Chapter 32

Vital Signs
NRS 102

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 General Survey
 Physical appearance
 Age
 Sex
 Level of consciousness
 Skin color
 Facial features

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 General Survey
 Body structure
 Stature
 Nutrition
 Symmetry
 Posture
 Position
 Body build, contour
 Mobility
 Gait
 Range of motion
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 General Survey
 Behavior
 Facial expression
 Mood and affect
 Speech
 Dress
 Personal hygiene

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 Guidelines for Measuring
Vital Signs
 Establish a baseline for future
assessments.
 Be able to understand and interpret
values.
 Appropriately delegate measurement.
 Communicate findings.
 Ensure equipment is in working order.
 Accurately document findings.

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 Body Temperature
Physiology
 Body temperature:
 Heat produced
 Heat lost
 Temperature range:
 98.6° F to 100.4° F or 36° C to 38° C
 Temperature sites:
 Oral, rectal, axillary, tympanic membrane,
temporal artery, esophageal, pulmonary artery

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Body Temperature Regulation
Neural and vascular Heat production
control

Heat loss Skin temperature

regulation

Behavioral control Thermoregulation

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 Factors Affecting Body
Temperature
Age Exercise

Hormonal level Circadian rhythm

Environment Temperature alterations

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 Abnormal Body Temp
Hypothermia
 Heat loss during prolonged exposure to cold
 Classified by core temp (mild-severe)
 May be intentional (surgery)
 Early signs- uncontrolled shivering, loss of
memory, poor judgment
 Later signs- Cyanosis, decreased VS, cardiac
dysrhythmias, loss of consciousness
 Frostbite- body exposure to subnormal temps

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 Abnormal Body Temp
Hyperthermia
 Elevated body temp related to body’s inability
to promote heat loss or reduce heat
production
 Heatstroke- prolonged exposure to sun or
high environmental temp. Heat depresses
hypothalamus function
 Heat Exhaustion- profuse diaphoresis result
in fluid & electrolyte loss

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 Nursing Process
and Temperature
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation

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Pulse, Physiology, and Regulation

 The indicator of circulatory status

 Electrical impulses originate from the
sinoatrial (SA) node.
 Cardiac output, heart rate, stroke volume
 Mechanical, neural, and chemical factors
regulate ventricular contraction and stroke
volume.

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 Assessment of Pulse
 Sites
 Use of stethoscope
 Character of pulse
 Nursing process and pulse determination

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 Knowledge check!
Which patient would be most likely to present
with a pulse rate that is lower than normal?
A. A 70-year-old telephone salesman
presenting with dehydration.
B. A 20-year-old runner who had surgery 4
days ago for a fractured leg.
C. A 67-year-old who presented with an
exacerbation of his COPD

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 Respiration
 Ventilation
 Diffusion
 Perfusion
 Physiological control
 Mechanics of breathing

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 Assessment of Ventilation
 Easy to assess
 Respiratory rate
 Ventilatory depth
 Ventilatory rhythm
 Diffusion and perfusion
 Arterial oxygen saturation

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 Assessing Respirations
 Assessing rate- observe full inspiration &
expiration
 Assess for full minute
 Normal adult 12 –20 breaths/minute
 Varies with age, rate declines throughout life
 Apnea Monitor

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Normal & Abnormal Respirations
 Eupnea- normal respirations
 Bradypnea- abnormally slow < 12
 Tachypnea- abnormally fast >20
 Hyperpnea- labored, after exercise
 Hyperventilation/Hypoventilation
 Cheyne-Stokes

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 Nursing Process and Respiratory
Vital Signs
 Measurements include:
 Respiratory rate, pattern, depth, SpO2,
ventilation, diffusion, perfusion
 Nursing diagnosis
 Interventions
 Planning
 Evaluation

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 Arterial Blood Pressure
and Physiology
 Force exerted on walls of an artery
 Systolic and diastolic
 Cardiac output
 Peripheral resistance
 Blood volume
 Viscosity
 Elasticity

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Factors Influencing Blood Pressure
 Age
 Stress
 Ethnicity
 Gender
 Daily Variation
 Medications
 Activity, weight
 Smoking

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Hypertension and Hypotension
 Hypertension  Hypotension
 More common than  90 mm Hg
hypotension  Dilation of arteries
 Thickening of walls  Loss of blood volume
 Loss of elasticity  Decrease of blood flow
 Family history to vital organs
 Risk factors  Orthostatic/postural

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Factors controlling Blood
Pressure

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Measurement of Blood Pressure

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 Vital Signs

 Blood pressure
 Systolic pressure
 Diastolic pressure
 Pulse pressure
 Mean arterial pressure

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Slide 9-29
 Measurement of Blood Pressure

 Equipment
 Auscultation
 Children
 Ultrasonic stethoscope
 Palpation
 Lower extremity
 Electronic blood pressure

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 Nursing Process and Blood
Pressure Determination
 Assessment of blood pressure and pulse
evaluates the general state of
cardiovascular health.
 Hypertension, hypotension, orthostatic
hypotension, or narrow/wide pulse
pressures define nursing diagnoses.

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 Knowledge check!
Significant elevation in blood pressure
measurements from one day to the next
could be attributed to:
A. A decrease in cuff size
B. An increase in cuff size
C. New onset of pain or anxiety
D. A and C

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Measurement of Arterial Oxygen
Saturation
 Pulse oximeter
 Allows indirect measurement of oxygen
saturation
 SpO2 is a reliable estimate of SaO2
 Measurement is affected if extremity is cold,
edematous or if nail polish is present
(interference with light transmission)

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Slide 9-35
Health Promotion and Vital Signs

 Monitor vital signs.

 Include age-related factors.
 Include environmental and activity factors.

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