Vital Signs

Temp
Pulse
Respirations
Blood Pressure
Pulse oximetry
 Quick, efficient
• Monitoring condition
• Identifying problems
• Evaluating response to treatment
 Guidelines
• 96.8—100.4
• 12-16/min
• 120/80mmHg
• Pulse pressure: 30—50mmHg
• BASELINE---REALIZE--INDIVIDUALIZE!
 When to take
• When you think they should be
taken
• Protocol
• MD orders
• Before and after med administration
 Temperature

• Temperature alterations
– Pyrexia (fever)
– Hyperthermia
• Heatstroke
• Heat exhaustion
– Hypothermia
• Frostbite

Mosby items and derived items © 2005 by Mosby, Inc.

 Temperature

• Nursing diagnoses
– Risk for imbalanced body temperature
– Hyperthermia
– Hypothermia
– Ineffective thermoregulation

Mosby items and derived items © 2005 by Mosby, Inc.

 Temperature (cont'd)

• Implementation
– Prevention of alterations
– Interventions for fever
– Interventions for hyperthermia
– Interventions for hypothermia

Mosby items and derived items © 2005 by Mosby, Inc.

 Fever
1. Bacteria or viruses stimulate immune
system
2. Chills, shivers, feeling cold
3. Temp increases
4. Feeling warm and dry
5. Warm, flushed, diaphoretic
6. Temp returns to normal
 Fever
• Up to 102.2 F (39 degrees Celsius) is
beneficial
• WBC
• Suppresses bacterial growth
• Stimulates interferon
• Increased metabolic demands=
pulse, respirations
 Fever
• Energy conservation
• Monitoring
• Fluids
• Oxygen
• Meds
• Environment
• Nursing diagnosis
Pulse (the beat of the heart)

• Character of the pulse

– Rate
– Rhythm
– Strength
– Equality

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 Pulse problems
• If irregular: count apical one minute
• Count apical and radial x 1 minute
• Pulse deficit: >2 difference
• Tachycardia: >100 beats/min
• Bradycardia: <60 beats/min
• Abnormal rhythm: dysrhythmia
 Pulse
• Pulse rate x Stroke volume= cardiac
output
• Cardiac output= tissue
perfusion/oxygenation
• Strength of muscle, volume, ………
• 30 second x 2 count is alright for slow,
rapid, regular pulse rates
 Pulse

• Nursing diagnoses
– Activity intolerance
– Decreased cardiac output
– Ineffective tissue perfusion

Mosby items and derived items © 2005 by Mosby, Inc.

 Respiration

• Physiological control
– Oxygen
– Carbon dioxide
• Mechanics of breathing
– Inspiration
– Expiration
– Tidal volume

Mosby items and derived items © 2005 by Mosby, Inc.

 Respiration
• Ventilation—gases in and out
• Diffusion—Oxygen and carbon dioxide
between alveoli and red blood cells
• Perfusion—red blood cells to and from
pulmonary capillaries
 Resp
• Deep
• Normal
• shallow
• Labored—unlabored
• Rate
• Dyspnea
Cheyne Stokes Breathing
 Respiration (cont'd)

• Nursing diagnoses
– Activity intolerance
– Ineffective airway clearance
– Ineffective breathing pattern
– Impaired gas exchange
– Ineffective tissue perfusion

Mosby items and derived items © 2005 by Mosby, Inc.

 Blood Pressure
• 120—80 is magical number

Depends on:
blood volume; greater heart muscle
contractility; arterial wall resistance; heart
rate
 Blood Pressure

• Physiology
– Cardiac output
– Peripheral resistance
– Blood volume
– Viscosity
– Elasticity

Mosby items and derived items © 2005 by Mosby, Inc.

Blood pressure is
the force exerted on
the blood vessel
walls by the blood
 Systolic
• Ventricles are contracting
• Condition of heart and great arteries
• Max pressure
 Diastolic
• Ventricles are relaxed
• Minimum pressure
• Indicates arteriolar or peripheral vascular
resistance
 Pulse pressure
• Difference between systolic and diastolic
– Normally 30-50 mm/Hg.
 Correct procedure
• Not crossing legs!
• Palpate brachial
• Correct cuff size—look at yours
 Blood Pressure (cont'd)

• Nursing diagnoses
– Anxiety
– Decreased cardiac output
– Deficient/Excess fluid volume
– Risk for injury
– Acute pain
– Ineffective tissue perfusion

Mosby items and derived items © 2005 by Mosby, Inc.

 Pulse oximetry
• P. 519
• > 90% is okay but higher is better!
• Remove nail polish!!
 Last but not least
Potter & Perry

• P. 666 client teaching

• P. 667 Focus on older adults

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