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- 1) TEMPURATURE
- 2) PULSE
- 4)OXYGEN SATURATION
- 5)BLOOD PRESSURE
when to delegate vital signs
- -On admission to a health care facility
- -When assessing the client during home care visits
- -In a hospital on a routine schedule according to the health care provider's order or the hospital's standards of practice
- -Before and after a surgical procedure or invasive diagnostic procedure
- -Before, during, and after a transfusion of blood products
- -Before, during, and after the administration of medication or therapies that affect cardiovascular,
- respiratory, or temperature-control functions
- -When the client's general physical condition changes (e.g., loss of consciousness or increased intensity of pain)
- -Before and after nursing interventions influencing a vital sign (e.g., before a client previously on bed rest ambulates or before a client performs range-of-motion exercises)
- -When the client reports nonspecific symptoms of physical distress (e.g., feeling “funny” or “different”)
- Verify and communicate significant changes in vital signs. Document vital signs, andcommunicate information to the client's caregivers. Baseline measurements allow a nurse to identify changes in vital signs. When vital signsa ppear abnormal, it helps to have another nurse or health care provider repeat the measurement. Inform the health care provider or nurse in charge of abnormal vital signs.
Develop a teaching plan to instruct the client or caregiver in vital sign assessment and the significance of findings.
FACTURES INFLUENCING TEMPERATURE
- -HORMONE LEVEL
- -CIRCADIAN RHYTHM
Temperature Alternations: Changes in body temperature outside the usual range affect the hypothalamic set point. These
changes are related to excess heat production, excessive heat loss,
minimal heat production, minimal heat loss, or any combination of these
alterations. The nature of the change affects the type of clinical
problems a client experiences.
- - Pyrexia or Fever
- - Hyperthermia
- -heat stroke
- -Heat exhaustion
Two types of thermometers are available for measuring body temperature
electonic and disposal
The greatest advantages of electronic thermometers are that their
readings appear within seconds and they are easy to read. The plastic
sheath is unbreakable and ideal for children. Their expense is a major
disadvantage. Maintaining cleanliness of the probes is an important
consideration. If not properly cleaned between clients, gastrointestinal
contamination of the rectal probe will cause disease transmission.
Electronic thermometers provide two modes of operation: a 4-second
predictive temperature and a 3-minute standard temperature. In
day-to-day clinical situations, most nurses use the 4-second predictive
mode. A sound signals and a reading appears on the display unit when the
peak temperature reading has been measured.
Temporal artery thermometer
Chemical Dot Thermometers:
- In the Celsius version there are 50 dots, each representing a temperature
- increment of 0.1° C, over a range of 35.5° C to 40.4° C. The Fahrenheit
- version has 45 dots with increments of 0.2° F and a range of 96.0° F to
- 104.8° F. Chemical dots on the thermometer change color to reflect
- temperature reading, usually within 60 seconds. Most are for single use.
Chemical dot thermometers are useful for screening temperatures,
especially in infants and young children. Research has also demonstrated
the ability of oral chemical dot thermometers to screen temperatures in
orally intubated critical care clients (Potter and others, 2003).
Because chemical dot thermometers often underestimate oral temperature
by 0.4° C or more, use electronic thermometers to confirm measurements
made with a chemical dot thermometer when treatment decisions are
involved (Potter and others, 2003).
They are useful when caring for clients on protective isolation to
avoid the need to take electronic instruments into client rooms (Disposable)
There are several sites for measuring core and surface body temperature. Intensive care units use the core temperatures of the pulmonary artery, esophagus, and urinary bladder. These measurements require the use of continuous invasive devices placed in body cavities or organs and continually display readings on an electronic monitor.(Potter , Patricia A. . Fundamentals of Nursing
Obtain intermittent temperature measurements from the routinely used sites of the mouth, rectum, tympanic membrane, temporal artery, and axilla. You can also apply noninvasive chemically prepared thermometer patches to the skin. Oral, rectal, axillary, and skin temperature sites rely on effective blood circulation at the measurement site.
the temperature obtained varies, depending on the site used, but it is usually between 36.0° C (96.8° F) and 38.0° C (100.4° F). Rectal temperatures are usually 0.5° C (0.9° F) higher than oral temperatures, and axillary temperatures are usually 0.5° C (0.9° F) lower than oral temperatures
The pulse is the palpable bounding of blood flow noted at various points on the body. Blood flows through the body in a continuous circuit. The pulse is an indicator of circulatory status
he number of pulsing sensations occurring in 1 minute is the pulse rate.(Potter , Patricia A. .
The volume of blood pumped by the heart during 1 minute
- cardiac output
- he product of heart rate (HR) and the ventricle's stroke volume (SV)
. In an adult the heart normally pumps 5000 ml of blood per minute. A change in heart rate or stroke volume does not always change the heart's output or the amount of blood in the arteries. For example, if a person's heart rate is 70 beats per minute and the stroke volume is 70 mL, the cardiac output is 4900 mL per minute (70 beats per minute times 70 mL per beat). If the heart rate drops to 60 beats per minute and the stroke volume rises to 85 mL per beat, then the cardiac output increases to 5100 mL or 5.1 L per minute (60 beats per minute times 85 mL per beat)
The pulse wave moves 15 times faster through the aorta and 100 times faster through the small arteries than the ejected volume of blood
You can assess any artery for pulse rate, but you will typically use the radial or carotid arteries because they are easy to palpate.
FACTORS INFLUENCING PULSE
Assessment of Pulse
You can assess any artery for pulse rate, but you will typically use the radial or carotid arteries because they are easy to palpate.The radial and apical locations are the most common sites for pulse rate assessment. Use the radial pulse to teach clients to learn how to monitor their own heart rates
NORMAL PULSE RATE 60-100 BEATS PER MINUTE
Determine strength of pulse. Note whether thrust of vessel against fingertips is strong, bounding (4+), full, easy to palpate (3+), normal, easy to palpate (2+), diminished, difficult to palpate, weak and thready (1+), or absent (0
Apical pulse is greater than 100 beats per minute
Apical pulse is less than 60 beats per minute
every 3rd beat is skipped
example of dysrhyhmia
Acceptable heart rates
- infant 120-160 per minute
- toddler 90-140
- preschooler 80-110
- school aged child 75-100
- adolescent 60-90
- adult 60-100
Factors Influencing Pulse Rate
- postural changes
- pulmonary conditions