Transcript LL3a & 3b - VITAL SIGNS

NURSING INTERVENTIONS
VITAL SIGN
MEASUREMENT
VITAL SIGNS
Vital signs are indicators of the
body's:
 Physiological status
Response to Physical stressors
Environmental stressors
Psychological stressors
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VITAL SIGNS
Temperature, Pulse Blood Pressure &
respiration rate can REVEAL the
patients ability to:
 Maintain
body temperature regulation
 Maintain
local & systemic blood flow
 Maintain
oxygenation of the tissues
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VITAL SIGNS
Any difference between a clients
NORMAL EXPECTED baseline
measurement and the ACTUAL
PRESENT vital sign is an indication for
the nurse to PURSUE APPROPRIATE
necessary care and INITIATE nursing
action/therapies.
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VITAL SIGNS
Temperature & Respiration
 Vital
sign changes may reveal sudden
changes as well as progressive changes
 raised temperature may indicate an
infection;
 raised pulse - ?bleeding;
 lowered blood pressure - ?bleeding
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CONSIDERATIONS OF VITAL SIGN
MEASUREMENT
From a nursing viewpoint
 Measurement provides information used to determine a
patient / clients baseline data & response to medical ./
nursing therapy
 Vital sign recording is a quick, efficient way of monitoring
a condition or identifying problems. Can be used as a basis
for clinical problem solving
 Vital sign measurement is incorporated into Practice for
assessment & determining the need for intervention(s),
Viewed as routine care measures
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TEMPERATURE
In health, tissues & cells function best within a
relatively narrow range of temperature controlled by the hypothalamus.
 Body Core temperature is maintained within + or 0.6 of a degree Celsius / centigrade.
 Surface body temperature fluctuates according to
environmental changes.
 Skin temperature can range between 20o - 40oC
without causing tissue damage.

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TEMPERATURE

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Temperature range is balanced & regulated to allow for changes that
result from Exercise, Activity and Rest.
Temperature regulatory mechanisms include: Vasodilatation,
Vasoconstriction, Sweating & avoiding environmental extremes
hot/cold.
For body temperature to stay constant HEAT PRODUCED must equal
HEAT LOST to the environment.
When internal control mechanisms fail the nurse may initiate measures
to
 CONTROL the immediate environments
 REMOVE or ADD coverings
 GIVE MEDICATIONS - antipyretics
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Monitoring temperatures
Types of thermometers
 Glass
with a mercury column;
 Electronic;
 Disposable;
 Tympanic Thermometry.
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Factors influencing /
affecting temperature

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General age; exercise; hormones; stress; environment;
medications; daily fluctuation / time / gender
Specific diagnosed infections; burns / open wounds;
Low white cell count <5,000; High WBC > 12,000;
immunosuppresive drug therapy; post operative state;
hyperthermic therapy; hypothermic therapy;
injury to the hypothalamus; infusion of blood products
Nurses asses for Fever or Hypothermia
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 Show Video on Genius thermometers
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RESPIRATIONS
Human survival depends on the ability for
Oxygen to reach the body cells and Carbon
Dioxide to be removed from the cells.
 Factors
affecting character of respirations Exercise; acute pain; anxiety; smoking;
anaemia; body position; medications; brain
stem injury.
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ASSESSMENT OF RESPIRATIONS
Easiest of all vital signs to measure but most often
haphazardly recorded.
 NEVER estimate a respiratory rate
 Accurate measurement of the chest wall rising and
falling is required.
 Any change may be important
 Respiration is tied to the function of numerous
body systems, therefore the nurse must consider
all variables when change occurs.

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MEASUREMENT
RATE - determined by a full inspiration and
expiration, will vary with age
 DEPTH - assessed by observing the degree of
movement in the chest wall and is usually
considered to be deep, normal or shallow.
 RHYTHM - regular occurrence of respiration will
depict a normal range. During assessment the
nurse estimates the time interval; after each
respiration cycle. Respiration is then either regular
or irregular in rhythm

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ALTERATIONS IN BREATHING
PATTERN

Bradypnoea
rate regular, but abnormally slow < 12
b/min
rate regular, but abnormally fast > 20 b/min

Tachypnoea
Hyperpnoea

Biots resp.
abnormally shallow for 2-3 breaths, followed
by irregular periods of apnoea

laboured respirations, increased depth,
increased
rate > 20 breaths / minute
 Hyperventilation rate & depth increased
 Hypoventilation rate & depth abnormally low
 Cheyne-Stoke
rate & depth irregular, alternating periods
of apnoea and hyperventilation
 Kussmaul resp.
abnormally deep, regular but increased in rate
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WHEN TO RECORD VITAL
SIGNS
On clients admission to a health care facility
 In hospital, on routine or schedule according to
physicians order or hospital policy
 During clients visit to clinic or physicians office
 Before & after any surgical procedure
 Before & after any invasive diagnostic procedure
 Before & after administration of medications that
affect cardiovascular, respiratory & temperature
control function

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WHEN TO RECORD VITAL
SIGNS
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When the clients general physical condition changes e.g. loss of consciousness or increased intensity of pain
Before & after nursing interventions influencing any
one of the vital signs e.g. before ambulating client previously on bed rest or
before client performs range of movement
exercises
Whenever client reports to nurse any non- specific
symptoms of physical distress e.g. "feeling funny or different"
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Patient at risk score.
 PAR
 Research completed in Swansea NHS trust.
 Reduced observation of Respiratory
recording.
 Aim = Early indications of deteriation.
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References:
 Potter,A.
Perry,A. (1997) Fundamentals of
Nursing, Concepts, Process & Practice St
Louis: Mosby Ch 32 p 594
 Taylor,C.
Lillis,C. LeMonde,P. (1997)
Fundamentals of Nursing - The Art &
Science of Nursing Care. Philadelphia:
Lippincott
Ch25 p432
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