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