HA mod2

• Vital signs are physical signs that indicate an individual is alive, such as heart beat, breathing rate, temperature, blood pressures and recently oxygen saturation.
• Vital signs may be observed, measured, and monitored to assess an individual's level of physical functioning.
• Vital signs provide objective data that contributes to all other nursing and medical information.
• Baseline values establish the norm against which subsequent measures are compared.
• Accurate information is essential in obtaining and recording vital signs.
• Normal vital signs change with age, sex, weight, exercise tolerance, and condition.
• Hospital: Every 4 - 8 hours
• Home health: each visit
• Clinic: Each visit
• The Visual Analog Tool is a pain assessment tool.
• The Simple Descriptive Graphic Pain Intensity Scale is a pain assessment tool.
• The Numeric Rating Scale is a pain assessment tool.
• The Verbal Descriptor Scale is a pain assessment tool.
• Collecting the Subjective Nursing History involves understanding the location, quality, pattern, precipitating factors, pain relief, effects of pain on daily activities, and using a pain assessment tool.
• The Numeric Pain Intensity Scale is a pain assessment tool.
• Culture influences the meaning placed on pain and the response to pain that is expected in the culture in which the person is raised.
• The Faces Pain Scales are a type of pain assessment tool.
• Skilled facility: Daily and as needed
• The nurse must be able to do all of the following when obtaining vital signs: measure correctly, understand and interpret the values, communicate findings appropriately, begin interventions as needed, know environmental factors that affect vital signs like exercise, stress, etc, use a systematic, organized approach, verify and communicate changes in vital signs, monitor VS regularly, and the frequency is determined by MD order, nursing judgment, client condition and facility standards.
• Body Temperature reflects the balance between the heat produced and the heat lost from the body, and is measured in heat units called degrees.
• Body Temperature is measured in either Celsius or Fahrenheit, with a fever defined as greater than 38 - 38.5 C or 101 - 101.5 F.
• There are two kinds of Body Temperature: core temperature and surface temperature.
• Core temperature is the temperature of the deep tissues of the body, such as the abdominal cavity and pelvic cavity, and remains relatively constant.
• Surface temperature is the temperature of the skin, the subcutaneous tissue, and fat, and rises and falls in response to the environment.
• The body continually produces heat as a by-product of metabolism.
• Basal Metabolic Rate (BMR) is the rate of energy utilization in the body required to maintain essential activities such as breathing, and metabolic rates decrease with age.
• Respiration rates over 25 or under 12 breaths per minute (when at rest) may be considered abnormal.
• Abdominal breathing is breathing involving chiefly the muscles of the abdomen and diaphragm, while Costal breathing is breathing accomplished chiefly by the rib muscles.
• Systole is the working period of the heart when the heart contracts and pumps blood out into the circulation, while Diastole is the resting period of the heart when the heart is filling with blood, which will be pumped out during the next systole.
• Bradypnea is an abnormal decrease in respiratory rate, while Orthopnea is the inability to breathe when in a horizontal position.
• Chemical receptors detect changes and signal the CNS (medulla), with normal respiratory rate being 12 - 20 breaths per minute.
• Diaphragmatic breathing is breathing accomplished chiefly by the diaphragm.
• Ingestion of food and exercise increases metabolism, increasing the need for oxygen and increasing respiratory rate.
• Stertorous respiration is noisy breathing as in snoring, while Cheyne Stokes respiration is respiration with alternating periods of hyperpnea and apnea.
• Hypoxia is a decrease in oxygen in tissues.
• Hyperventilation is a very deep rapid respiration, while Hypoventilation is shallow and slow respiration.
• Apnea is the temporary cessation of breathing, while Eupnea is normal respiration.
• Dyspnea is difficult respiration, while Polypnea is an abnormal increase in respiratory rate.
• Hyperpnea is an increase in rate and depth of respiration, while Hypoxemia is a decrease in oxygen in the blood.
• Kussmaul’s Respiration is paroxysmal breathing/sudden attack (diabetic coma) characterized by deep labored breathing.