Scribd Logo
Upload

Welcome to Scribd!

  • 1 views

    NU 136 Unit 3 Vital Signs - Student

    Uploaded by

    Kayla Weatherred

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd

    NU 136 Unit 3 Vital Signs - Student

    Uploaded by

    Kayla Weatherred
    1 views24 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    PPTX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    1 views24 pages

    NU 136 Unit 3 Vital Signs - Student

    Uploaded by

    Kayla Weatherred

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 24

    GALEN COLLEGE OF

    NURSING
    Fundamentals of Nursing

    Vital Signs
    What are Vital Signs?

    5 vital signs- what are they?


    • Temperature
    • Pulse
    • Respiration
    • Blood Pressure
    • Pain
    • Also, oxygen saturation (O2 sats)

    Give indications as to the health status of the patient

    Accurate measurements are required


    Production of Body Heat

    • Metabolism
    Production
    of Body • Basal metabolic rate (BMR)
    Heat
    Hypothalamus Pyrogens
    Body
    Temperature
    Regulation
    Decrease in Increase in
    body body
    temperature temperature
    Hyperthermia

    Problems of Hypothermia
    Temperature
    Regulation
    Normal range: 97.5-99.5
    • Elderly: 96.5-97.5
    Time of Day

    Environment
    Drugs
    Temperature

    8 Factors
    affecting
    temperature Disease
    Patient’s age
    measurements conditions

    Emotional stress Physical Exercise

    Menstrual cycle
    and pregnancy
    Ways to
    measure body
    temperature
    1. Oral
    2. Rectal
    3. Axillary
    4. Tympanic
    5. Temporal
    Encourage increased intake of fluids unless
    contraindicated

    Lower room temperature


    Nursing
    Interventions Increase rate of circulating air

    to
    Reduce Fever Remove layers of clothing or bedding

    Reduce/control body activity

    Carry out MD orders: tepid bath, cooling blanket,


    antipyretics to lower temp
    Pulse

    Produced by
    Heart rate cardiac
    contractions

    Lub Dub
    • Normal Pulse Rate- 60-100 BPM
    • Normally found by palpation or by auscultation
    • Rate
    • Bradycardia
    • Tachycardia
    • Rhythm
    • Regular
    Pulse • Irregular (arrhythmia)
    • Strength
    • 0-
    • 1+
    • 2+
    • 3+
    Pulse
    points
    Respirations
    Involuntary

    • Decreased O2 levels
    • Increased CO2 levels

    Organs of respiration

    • Nose, pharynx, larynx, trachea,


    bronchi, lungs
    Normal Range: 12-20
    • elderly-: 16-20

    Recorded in breaths per minute


    Measuring
    Respirations • RR

    Counting respirations
    • 30 sec, multiply by 2
    • 1 full minute
    Respiratory Patterns

    Eupnea

    Dyspnea

    Tachypnea

    Bradypnea
    Crackles
    • Abnormal, nonmusical sound heard on auscultation of the
    lungs during inspiration

    Rhonchi
    Respiratory
    • Snoring sound produced when patient unable to cough up
    Patterns: secretions from the trachea or bronchi
    Noisy Stridor
    Respirations • Crowing sound on inspiration caused by obstruction of the
    upper air passages, as occurs in croup or laryngitis

    Wheeze
    • Whistling sound of air forced past a partial obstruction
    Measuring Pulse oximeter
    Oxygen • O2 sat- given in percentage
    Saturation
    of Blood
    Normal range- 92-100%
    Pressure
    exerted on
    arterial walls

    Blood • Exerted on the arterial


    Systolic wall during cardiac
    Pressure pressure contraction

    • Exerted on the arterial


    Diastolic wall between
    pressure contractions
    Stress and
    Age Obesity
    emotions

    Factors that
    time of day Environment Exercise
    Influence
    Blood
    Pressure Right vs. left
    arm
    Vasodilation Vasoconstriction

    Increase /
    decrease in
    blood volume
    Measuring the
    Blood Pressure
    Recorded as systolic/diastolic

    Take a person’s blood pressure in a


    quiet room with a relaxed environment

    Average adult: 120/80 mmHg


    Korotkoff Sounds

    • May be heard related to the effect of the blood pressure cuff


    on the arterial wall
    – Phase I: tapping
    – Auscultatory gap: no sound
    – Phase II: swishing
    – Phase III: knocking
    – Phase IV: muffling
    – Phase V: silence
    Hypertension

    • Pressure consistently above the normal range


    – Systolic pressure above 130 mm Hg
    – Diastolic pressure above 80 mm Hg
    • Can cause permanent damage to organs
    Less than 90/60 mm Hg

    Hypotensio Orthostatic hypotension


    n
    • A drop of 15 to 20 from
    baseline along with symptoms
    faintness, blurred vision,
    and/or dizziness.
    Pain is recognized by
    Pain The Joint Commission Subjective
    as the fifth vital sign

    The Fifth
    Vital Sign Standardized pain
    scale used for 0-10
    assessment
    Lower
    Vital Sign Temperature
    metabolic rate
    Changes
    Occurring
    with Aging Systolic and
    Respiratory
    diastolic blood
    rates
    pressure

    You might also like