4 vital signs

Body TemperatureOBody temperature = balance between heat produced and heat lost from body.. Body TemperatureO Heat Production O Basal Metabolic Rate BMR O Rate of energy utilization to

Vital Signs

N200/200L

Spring 2012

11/12/16

Guidelines for Measuring

OEnsure equipment is in working order.

OAccurately document findings.

Vital Signs

How often should you assess vital signs?

O Change in client’s health status

O Client reports symptoms (baseline

changes)

O Pre and post procedures

O Pre and post medication administration

that may affect CV system

O Pre and post nursing intervention that

may vital signs

O Routine according to agency

O According to specific orders

Body Temperature

OBody temperature = balance between

heat produced and heat lost from

body Measured in degrees.

OTemperature range:

O 98.6°F to 100.4°F or 36°C to 38°C

OTemperature sites:

O Oral, rectal, axillary, tympanic

membrane, temporal artery, esophageal,

pulmonary artery

O Temperature of skin, subcutaneous tissue

and fat Not as constant as core temperature rises and falls in response to the temperature

Body Temperature Regulation

Neural and vascular

regulation

Body Temperature

O Heat Production

O Basal Metabolic Rate (BMR)

O Rate of energy utilization to maintain

essential physiological activities such as breathing Rates decrease with age.

O Muscle Activity

O Thyroxine output (Thyroid Gland)

O Increases cellular metabolic rates

Chemical thermogenesis

Body Temperature

O Heat Production

O Epinephrine, Norepinephrine, and

sympathic stimulation

O All three increase the rate of

metabolism in many body tissues.

O Fever

O Increases cellular metabolic rate, thus

increasing body temperature (infectious process)

Factors Affecting Body Temperature

Sites for Measuring Body Temperature

Nursing Care for Fever

O Monitor vital signs

O Assess skin color and

blankets when the

client feels warm

O Provide adequate

nutrition and fluid

O Measure intake and output

O Reduce physical

activity

O Administer antipyretic

as ordered

O Provide oral hygiene

O Provide a tepid sponge

bath

O Provide dry clothing

and bed linens

Pulse, Physiology, and Regulation

O An indicator of circulatory status

O Electrical impulses originate from the sinoatrial

(SA) node

O Cardiac output, heart rate, stroke volume

O Mechanical, neural, and chemical factors

regulate ventricular contraction and stroke

volume

O Pulse – wave of blood created by contraction

of the left ventricle of heart

O Peripheral Pulse – pulse located away from the heart, i.e radial.

O Apical Pulse – central pulse, located at the

apex of heart.

O Posterior tibial (usually condition specific)

O Dorsalis pedis (usually condition specific)

Characteristics of the Pulse

11/12/16

SURFACE ANATOMY LANDMARKS & APICAL PULSE SITES

Measuring Apical Pulse

Mechanics of Breathing

O Ratio is 1:2 (inhale:exhale)

O Inhalation

O Diaphragm contract; Ribs move upward and

outward; Sternum moves outward (Active Phase).

O Exhalation

O Diaphragm relaxes; Ribs move downward and

inward; Sternum moves inward (Passive Phase)

Ventilatory Rate, Rhythm,

O Costal (thoracic) Breathing

O Diaphragmatic (abdominal) Breathing

O Diffusion and perfusion

O Arterial oxygen saturation

O Transport and elimination of CO2

O Recognizing Inadequate Breathing

O Labored breathing

O Use of accessory muscles

O Pale or blue skin

O Cool, clammy skin

O Irregular respirations

O Abnormal lung sounds

Pulse Oximetry

O Noninvasive

O Estimates arterial blood

oxygen saturation (SpO2)

Systolic and Diastolic Blood

120/80

O Systolic = 120 and

Diastolic = 80

SystoleDiastole

Arterial Blood Pressure

and Physiology

O Force exerted on walls of an artery

O Systolic and diastolic

Factors Influencing Blood Pressure

Korotkoff’s Sounds

Hypertension and Hypotension

 Decrease of blood flow to vital organs

 Orthostatic/postural

be delegated to UAP

O UAP reports abnormal temperatures

O Nurse interprets abnormal

temperature and determines response