Professional Documents
Culture Documents
Vital Signs
Vital Signs
Vital Signs
Nursing Program
Nancy Pares, RN, MSN
Nurse must
Know environmental factors that affect vital signs
Exercise, stress, etc.
Hospital:
Every 4-8 hours
Home health:
each visit
Clinic:
Each visit
Skilled facility
Daily and as needed
Core temperature
Normal
96.2 degrees F to 100.4 degrees F
36.2 degrees C to 38 degrees C
Surface temperature
Lower than core temperature
Use oral and axillary method
Neural control
Hypothalmus acts as thermostat
Vascular control
Vasoconstriction ---hypothalmus directs the body
to decrease heat loss and increase heat production
If cold, vasoconstriction will conserve heat
shivering will occur
Vasodilation
If body temp is above normal, the hypothalmus will
direct the body to decrease heat production;
Perspiration and increased respiratory rate
Conduction
Transfer of heat from a warm to cool surface by
direct contact
Convection
Transfer of heat through currents of air or water
Radiation
Loss of heat through electromagnetic waves from
surfaces that are warmer than the surrounding air
Evaporation
Water to vapor lost from skin or breathing
Age
Exercise
Hormones
Circadian cycle
Stress
Ingestion of food
smoking
Fever (pyrexia)
Abnormally high body temperature (>100.4 F)
Occurs in response to pyrogens (bacteria)
Pyrogens induce secretion of prostoglandins that
reset the hypothalmic thermostat to a higher
temperature
Hyperpyrexia
Fever > 105.8
Temp increases:
Immune system stimulates hypothalmus to new set
point
Chills, shivers
Feels cold even though temp increasing
When body temp is reset, chills subside
Metabolism increases
O2 consumption increases
HR and RR increase
Energy stores are used
Dehydration and confusion
When cause is removed, set point drops
Vasodilation
Warm flushed skin and diaphoresis
Benefits
Chill stage:
Temp every 1-4 hours
Reduce activity
Warm blankets
Throughout course
Fluids, tepid baths, limit activity, keep dry
Provide oral hygiene
Provide air circulation
Heat stroke
Hypothermia
Below 95 degrees
Uncontrolled shivering, loss of memory,LOC
decreases
Oral
Most accessible and accurate
Do not use if unconscious, confused recent oral or
facial OR
Rectal
99 F
Avoid with MI and after lower GI
Axillary
97 Fleast accurate, most safe
Tympanic
98 Favoid with infection, after exercise, w
hearing aid
Diastole
Resting phase of the heart
Rate
Measured in beats per minute (bpm)
Normal
60-100 bpm
Females slightly higher
Average
70-80 bpm
Dysrhythmia (arrhythmia)
Pulse deficit
Exercise
Body temperature
Anxiety
position
Emotions
Medications
Hemorrhage
Pulmonary
condition
Stroke volume
The quantity of blood pumped out by each
contraction of the left ventricle
Cardiac output
Stroke volume x pulse (heart) rate
Pallor
Paleness of skin when compared with another part
of the body
Cyanosis
Bluish-grayish discoloration of the skin due to
excessive carbon dioxide and deficient oxygen in
the blood
Mechanical
Pulmonary ventilation; breathing
Ventilation:
Active movement of air in and out of the respiratory
system
Conduction
Movement through the airways of the lung
Chemical
Exchange of oxygen and carbon dioxide
Diffusion
Movement of oxygen and CO2 between alveoli and RBC
Perfusion
Distribution of blood through the pulmonary
capillaries
Inspiration
Drawing air into the lung
Involves the ribs, diaphragm
Creates negative pressure-allows air into lung
Expiration
Relaxation of the thoracic muscles and diaphragm
causing air to be expelled
Depth
Normal: diaphragm moves inch
Deep
Shallow
Rhythm
Assessment of the pattern
Abnormal
Cheyne stokes, Kusmaul,
Effort
Work of breathing
Dypsnea: labored breathing
Orthopnea: inability to breath when horizontal
Observe for retractions, nasal flaring and
restlessness
Wheeze
Rhonchi
Crackles
Stridor
Piercing, high pitched sound heard during
inspiration
Stertor
Labored breathing that produces a snoring sound
Hyperventilation
Rapid and deep breathing resulting in loss of CO2
(hypocapnea); light headed and tingly
Hypoventilation
Rate and depth decreased; CO2 is retained
Cheyne Stokes
Irregular, alternating periods of apnea and
hyperventilation
ABG
directly measures the partial pressures of
oxygen, carbon dioxide and blood ph
normal= paCO2 80-100)
Pulse oximetry
non invasive method for monitoring
respiratory status; measures O2 saturation
normal= >95%
Diastolic
Normal = 5000 ml
Volume increases=BP increases
Volume decreases= BP decreases
Viscosity= reaction same as volume
Elasticity
Less elasticity creates greater resistance to blood
flow= > systolic BP
Decreased in smokers and increased cholesterol
Palpation
Used when BP is too weak to hear
Errors
Wrong size cuff, deflating too rapidly, incorrect
placement
Thigh
Measures 30-40 mm HG less than normal
Age
Stress
Gender
race
Circadian
Medications
nutrition
Values
Persistant increase in BP
Damage to vessels; loss of elasticity; decrease in
blood flow to vital organs
Indirect
Direct
Indirect
Equipment
Sphygomanometer and stethescope
Korotkoffs sounds
1st
2nd
3rd
4th
5th
1st
2nd
3rd
4th
5th
Data collection
Location (place and position)
Intensity
1-10
Strength and severity
What is your pain at present? What makes it worse? What is
the best that it gets?
Describe
Aching, stabbing, tender, tiring, numb,..
Duration
When did it start? Is is always there?
Aggrevate/alleviate
What makes it better/worse?
Energy
Appetite
Sleep
Activity
Mood
Relationships
Memory
concentration
VS
Knowledge of pain
Med history
Side effects of meds
Use of non
pharmacological
therapies