Vital Signs Nursing Student Notes PDF

Vital Signs  Vital Signs Temperature Pulse Respiration Blood pressure Pain Oxygen saturation  When to Assess Vital Signs Upon admission to any healthcare agency Based on agency institutional policy and procedures Anytime there is a change in the pa...

Vital Signs  Vital Signs Temperature Pulse Respiration Blood pressure Pain Oxygen saturation  When to Assess Vital Signs Upon admission to any healthcare agency Based on agency institutional policy and procedures Anytime there is a change in the patient’s condition Before and after surgical or invasive diagnostic procedures Emergency situations Before administering medications that affect cardiac rate/rhythm  Terminology Temperature Afebrile Febrile Hyperthermia Hypothermia  Transfer of Body Heat to External Environment Radiation Conduction Range of Human Body Temperature  Equipment for Assessing Temperature Electronic and digital thermometer Tympanic membrane thermometer Disposable single-use thermometer Temporal artery thermometer Automated monitoring devices Different Sites for Body Temperatures  Causes of Hypothermia Exposure to cold environment Immersion in cold water Lack of adequate clothing, shelter, heat Associated with near-drowning episodes Other causes ▪ Ingestion of alcohol, drugs, trauma ▪ Overwhelming sepsis Hypothermia in infants ▪ Limited insulating subcutaneous fat ▪ Loses four times more heat than adult ▪ Poor thermal stability ▪ Radiation and conduction losses  Implementation All clients ▪ Removing from cold, rewarming ▪ Mild hypothermia → warm with blankets ▪ Severe hypothermia → hyperthermia blanket ▪ Warm IV fluids ▪ Dry clothing ▪ Monitor vital signs, urine output ▪ Assess for cold-related injuries Newborns ▪ Head coverings ▪ Swaddling, nesting  Causes of Hyperthermia May occur in response to infection May occur in response to tissue breakdown ▪ Following MI, malignancy, surgery, trauma  Implementation Acetaminophen, ibuprofen ▪ Preferred antipyretics for children Antibiotics ▪ Administered for infectious diseases Decrease morbidity, mortality from infections Resistant strains of bacteria Monitor temperature every 2 hours Promote adequate fluid and nutritional intake Monitor I&O Apply ice bag covered with towel to groin Cover client with only a sheet  Question Tell whether the following statement is true or false. The normal pulse rate for adolescents and adults ranges from 60 to 100 beats/min. A. True B. False  Answer Answer: A. True The normal pulse rate for adolescents and adults ranges from 60 to 100 beats/min.  Question Which one of the following pulse sites is located on the inside of the elbow? A. Temporal B. Radial C. Femoral D. Brachial  Answer Answer: D. Brachial Rationale: The brachial pulse site is located on the inner elbow. The temporal site is located on the side of the head, the radial site is on the wrist, and the femoral site is located on the groin.  Pulse Physiology Regulated by the autonomic nervous system through cardiac sinoatrial node Parasympathetic stimulation—decreases heart rate Sympathetic stimulation—increases heart rate Pulse rate = number of contractions over a peripheral artery in 1 minute Assessed by palpation (feeling) or auscultation (hearing) Middle three fingertips (Pads) are used to palpate pulses using moderate pressure  Pulse Characteristics Rate: ▪ normal (60-100) ▪ tachycardia (>100) ▪ bradycardia ( 20 breaths in adults Bradypnea< 10 breaths in adults Apnea- absence of breathing  Assessing Respirations Inspection Listening with stethoscope Using a pulse oximeter  Physiology of Blood Pressure Force of the blood against arterial walls Controlled by a variety of mechanisms to maintain adequate tissue perfusion Pressure rises as left ventricle contracts (systole) and falls as heart relaxes (diastole) ▪ Highest pressure is systolic ▪ Lowest pressure is diastolic ▪ Difference between the systolic and diastolic pressure is called pulse pressure Factors Affecting Blood Pressure Age, gender, race Circadian rhythm Food intake Exercise Weight Emotional state Body position Drugs/medications Equipment for Assessing Blood Pressure Stethoscope and sphygmomanometer Doppler ultrasound Electronic or automated devices Errors in BP Assessment  Assessing Blood Pressure Listening for Korotkoff sounds with stethoscope ▪ First tapping sound is systolic pressure ▪ Change or cessation of sounds occurs—diastolic pressure The brachial artery and popliteal artery are commonly used  Normal Ranges for Vital Signs for Healthy Adults Oral temperature—37.0°C, 98.6°F Pulse rate—60 to 100 (80 average) Respirations—12 to 20 breaths/min Blood pressure—120/80  NCLEX Question The nurse is giving report to the PCT on the care of four patients. The nurse should inform the PCT to avoid taking a rectal temperature for which client? A. An adult who underwent ileostomy surgery because of a perforated bowel B. An adult who has a productive cough and is receiving oxygen by nasal cannula C. An adult who develops thrombocytopenia after receiving chemotherapy treatments D. An adult who has hypothermia after being outside in a below zero temperature  NCLEX Question The PCT tells the nurse that the unit’s small adult BP cuff cannot be found and that the client’s arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the PCT? A. Document the other vital signs and note that the proper- fitting BP cuff is not available. B. Go to another nursing unit to obtain their small- adult BP cuff and take the client’s BP. C. Use the regular sized BP cuff and add 10 to the diastolic and systolic BP readings. D. If the cuff closes around the arm, take the client’s BP using the regular adult cuff.  NCLEX Question Before ambulating the client for the first time, the nurse obtains the client’s BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm. A. Assess the client for dizziness and feel the temperature of extremities B. Obtain a manual BP cuff and retake the client’s BP C. Elevate the head of the client’s bed and assist the client out of bed D. Review the medical record and determine the client’s normal BP range. Activity: Correlation of Concept Vital Safety Signs