Transcript Chapter 32 Vital Signs

Chapter 32
Vital Signs
NRS 102
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General Survey
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Physical appearance
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Age
Sex
Level of consciousness
Skin color
Facial features
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General Survey
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Body structure
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Stature
 Nutrition
 Symmetry
 Posture
 Position
 Body build, contour
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Mobility
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Gait
Range of motion
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General Survey
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Behavior
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Facial expression
Mood and affect
Speech
Dress
Personal hygiene
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Guidelines for Measuring
Vital Signs
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Establish a baseline for future
assessments.
Be able to understand and interpret
values.
Appropriately delegate measurement.
Communicate findings.
Ensure equipment is in working order.
Accurately document findings.
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Body Temperature
Physiology
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Body temperature:
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Temperature range:
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Heat produced
Heat lost
98.6° F to 100.4° F or 36° C to 38° C
Temperature sites:
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Oral, rectal, axillary, tympanic membrane,
temporal artery, esophageal, pulmonary artery
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Body Temperature Regulation
Neural and vascular
control
Heat production
Heat loss
Skin temperature
regulation
Behavioral control
Thermoregulation
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Factors Affecting Body
Temperature
Age
Exercise
Hormonal level
Circadian rhythm
Environment
Temperature alterations
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Abnormal Body Temp
Hypothermia
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Heat loss during prolonged exposure to cold
Classified by core temp (mild-severe)
May be intentional (surgery)
Early signs- uncontrolled shivering, loss of
memory, poor judgment
Later signs- Cyanosis, decreased VS, cardiac
dysrhythmias, loss of consciousness
Frostbite- body exposure to subnormal temps
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Abnormal Body Temp
Hyperthermia
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Elevated body temp related to body’s inability
to promote heat loss or reduce heat
production
Heatstroke- prolonged exposure to sun or
high environmental temp. Heat depresses
hypothalamus function
Heat Exhaustion- profuse diaphoresis result
in fluid & electrolyte loss
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Nursing Process
and Temperature
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Assessment
Diagnosis
Planning
Implementation
Evaluation
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Pulse, Physiology, and Regulation
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The indicator of circulatory status
Electrical impulses originate from the
sinoatrial (SA) node.
Cardiac output, heart rate, stroke volume
Mechanical, neural, and chemical factors
regulate ventricular contraction and stroke
volume.
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Assessment of Pulse
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Sites
Use of stethoscope
Character of pulse
Nursing process and pulse determination
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Knowledge check!
Which patient would be most likely to present
with a pulse rate that is lower than normal?
A. A 70-year-old telephone salesman
presenting with dehydration.
B. A 20-year-old runner who had surgery 4
days ago for a fractured leg.
C. A 67-year-old who presented with an
exacerbation of his COPD
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Respiration
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Ventilation
Diffusion
Perfusion
Physiological control
Mechanics of breathing
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Assessment of Ventilation
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Easy to assess
Respiratory rate
Ventilatory depth
Ventilatory rhythm
Diffusion and perfusion
Arterial oxygen saturation
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Assessing Respirations
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Assessing rate- observe full inspiration &
expiration
Assess for full minute
Normal adult 12 –20 breaths/minute
Varies with age, rate declines throughout life
Apnea Monitor
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Normal & Abnormal Respirations
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Eupnea- normal respirations
Bradypnea- abnormally slow < 12
Tachypnea- abnormally fast >20
Hyperpnea- labored, after exercise
Hyperventilation/Hypoventilation
Cheyne-Stokes
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Nursing Process and Respiratory
Vital Signs
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Measurements include:
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Respiratory rate, pattern, depth, SpO2,
ventilation, diffusion, perfusion
Nursing diagnosis
Interventions
Planning
Evaluation
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Arterial Blood Pressure
and Physiology
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Force exerted on walls of an artery
Systolic and diastolic
Cardiac output
Peripheral resistance
Blood volume
Viscosity
Elasticity
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Factors Influencing Blood Pressure
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Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity, weight
Smoking
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Hypertension and Hypotension
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Hypertension
More common than
hypotension
 Thickening of walls
 Loss of elasticity
 Family history
 Risk factors
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Hypotension
90 mm Hg
 Dilation of arteries
 Loss of blood volume
 Decrease of blood flow
to vital organs
 Orthostatic/postural
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Factors controlling Blood
Pressure
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Measurement of Blood Pressure
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Vital Signs
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Blood pressure
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Systolic pressure
Diastolic pressure
Pulse pressure
Mean arterial pressure
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Slide 9-29
Measurement of Blood Pressure
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Equipment
Auscultation
Children
Ultrasonic stethoscope
Palpation
Lower extremity
Electronic blood pressure
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Nursing Process and Blood
Pressure Determination
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Assessment of blood pressure and pulse
evaluates the general state of
cardiovascular health.
Hypertension, hypotension, orthostatic
hypotension, or narrow/wide pulse
pressures define nursing diagnoses.
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Knowledge check!
Significant elevation in blood pressure
measurements from one day to the next
could be attributed to:
A. A decrease in cuff size
B. An increase in cuff size
C. New onset of pain or anxiety
D. A and C
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Measurement of Arterial Oxygen
Saturation
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Pulse oximeter
Allows indirect measurement of oxygen
saturation
SpO2 is a reliable estimate of SaO2
Measurement is affected if extremity is cold,
edematous or if nail polish is present
(interference with light transmission)
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Slide 9-35
Health Promotion and Vital Signs
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Monitor vital signs.
Include age-related factors.
Include environmental and activity factors.
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