VITAL SIGNS
guidelines for obtaining vital signs
nurse should be able to measure them correctly
understand and interpret the values
communicate the findings
the more ill the patient the more frequent vital signs are
a rise temp of 1F mat cause an increase in the pulse rate by 4 beats per minute
respiratory rate and blood pressure readings increase w a rise of temp
Blood pressure falls bc of Hemorrhage, the pulse rep increase and the temp decreases
Recording Vital Signs
graphic flow sheet
used for charting vital signs
“R”indicates a rectal temp
“Ax” indicates an axillary temp
blood pressure are always written w the first and diastolic beneath
Ex: 120/80
Apical pulse is indicated with an “ap next to the number
Ex: 78 ap
Temperature
A body’s regulation of temperature
a relative measure of sensible heat or cold
the body strives to maintain a temp of 98.9F (37 C) which is normal
Normal range is 97 to 98.8F ( 36.1 F to 37.5)
98.6
Many factors can cause body temp variances like envorolmemnt, time of day, patients state of health, and monthly menstrual cycle
Tempatire
the body’s regulation of temp
two types
core temo
temperature of deep tissues of the body
Body’s regulation of temp
temp elevates are frequently signs of illness
Define terms pyrexia, febrile, hypothermia and hyperthermia
(pyrexia) High Fever
Febrile ( fever)
Hyper and hypo
Fever is a body defense and can destroy invading bacteria
Fevers are classified, interment, or remittent
Different ways to obtain temp
Temperature measurements are obtained by
heat sensitive patches
electronic thermometer
tympanic thermometer
temporal artery method
Auscultating using the stethoscope
Major parts of stethoscope
earpieces
should fit smugly and comfortable in nurse ears
binaurals : should be angled and strong enough that eappieces stay firmly in ears w/o causing discomfort
Auscultating using the stethoscope
Auscultate -- listen for sounds within the body to evaluate or detect potential abnormalities
when using the stethoscope is it best to remain quiet
clean stethoscope between patient
Pulse
body’s regulation of pulse
pulse is rhythmic beating or vibrating moment
adult pulse rate is normally 60 to 100 per minute
nurse notes rate, rhythm, and volume of pulse
pulse is the the regular expansion and contraction of an artery
More than 100 is Tachycardia
Bradycardia > less than 60
The bodys regulation of pulse
Dysrhythmia is any irregulatary of your rhythm of pulse
Note rhythm, rate, and volume or strength
palpate pushes using pads of your index and middle fingers
it is acceptable to access all symmetric pulses simultaneously except the carotid pulse.
obtaining pulse measurements
measure the carotid pulse in patients neck on the side facing you
when patients condition deteriorates the carotid pulse id best to access first
major pulses include temporal, facial, carotid, brachial, radial, femoral, popliteal, postural tibial, and dorsals pedis; the pulses provide both general specific information.
Carotid artery is in your neck
we have many pulses/arteries throughout our body
Temporal artery, facial, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis
Respiration
a patient can experience hypoventilation after certain procedures such as surgery because deep breathing can cause pain and discomfort
Blood pressure
Factors determining blood pressure
normal adult pressure is 120/80 mm Hg
Hypertension- Blood pressure elevated
Hypotension- Blood pressure below normal
How do you diagnose blood pressure ?
Blood pressure is a silent killer
the more you visit the clinic, and get evaluated
Which is true regarding the body ?
core temp is the deep tissue of the body
Which is known as the fifth vital sign ?
Pulse
when developing a care plan for a patient who has congestive heart failure, what would be the the priority nursing intervention
Daily weights
VITAL SIGNS
guidelines for obtaining vital signs
nurse should be able to measure them correctly
understand and interpret the values
communicate the findings
the more ill the patient the more frequent vital signs are
a rise temp of 1F mat cause an increase in the pulse rate by 4 beats per minute
respiratory rate and blood pressure readings increase w a rise of temp
Blood pressure falls bc of Hemorrhage, the pulse rep increase and the temp decreases
Recording Vital Signs
graphic flow sheet
used for charting vital signs
“R”indicates a rectal temp
“Ax” indicates an axillary temp
blood pressure are always written w the first and diastolic beneath
Ex: 120/80
Apical pulse is indicated with an “ap next to the number
Ex: 78 ap
Temperature
A body’s regulation of temperature
a relative measure of sensible heat or cold
the body strives to maintain a temp of 98.9F (37 C) which is normal
Normal range is 97 to 98.8F ( 36.1 F to 37.5)
98.6
Many factors can cause body temp variances like envorolmemnt, time of day, patients state of health, and monthly menstrual cycle
Tempatire
the body’s regulation of temp
two types
core temo
temperature of deep tissues of the body
Body’s regulation of temp
temp elevates are frequently signs of illness
Define terms pyrexia, febrile, hypothermia and hyperthermia
(pyrexia) High Fever
Febrile ( fever)
Hyper and hypo
Fever is a body defense and can destroy invading bacteria
Fevers are classified, interment, or remittent
Different ways to obtain temp
Temperature measurements are obtained by
heat sensitive patches
electronic thermometer
tympanic thermometer
temporal artery method
Auscultating using the stethoscope
Major parts of stethoscope
earpieces
should fit smugly and comfortable in nurse ears
binaurals : should be angled and strong enough that eappieces stay firmly in ears w/o causing discomfort
Auscultating using the stethoscope
Auscultate -- listen for sounds within the body to evaluate or detect potential abnormalities
when using the stethoscope is it best to remain quiet
clean stethoscope between patient
Pulse
body’s regulation of pulse
pulse is rhythmic beating or vibrating moment
adult pulse rate is normally 60 to 100 per minute
nurse notes rate, rhythm, and volume of pulse
pulse is the the regular expansion and contraction of an artery
More than 100 is Tachycardia
Bradycardia > less than 60
The bodys regulation of pulse
Dysrhythmia is any irregulatary of your rhythm of pulse
Note rhythm, rate, and volume or strength
palpate pushes using pads of your index and middle fingers
it is acceptable to access all symmetric pulses simultaneously except the carotid pulse.
obtaining pulse measurements
measure the carotid pulse in patients neck on the side facing you
when patients condition deteriorates the carotid pulse id best to access first
major pulses include temporal, facial, carotid, brachial, radial, femoral, popliteal, postural tibial, and dorsals pedis; the pulses provide both general specific information.
Carotid artery is in your neck
we have many pulses/arteries throughout our body
Temporal artery, facial, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis
Respiration
a patient can experience hypoventilation after certain procedures such as surgery because deep breathing can cause pain and discomfort
Blood pressure
Factors determining blood pressure
normal adult pressure is 120/80 mm Hg
Hypertension- Blood pressure elevated
Hypotension- Blood pressure below normal
How do you diagnose blood pressure ?
Blood pressure is a silent killer
the more you visit the clinic, and get evaluated
Which is true regarding the body ?
core temp is the deep tissue of the body
Which is known as the fifth vital sign ?
Pulse
when developing a care plan for a patient who has congestive heart failure, what would be the the priority nursing intervention
Daily weights