a lot harder more fluid in body
  126. Strong Pulse
  127. Weak Pulse
    you can feel it but its hard to find
  128. Thready Pulse
    don’t feel every beat could feel irregular, adjust fingers sometimes to feel it

    • *is the pulse the same on each side
    • -if unequal than there is some kind of problem
  129. Blood pressure is the force
    exerted on the walls of an artery created by the pulsing blood under pressure from the heart.
  130. Blood pressure reflects the
    interrelationships of cardiac output, peripheral vascular resistance, blood volume, blood viscosity, and artery elasticity.
  131. your temperature is lowest
    around 1- 4:00 am
  132. you temperature is at its Maximum at
    6:00 pm, and then declines to early morning levels
  133. When the fever “breaks,” the client becomes
  134. The heat of the blood is what to the thermometer??
    conducted to the thermometer probe
  135. Tympanic temperature relies on the
    radiation of body heat to an infrared sensor.
  136. Bladder or cuff too wide
    False low reading
  137. Bladder or cuff too narrow or too short
    False high reading
  138. Cuff wrapped too loosely or unevenly
    false high reading
  139. Arm below heart level
    False high
  140. Arm above heart level
    False low
Card Set
Vital Signs