Download Vital Signs - Bakersfield College

Vital Signs
Vital Signs
 Baseline data
 Guidelines for taking VS
 When to take VS
Guidelines For Taking VS










Know the patient
Check equipment
Know normal range
Control environment
Have a system
Take as often as necessary
Analyze
Be aware of your communication
Verify
Report!!!
When Do I take VS???






On admission
Routine
Before and after any invasive procedure
When conditions change
Before and after nursing intervention
Any complaints of non specific symptoms
Regulation of Body Temp




Neural control
Heat production
Skin’s role
Heat loss





Radiation
Conduction
Convection
Evaporation
Behavioral control
Factors Affecting Body
Temperature
 Factors affecting body temperature






Age
Exercise
Hormones
Circadian rhythms
Stress
Environment
Temp. Alterations
 Fever
 Causes
 Treatment Issues
 Children
Nursing Process for Fever




Assessment
Nursing Dx
Plan and Implementation
Evaluation
Assessment of Body Temp
 Sites





Mouth
Rectum
Axilla
Tympanic
Forehead
Thermometers




Mercury
Electronic
Disposable
Digital
Pulse
 Indicator of circulatory status
 Assess by palpating or using a
stethoscope
Pulse Assessment




Radial and carotid pulse
Apical Pulse
Use first two fingers
Use stethoscope
Characteristics
 Rate





Newborn 100-180
1 week-3 months 100-220
3 months-2 years 80-150
2 years-10 years 70-100
10 years-adult 55-90
 Regular pulse
 Count for 15 seconds and multiply by 4
 Irregular pulse
 Count for full minute
Factors influencing pulse









Exercise
Fever
Heat
Acute pain
Anxiety
Unrelieved severe and chronic pain
Medication
Hemorrhage
Postural changes
Apical Pulse
 Every heart beat has 2 sounds
 S1 – lubb
 S2 – dubb
 PMI
 Point of maximal impulse
Variations in Heart Rate
 Tachycardia
 Bradycardia
 Always assess apical pulse if you
suspect one of these!!
Rhythm
 Normal
 Dysrhythmia
 Count an irregular pulse for 1 FULL
minute
 Pulse deficit
Strength and Equality




Normal
Bounding
Weak
Should be equal on both sides!!
Respirations
 Generally a passive process
 CO2 is the most important factor
 Chemoreceptors
 Rising CO2 levels
 Mechanics of Breathing
 Inspiration
 Expiration
Assessment






Always at rest
Prior to taking temp in children
Immediately following pulse in adults
Inspect chest
Intercostal spaces
Use of accessory muscles
Rate







Newborn 35-40
2 years 25-32
8 years 20-30
12 years 16-19
Adult 12-20
Tachypnea in adult > 24
Bradypnea in adult < 10
Alterations in Respirations











Hyperventilation
Cheyne Stokes
Apnea
Hypoventilation
Kussmaul
Dyspnea
Sighing
Orthopnea
Stertor
Stidor
Biot’s
Oxygen Saturation
 Pulse oximetry
 Above 90%
 Pay attention to your PATIENT not just
the monitor!!!