What is included in taking Vital Signs?
Temp
Pulse
Respiration
Blood Pressure
How often should vital signs be assessed?
-Upon admission
-Before and After surgical or invasive diagnostic
-Before giving meds that affect cardio or resp function
-anytime there is a change in patients condition
What should you ask a patient before taking their oral temp?
Have they had anything to eat or drink in the past 15-30 mins
Also goes for smoking or chewing gum
What is important to ask a patient before taking their blood pressure?
What is their normal blood pressure?
How do you know how high to pump the gauge when taking a blood pressure?
Ask patient what their normal blood pressure is and pump 30 above that.
What is the primary source of heat loss?
The skin
Which method of taking temp is the most accurate in adults?
Rectal
But it is also the most invasive
medical term for an elevation in body temperature
Pyrexia or hyperthermia
medical term for having a fever
Febrile
Medical term for decreased body temp
Hypothermia
Mechanisms of Heat Loss
1) RADIATION - ex: taking off a hat to cool head or removing a blanket
2) CONDUCTION - ex: ice packs , wash cloths.
3)EVAPORATION - ex: sweating
4)CONVECTION - ex: Air Conditioning or a fan blowing on you
More on 4 mechanisms of heat loss
1. Radiation-transference of heat from the surface of one object to another
WITHOUT contact
. Ex-I'm cold so I will go outside
2. Conduction-transference of heat from one object to another
WITH direct contact
. Ex-ice packs, heating pads, cooling blankets
Where do you insert an oral thermometer for taking temp?
Posterior Sublingual Pocket
When is rectal temp contraindicated?
In newborns, children with diarrhea, rectal disease, or rectal surgery
* not usually used for patients with heart disease/surgery bc bradycardia can be caused by stimulating the Vagus nerve
When is tympanic temp contraindicated?
Not used with patients who have drainage from the ear
*ear wax does not effect temp
What method of taking temp is used with newborns?
Axillary Temp
What should nurse do if vital is abnormal?
Document it and then notify the HCP
Pulses are caused by what?
contractions of the left ventricle of the heart
Amount of blood that enters the arteries with each ventricle contraction is called ____ ____
Stroke Volume
Pulse characteristics for dehydration
Fast yet thready pulse
Pulse characteristics for congestive heart failure.
Fast yet bounding pulse
Pulse over 100 beats/min in adult
Tachycardia
Pulse less than 60 beats/min in adults
Bradycardia
Locations of Peripheral Arterial Pulses
Carotid Artery
Brachial
Radial
Dorsalis Pedis
Normal pulse range for adults
60-100
An irregular rhythm is called ____
Dysrhythmia
What are you checking for when taking Dorsalis Pedis pulses?
Bilateral equality
& circulation to the feet
What can you use if you have trouble palpating a pulse?
A doppler ultrasound
Where is the apical pulse located?
Between the 5th and 6th intercostal spaces and to the left of the midclavicular line
Resp Rate greater than 24 breaths/min
Tachypnea
Resp Rate slower than 10 breaths/min
Bradypnea
Normal Resp Rate range is ____
12-20 breaths a min
Normal inspiration and expiration (or volume) of air exchanged with each breath
Tidal Volume (about 500 ml)
term meaning difficulty with breathing
Dyspnea
BP with systolic 140 mmHg or higher
Hypertension
BP with systolic less than 90 mmHg
Hypotension
Systolic pressure is a result of:
contraction of the ventricles
This is the maximum pressure against arterial walls
Diastolic pressure is a result of:
Ventricles relaxing and refilling with blood
This is the minimal pressure exerted against arterial walls
the difference between the systolic and diastolic pressure
Pulse pressure
Normal blood pressure range is
120 / 80 mm Hg