Card Set Information
Vital Signs FT1
What to keep in mind when monitoring vital signs.
Performed on a regular basis
Frequency determined by
--Physician order and/or nursing judgment
Analyze all vital signs at same time. Put the puzzle togther.
When to assess VSs
: determine baseline to assess whether or not course of health is working.
Change in client’s health status
Client reports symptoms such as chest pain, feeling hot, or faint
Pre and post surgery/invasive procedure
Pre and post medication administration that could affect CV system
Pre and post nursing intervention that could affect vital signs
What do you need to know about taking an axillary temp?
Takes longer than oral
~1degree lower than oral. Document site temp was taken.
Stuff to know about rectal temp
Don't give to pt with MI. May stimulate vagus nerve.
Stuff to know about assessing Temp
Hypothalamus is the thermostat of the body
: radiation, conduction, convection, evaporation, diaphoresis.
: vasconstriction, vasodilation, shunting.
The “old standby” normal range
: 97°F to 100.8°F (36.1°C to 38.2°C) with some variation
Typically 1°F to 2°F (0.6°C to 1.2°C) higher than skin temperature
Types of Instruments:
--Scanning infrared (temporal artery)
: Preferred, accurate, low risk of hurting pt.
Factors affecting core temperature
Diurnal variations (circadian rhythms)
: highest at early evening/night. Lowest just before rising.
Terms and values for changes in core temp
: Abnormally high body temperature (>100°F or 37.8°C)
: Fever >105.8°F (41.0°C): pt may have hallucinations.
: Heat stroke.
: CORE temp < 95°F (35.0°C)
Priorities for caring for pt with fever
What are your priorities? Comfort-->bring temp down
What are you, as the nurse, going to do? Cold cloths, cold packs, liquids.
Need Dr. order for fever, even if Dr. has already Rx'd same med for pain.
What are the pt educaiton factors?
For every 1 degree F temp rises, HR should increase by 10BPM to maintain metabolic activity.
Documenting and knowning your pulse
Rate and rhythm – how do you describe?
Why is it important? Want to know if it's regular/irregular.
–Equality and symmetry
--Strength of the quality; sometimes it is the quality and not the quantity
--1+=pulse diminished, barely palpable; thready
--2+=Easily palpable, normal pulse
--3+=Full pulse, increased
What are normal ranges for HR?
Normal range for healthy adults = 60–100 bpm
Average = 70–80 bpm
Normal range for healthy infants=120-160 bpm
Checking for pulse deficit
Locate apical and radial sites
Two nurse method
: Decide on starting timeNurse counting radial says “start”Both count for 60 seconds Nurse counting radial says “stop”Radial can never be greater than apical
Aspects of Respiration
The exchange of oxygen and carbon dioxide in the body Two separate processes
: physical process of inhalation/exhalation
: bonding of O2 to hemoglobin
Newborn normal value = 30 - 60 / min. In newborns rate can double with stress/injury/illness/etc.
Adult normal value = 12 - 20 / min
Components of Respiratory assessment
: normal breathing
: no breathing
Work of breath
: results during expiration
: labored breathing (during sleep). sounds like snoring.
: fluid in airways. Sounds like ricecrispies. Ronchi-deeper and wetter.
Tools to measure oxygenation
Arterial blood gasses (ABG) direct method
: indirect because measures hemoglobin, not gas.
Normal CO values are >90%, national value >95% (good to know for NCLEX)
Know this chart!
Pulse pressure: difference between systolic and diastolic. Should be >40.
Bood pressure general info
Measured in mm Hg
Recorded as systolic over diastolic.
BP influenced by
: probes directly inserted into vascular system.
--upper arm (brachial artery
--thing (popliteal artery)
Quibbles in taking BP.
: needs to be at least 2/3 size of upper arm (child whole upper arm)
Pump until systolic (radial) pulse stops, then add 30-40mm Hg on top of that.
Phases of Korotkoff sounds when taking BP
Auscultated Korotkoff Sounds
Phase I – First heard, generally a loud thump = Systolic
Phase II – A blowing or whooshing sound
Phase III – A softer thump than Phase I
Phase IV – A softer blowing sound that fades
Phase V – Silence = Diastolic
Normal = < 120/80
Mild (Stage 1) 140 -159 / 90-99
Moderate (Stage 2) 160-179 / 90 -99
Severe (Stage 3) > 180 / 110
Staging is achieved after obtaining two diastolic readings at two different occasions that average > 90mmHg. Or Systolic readings which average >135
For pt with hypotension
Take BP lying down, sitting, and standing.
For pt with Hypertension...
BP reading of 120–139 systolic or 80–89 diastolic Obtained with three readings, taken days apart , with the client sitting.