Rnsg 1105 Vital Signs

Vital Signs Temp Pulse Respirations Blood Pressure Pulse oximetry

Quick, efficient • Monitoring condition • Identifying problems • Evaluating response to treatment

Guidelines • • • • •

96.8—100.4 12-16/min 120/80mmHg Pulse pressure: 30—50mmHg BASELINE---REALIZE--INDIVIDUALIZE!

When to take • When you think they should be taken • Protocol • MD orders • Before and after med administration

Temperature • Temperature alterations – Pyrexia (fever) – Hyperthermia • Heatstroke • Heat exhaustion – Hypothermia • Frostbite Mosby items and derived items © 2005 by Mosby, Inc.

Temperature • Nursing diagnoses – Risk for imbalanced body temperature – Hyperthermia – Hypothermia – Ineffective thermoregulation

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Temperature (cont'd) • Implementation – Prevention of alterations – Interventions for fever – Interventions for hyperthermia – Interventions for hypothermia

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Fever 1. Bacteria or viruses stimulate immune system 2. Chills, shivers, feeling cold 3. Temp increases 4. Feeling warm and dry 5. Warm, flushed, diaphoretic 6. Temp returns to normal

Fever • Up to 102.2 F (39 degrees Celsius) is beneficial • WBC • Suppresses bacterial growth • Stimulates interferon • Increased metabolic demands= pulse, respirations

Fever • • • • • • •

Energy conservation Monitoring Fluids Oxygen Meds Environment Nursing diagnosis

Pulse (the beat of the heart) • Character of the pulse – Rate – Rhythm – Strength – Equality

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Pulse problems • • • • • •

If irregular: count apical one minute Count apical and radial x 1 minute Pulse deficit: >2 difference Tachycardia: >100 beats/min Bradycardia: <60 beats/min Abnormal rhythm: dysrhythmia

Pulse • Pulse rate x Stroke volume= cardiac output • Cardiac output= tissue perfusion/oxygenation • Strength of muscle, volume, ……… • 30 second x 2 count is alright for slow, rapid, regular pulse rates

Pulse • Nursing diagnoses – Activity intolerance – Decreased cardiac output – Ineffective tissue perfusion

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Respiration • Physiological control – Oxygen – Carbon dioxide

• Mechanics of breathing – Inspiration – Expiration – Tidal volume Mosby items and derived items © 2005 by Mosby, Inc.

Respiration • Ventilation—gases in and out • Diffusion—Oxygen and carbon dioxide between alveoli and red blood cells

• Perfusion—red blood cells to and from pulmonary capillaries

Resp • • • • • •

Deep Normal shallow Labored—unlabored Rate Dyspnea

Cheyne Stokes Breathing

Respiration (cont'd) • Nursing diagnoses – Activity intolerance – Ineffective airway clearance – Ineffective breathing pattern – Impaired gas exchange – Ineffective tissue perfusion

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Blood Pressure • 120—80 is magical number Depends on: blood volume; greater heart muscle contractility; arterial wall resistance; heart rate

Blood Pressure • Physiology – Cardiac output – Peripheral resistance – Blood volume – Viscosity – Elasticity

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Blood pressure is the force exerted on the blood vessel walls by the blood

Systolic • Ventricles are contracting • Condition of heart and great arteries • Max pressure

Diastolic • Ventricles are relaxed • Minimum pressure • Indicates arteriolar or peripheral vascular resistance

Pulse pressure • Difference between systolic and diastolic – Normally 30-50 mm/Hg.

Correct procedure • Not crossing legs! • Palpate brachial • Correct cuff size—look at yours

Blood Pressure (cont'd) • Nursing diagnoses – Anxiety – Decreased cardiac output – Deficient/Excess fluid volume – Risk for injury – Acute pain – Ineffective tissue perfusion Mosby items and derived items © 2005 by Mosby, Inc.

Pulse oximetry • P. 519 • > 90% is okay but higher is better! • Remove nail polish!!

Last but not least Potter & Perry • P. 666 client teaching • P. 667 Focus on older adults

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