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Vital Signs. Vital Signs. Baseline data Guidelines for taking VS When to take VS. Guidelines For Taking VS. Know the patient Check equipment Know normal range Control environment Have a system Take as often as necessary Analyze Be aware of your communication Verify Report!!!.
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Vital Signs • Baseline data • Guidelines for taking VS • When to take VS
Guidelines For Taking VS • Know the patient • Check equipment • Know normal range • Control environment • Have a system • Take as often as necessary • Analyze • Be aware of your communication • Verify • Report!!!
When Do I take VS??? • On admission • Routine • Before and after any invasive procedure • When conditions change • Before and after nursing intervention • Any complaints of non specific symptoms
Regulation of Body Temp • Neural control • Heat production • Skin’s role • Heat loss • Radiation • Conduction • Convection • Evaporation • Behavioral control
Factors Affecting Body Temperature • Factors affecting body temperature • Age • Exercise • Hormones • Circadian rhythms • Stress • Environment
Temp. Alterations • Fever • Causes • Treatment Issues • Children
Nursing Process for Fever • Assessment • Nursing Dx • Plan and Implementation • Evaluation
Assessment of Body Temp • Sites • Mouth • Rectum • Axilla • Tympanic • Forehead
Thermometers • Mercury • Electronic • Disposable • Digital
Pulse • Indicator of circulatory status • Assess by palpating or using a stethoscope
Pulse Assessment • Radial and carotid pulse • Apical Pulse • Use first two fingers • Use stethoscope
Characteristics • Rate • Newborn 100-180 • 1 week-3 months 100-220 • 3 months-2 years 80-150 • 2 years-10 years 70-100 • 10 years-adult 55-90
Regular pulse • Count for 15 seconds and multiply by 4 • Irregular pulse • Count for full minute
Factors influencing pulse • Exercise • Fever • Heat • Acute pain • Anxiety • Unrelieved severe and chronic pain • Medication • Hemorrhage • Postural changes
Apical Pulse • Every heart beat has 2 sounds • S1 – lubb • S2 – dubb • PMI • Point of maximal impulse
Variations in Heart Rate • Tachycardia • Bradycardia • Always assess apical pulse if you suspect one of these!!
Rhythm • Normal • Dysrhythmia • Count an irregular pulse for 1 FULL minute • Pulse deficit
Strength and Equality • Normal • Bounding • Weak • Should be equal on both sides!!
Respirations • Generally a passive process • CO2 is the most important factor • Chemoreceptors • Rising CO2 levels
Mechanics of Breathing • Inspiration • Expiration
Assessment • Always at rest • Prior to taking temp in children • Immediately following pulse in adults • Inspect chest • Intercostal spaces • Use of accessory muscles
Rate • Newborn 35-40 • 2 years 25-32 • 8 years 20-30 • 12 years 16-19 • Adult 12-20 • Tachypnea in adult > 24 • Bradypnea in adult < 10
Alterations in Respirations • Hyperventilation • Cheyne Stokes • Apnea • Hypoventilation • Kussmaul • Dyspnea • Sighing • Orthopnea • Stertor • Stidor • Biot’s
Oxygen Saturation • Pulse oximetry • Above 90% • Pay attention to your PATIENT not just the monitor!!!