Chapter 26 Vital Signs Copyright 2011 Delmar Cengage

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Chapter 26 Vital Signs Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Chapter 26 Vital Signs Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Vital Signs • • Temperature (T) Pulse (P) Respiratory rate (R) Blood pressure (BP)

Vital Signs • • Temperature (T) Pulse (P) Respiratory rate (R) Blood pressure (BP) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Physiological Function • Thermoregulation – Body’s function of heat regulation – Goal: • Maintain

Physiological Function • Thermoregulation – Body’s function of heat regulation – Goal: • Maintain constant internal body temperature – Heat production – Heat loss – Behavioral control of body temperature (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Physiological Function • Respiration – Act of breathing • • • External respiration Inspiration

Physiological Function • Respiration – Act of breathing • • • External respiration Inspiration Expiration Vital capacity (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Physiological Function • Hemodynamic regulation – Function of blood circulating – Goal: • Maintain

Physiological Function • Hemodynamic regulation – Function of blood circulating – Goal: • Maintain appropriate environment in tissue fluids – Pulse – Blood pressure Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Factors Influencing Vital Signs • • • Age Gender Heredity Race Lifestyle Environment •

Factors Influencing Vital Signs • • • Age Gender Heredity Race Lifestyle Environment • Medications • Pain • Other factors: – – Exercise Anxiety and stress Postural changes Daily variations Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Measuring Vital Signs • Equipment: – Thermometer – Stethoscope – Aneroid manometer (continued) Copyright

Measuring Vital Signs • Equipment: – Thermometer – Stethoscope – Aneroid manometer (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Measuring Vital Signs • Height and weight – Nursing considerations: • Documentation Copyright ©

Measuring Vital Signs • Height and weight – Nursing considerations: • Documentation Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Vital Signs and the Nursing Process • Monitoring vital signs – Critical nursing intervention

Vital Signs and the Nursing Process • Monitoring vital signs – Critical nursing intervention • System of measurements based on nursing vocabularies and taxonomies Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Thermoregulation and the Nursing Process • Assessment – Temperature scales – Sites: • Oral

Thermoregulation and the Nursing Process • Assessment – Temperature scales – Sites: • Oral • Rectal • Axillary (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Thermoregulation and the Nursing Process • Diagnosis – – Risk for imbalanced body temperature

Thermoregulation and the Nursing Process • Diagnosis – – Risk for imbalanced body temperature Hyperthermia Hypothermia Ineffective thermoregulation (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Thermoregulation and the Nursing Process • Planning and outcome identification – Involve client and/or

Thermoregulation and the Nursing Process • Planning and outcome identification – Involve client and/or family – Base on professional standards – Use best practices (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Thermoregulation and the Nursing Process • Implementation – Delegation • Assess and document competency

Thermoregulation and the Nursing Process • Implementation – Delegation • Assess and document competency of individuals performing vital signs – Client teaching – Documentation (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Thermoregulation and the Nursing Process • Evaluation – Determine client’s response – Compare with

Thermoregulation and the Nursing Process • Evaluation – Determine client’s response – Compare with desired outcome – Make necessary revisions Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Pulse • Sites: – – – Temporal Carotid Apical Brachial Radial (continued) Copyright ©

Pulse • Sites: – – – Temporal Carotid Apical Brachial Radial (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Pulse • Sites: – – Ulnar Femoral Posterior tibial Dorsalis pedis (continued) Copyright ©

Pulse • Sites: – – Ulnar Femoral Posterior tibial Dorsalis pedis (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Pulse • Assessing – Indirect measure of cardiac output – Characteristics: • • Quality

Pulse • Assessing – Indirect measure of cardiac output – Characteristics: • • Quality Rate Rhythm Volume (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Pulse • Nursing considerations: – Reporting of new abnormalities – Teaching of self-monitoring of

Pulse • Nursing considerations: – Reporting of new abnormalities – Teaching of self-monitoring of pulse – Documentation Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Respirations • Sites: – Chest wall, thorax – Nose, mouth (continued) Copyright © 2011

Respirations • Sites: – Chest wall, thorax – Nose, mouth (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Respirations • Assessing – Movement of diaphragm – Characteristics of normal and abnormal breath

Respirations • Assessing – Movement of diaphragm – Characteristics of normal and abnormal breath sounds • Eupnea, bradypnea, hypoventilation, tachypnea, and hyperventilation (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Respirations • Nursing considerations: – Skin color – Level of consciousness – Advanced monitoring

Respirations • Nursing considerations: – Skin color – Level of consciousness – Advanced monitoring • Oximeter • Apnea monitor – Documentation Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Blood Pressure • Sites: – Arm over brachial artery – Forearm – Leg sites

Blood Pressure • Sites: – Arm over brachial artery – Forearm – Leg sites (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Blood Pressure • Assessing – Auscultation – Palpation – Hypotension • Orthostatic hypotension –

Blood Pressure • Assessing – Auscultation – Palpation – Hypotension • Orthostatic hypotension – Hypertension (continued) Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.

Blood Pressure • Nursing considerations: – Documentation • • Systolic pressure Diastolic pressure Teaching

Blood Pressure • Nursing considerations: – Documentation • • Systolic pressure Diastolic pressure Teaching Compliance with medications Copyright © 2011 Delmar, Cengage Learning. ALL RIGHTS RESERVED.