Vital Signs

Created by

Jan Rochelle

Cards (66)

Vital signs 
Reflect the body's physiological status and ability to regulate temperature, maintain local and systematic blood flow and oxygenated tissues
Changes in vital signs can indicate sudden or gradual changes in clients' status. Significant changes should be reported immediately to the charge nurse and physician.
When to take vital signs
On the client's admission to hospital or extended care facility
In a hospital on a routine frequency according to a physician order
During a client visit to a clinic or to a physician's office
Before and after surgical procedure
Before and after any invasive diagnostic procedure
Before and after administration of medication that affects cardiovascular and respiratory functions
Whenever the client's general physical condition suddenly worsens
Before nursing interventions that may influence any one of the vital signs (ambulating after a week of bed rest)
Whenever the client reports to the nurse any none specific symptoms of physical distress
Whenever client's presents symptoms of confusion and disorientation
The 4 cardinal signs of vital signs
Body Temperature
Pulse Rate
Respiratory rate
Blood Pressure
Body temperature 
Maintained through a balance between heat production and heat loss, affected largely by the central nervous system control by Centre located in the hypothalamus (Located below the thalamus of the midbrain nearest to the pituitary gland)
Purposes of the body temperature
To obtain baseline data on admission to the hospital
To guard against hyperthermia or hypothermia
To monitor the client's response to procedure or therapy
To detect and follow the cause of febrile illness
Factors affecting heat production in the body
Basal Metabolic Rate
Muscular Activities
Thyroxin
Epinephrine, nor epinephrine and Sympathetic Activity
Body Temperature
Physical processes of heat loss
Radiation
Evaporation
Convection
Conduction
Factors affecting temperature maintenance and regulation
Environmental Temperature
Diurnal Variations
Exercise
Specific Dynamics action of blood
Hormonal activity
Age
Stress
Food, fluid and smoking
Fahrenheit Scale (oF) 
Water freezes at 32oF and boils at 212 oF
Celsius Scale or Centigrade (oC) 
Water freezes at 0oC and boils at 100 oC
Common sites for body temperature
Mouth (oral)
Rectum (rectal or anal)
Axilla (armpit)
Ear
Types of thermometer 
Mercury fluids
Electronic
Disposable Chemical
Parts of the thermometer
Bulb or mercury bulb
Stem of the body
Mercury
Pyrexia 
In lay term "FEVER" an elevated body temperature results higher than the normal value of 39.5 oC
Hypothermia 
An abnormally low body temperature. Body temperature falls below 34.5 oC and could lead to death
Hyperthermia 
An abnormally high body temperature. A very high fever about 41 oC
Pulse 
The ventricular contraction approximately 60-100 ml of blood enters the aorta, distending the aortic walls and creating the pulse wave
Purposes of pulse assessment
To obtain a baseline measure of the client's heart rate and rhythm
To monitor changes in the client's cardiovascular status
To monitor the hearts response to a disease, procedure or therapy
To assess blood flow to a specific body part
Pulse sites 
Apical - apex of the heart (central pulse)
Temporal pulse – temporal bone (superior and lateral to the eye)
Carotid Pulse – side of the neck, below the lobe of the ear
Radial pulse – palpated at the thumb side of the inner aspect of the wrist
Brachial pulse – antecubital space (medially)
Femoral Pulse – palpated between the anterior iliac spines
Popliteal Pulse - palpated in the popliteal Forsa (knee crease)
Dorsalis Pedis – palpated along the top of the foot pedal
Posterior Tibialis – palpated on the inner side of each ankle
Terms related to pulse
Tachycardia – increase beats about 100
Bradycardia – beats lower than 60
Bounding pulse – a pulse that reaches higher level than normal then disappears quickly
Feeble, weak, thread pulse – terms use for a pulse whose volume is small and can be readily literated. Very weak but rapid
Running pulse – a pulse rate that is too fast to counted sometimes difficult to count
Respiration 
