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Vital Signs

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

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  1. Vital Signs

  2. Vital Signs • Baseline data • Guidelines for taking VS • When to take VS

  3. 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!!!

  4. 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

  5. Regulation of Body Temp • Neural control • Heat production • Skin’s role • Heat loss • Radiation • Conduction • Convection • Evaporation • Behavioral control

  6. Factors Affecting Body Temperature • Factors affecting body temperature • Age • Exercise • Hormones • Circadian rhythms • Stress • Environment

  7. Temp. Alterations • Fever • Causes • Treatment Issues • Children

  8. Nursing Process for Fever • Assessment • Nursing Dx • Plan and Implementation • Evaluation

  9. Assessment of Body Temp • Sites • Mouth • Rectum • Axilla • Tympanic • Forehead

  10. Thermometers • Mercury • Electronic • Disposable • Digital

  11. Pulse • Indicator of circulatory status • Assess by palpating or using a stethoscope

  12. Pulse Assessment • Radial and carotid pulse • Apical Pulse • Use first two fingers • Use stethoscope

  13. 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

  14. Regular pulse • Count for 15 seconds and multiply by 4 • Irregular pulse • Count for full minute

  15. Factors influencing pulse • Exercise • Fever • Heat • Acute pain • Anxiety • Unrelieved severe and chronic pain • Medication • Hemorrhage • Postural changes

  16. Apical Pulse • Every heart beat has 2 sounds • S1 – lubb • S2 – dubb • PMI • Point of maximal impulse

  17. Variations in Heart Rate • Tachycardia • Bradycardia • Always assess apical pulse if you suspect one of these!!

  18. Rhythm • Normal • Dysrhythmia • Count an irregular pulse for 1 FULL minute • Pulse deficit

  19. Strength and Equality • Normal • Bounding • Weak • Should be equal on both sides!!

  20. Respirations • Generally a passive process • CO2 is the most important factor • Chemoreceptors • Rising CO2 levels

  21. Mechanics of Breathing • Inspiration • Expiration

  22. Assessment • Always at rest • Prior to taking temp in children • Immediately following pulse in adults • Inspect chest • Intercostal spaces • Use of accessory muscles

  23. 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

  24. Alterations in Respirations • Hyperventilation • Cheyne Stokes • Apnea • Hypoventilation • Kussmaul • Dyspnea • Sighing • Orthopnea • Stertor • Stidor • Biot’s

  25. Oxygen Saturation • Pulse oximetry • Above 90% • Pay attention to your PATIENT not just the monitor!!!

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