Vital Signs The most frequent measurements obtained by health care professionals are those of temperature, pulse, blood

pressure, respiratory rate and oxygen saturation (494). These measures are refer to as vital signs. They indicate the effectiveness of circulation, respiratory, neural and endocrine body function environmental, physiological and physical factors can alter these measurements outside acceptable norms. vital signs provide data to determine the usual state of health. A change in VS indicates a change in physiological function which may signal the need for nursing and surgical intervention. Measuring VS is a quick and efficient way of monitoring clients condition identifying problems or evaluating the response to evaluation e.g, A clients oxygen saturation might be below expected norm below 96, this will prompt an intervention of oxygen therapy or deep breathing exercise. These interventions should improve the oxygen saturation of the client. To determine this improvement, a reassessment of the oxygen saturation, will indicate the effectiveness of the intervention and prompt further action as needed. VS includes: Temperature: the body temperature is the difference between the amount of heat produced by the body process and the amount of heat loss to the external environment (494) normal temperature ranges are: 36-38 degree Celsius temperature scale

hypothermia normal ranges hyperthermia

lower than 36.5 Celsius 36.5- 37.5 degree Celsius higher than 38 degree Celsius

Nursing care plan Assessment: - palpate the skin to determine if the skin is warm to touch - observe clients behavior when taking a rest - Measure vitals If upon assessing a client and finding out that the patients temperature is above the expected findings, I will: Planning: Client will regain normal range of temperature with the next 2hrs Client will attain a sense of comfort and rest within the nest 3hrs Interventions/ rationale: - meet requirements of increase metabolic rate (oxygen therapy, provide fluids) - remove external coverings of clothes (blankets, sweaters) this will maximize the heat loss through conduction and convection - regulate the room temperature to acceptable norm: this is because increase in temperature could be as a result of elevated room temperatures. if all of these measures does not work, I will inform my buddy nurse of the increase in temperature and I will inform the attending physician of the increase in temperature, my attempts to control it and my rationale of giving appropriate meds or request for a lab work as this could be as a result of an infection. Evaluation: obtain body temperature measurements (continuous monitoring, starting with every 30mins, to every hour to regular vitals signs check). At this point body temperature should be with expected norm and client will be comfortable. Pulse: Pulse: pulse is the bounding blood flow that is palpable at any point on the body (509). The pulse is an indicator of the circulatory system. The number of pulse sensation

happening in one minute is the pulse rate. The volume of blood pump by the heart in one minute is the cardiac output. Expected pulse is 60-100 per minute. When you asses the pulse, you are checking for rhythm, the strength, rate and equality of pulse. Nursing care plan Assessment: Assess radial, posterior tibial, dorsalis pedis and popliteal pluse If upon assessing the client and there are abnormal pulse findings, I will Planning: - Client will regain normal pulse rate in 1hr. Intervention: - Assess for factors that might alter heart rates such as cardiac medications. This is important because it might be necessary to withhold some meds. (Inform my buddy nurse; check the chart to see the instructions on the cardiac medication orders). - assess for factors associated with decrease cardiac output. tachypnea, orthopnea,
dyspnea, frothy sputum, edema, weight gain, decreased urine output, dizziness, restlessness, anxiety, fatigue, weakness, cold clammy skin, decreased peripheral pulses, change in mental status, confusion, angina, etc. this is important because addressing these issues can lead to attaining regular pulse. Evaluations: Continuous assessment of the client to determine if intervention were successful or not. Pulse will return to normal rates at this point. Respiration: Expected rate is 12-20 times a minute.

NCP Assessment: Assess breathing patterns. Is it labored, shallow, fast or slow? if there are noticeable abnormal findings with the respirations of the clients, I will: Planning: client will regain normal respirations in two hours. Intervention: I will access for factors that might alter respiration rates, anxiety, fear,