Act of breathing which include the intake of oxygen and output of carbon dioxide. Process of oxygen intake and carbon dioxide output by the lungs
Purposes of respiration assessment
To obtain baseline data on respiratory rate and characteristics
To monitor effect by pathogenic condition such as infection on the client respiration
To monitor the client's response to a specific therapy
Interrelated processes of respiration
Ventilation – the movement of air into and out of the lungs
Conduction – the movement of air through lung airways
Diffusion – the movement of oxygen and carbon dioxide between the alveoli and red blood cells
Perfusion – the distribution of blood flow through pulmonary capillaries
Terms related to respiration
Eupnea – normal breathing. Inspiration is 1.5 sec. expiration 2-3 secs
Apnea - absence of breathing
Bradypnea – decrease of respiratory rate
Dyspnea – difficulty and painful breathing
Tachypnea – fast shallow breathing there is an increase of respiratory rate
Kussmaul respiration – air hunger. A rapid or intense respiration
Orthopnea – breathing easier when person sit or stand
Biot's respiration – irregular in rate and depth without emerging patterns
Hyperventilation – refers to very deep, rapid respiration
Hypoventillation – refers to very shallow respiration
Blood pressure 
Force exerted by the blood against the arterial walls. Consists of systolic and diastolic pressure. Systolic is the pressure of the blood as a result of the contraction of ventricles. Diastolic is the pressure when the ventricles are at rest
Purposes of blood pressure assessment
To obtain baseline blood pressure measurements
To assess the client's cardiovascular status
To assess the client's response to blood or fluid volume loss after surgery, childbirth, trauma or burns
To evaluate the client's response to charges in his condition after treatment with fluids, Medication, or other therapies
Korotkoff's sounds 
The sound than can hear. Gradually lowered. When taking a blood pressure using a stethoscope, the nurse identifies five phases in the series of sounds called KOROTKOFF
Parts of the stethoscope
Diaphragm
Ear piece
Tube or Stem
Types of sphygmomanometer 
Aneroid
Mercury
Parts of sphygmomanometer 
Cuff
Scale/mercury scale/ manometer
Pump/bulb
Regulator/Valve
Hypertension 
Abnormally high BP over 140 mmHg systolic and 90 mmHg diastolic confirmed by minimum of 2 consecutive visits
Hypotension 
Abnormally low BP with systolic below 100 mmHg
Vital signs 
Reflect the body's physiological status and ability to regulate temperature, maintain local and systematic blood flow and oxygenated tissues
Changes in vital signs can indicate sudden or gradual changes in clients' status. Significant changes should be reported immediately to the charge nurse and physician.
When to take vital signs
On the client's admission to hospital or extended care facility
In a hospital on a routine frequency according to a physician order
During a client visit to a clinic or to a physician's office
Before and after surgical procedure
Before and after any invasive diagnostic procedure
Before and after administration of medication that affects cardiovascular and respiratory functions
Whenever the client's general physical condition suddenly worsens
Before nursing interventions that may influence any one of the vital signs (ambulating after a week of bed rest)
Whenever the client reports to the nurse any none specific symptoms of physical distress
Whenever client's presents symptoms of confusion and disorientation
The 4 cardinal signs of vital signs
Body Temperature
Pulse Rate
Respiratory rate
Blood Pressure
Body temperature 
Maintained through a balance between heat production and heat loss, affected largely by the central nervous system control by Centre located in the hypothalamus (Located below the thalamus of the midbrain nearest to the pituitary gland)
Purposes of the body temperature
To obtain baseline data on admission to the hospital
To guard against hyperthermia or hypothermia
To monitor the client's response to procedure or therapy
To detect and follow the cause of febrile illness
Factors affecting heat production in the body
Basal Metabolic Rate
Muscular Activities
Thyroxin
Epinephrine, nor epinephrine and Sympathetic Activity
Body Temperature