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Vital Signs for Nursing Students

Vital Signs for Nursing Students

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Vital signs Vital signs Presentation Transcript

  • I CAN…….I WILL VITAL SIGNS Presented by Fred Cohen, Nursing Instructor Columbia University School of Nursing Slide 1 Slide 1Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Vital Signs They are called vital signs because they are important. They include:  Temperature  Pulse  Respirations  Blood pressure Vital signs and other physiologic measurements can be part of data base for problem solving. Many facilities have developed a fifth vital sign pain level/comfort level. Slide 2 Slide 2 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Guidelines for Measuring Vita SignsThe nurse must be able to do all of the following: Measure vital signs correctly Ensures that equipment are in proper working condition Control environmental factors affecting vital signs Understand and interpret the values Communicate findings appropriately Begin interventions as needed Slide 3 Slide 3 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Factors Affecting Body TemperatureAgeExerciseHormonal influencesDiurnal Influences (Happening Daily)StressEnvironmentIngestion of hot and cold liquidsSmoking Slide 4 Slide 4 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Temperature Temperature is a relative measure of sensible heat or cold. The body strives to maintain a temperature of 98.6° F (37° C), which is considered normal. Normal range is 97° to 99.6° F (36.1° to 37.5°C). Many factors can cause body temperature variances. Environment, time of day, patient’s state of health, activity levels, and stage of monthly menstrual cycle The hypothalamus helps maintain a balance between heat lost and heat produced by the body. Slide 5 Slide 5 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • TemperatureTwo Types of Body Temperature Core Temperature  Temperature of the deep tissues of the body  Remains relatively constant unless exposed to severe extremes in environmental temperature  Assessed by using a thermometer Surface Temperature  Temperature of the skin  May vary a great deal in response to the environment  Assessed by touching the skin Slide 6 Slide 6 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • TemperatureTemperature measurements are obtained by several methods. Heat-sensitive patches  Patch placed on the skin; color changes on the patch indicate temperature readings Electronic thermometers  Consist of a rechargeable battery-powered display unit, a thin wire cord, and a temperature processing probe Tympanic thermometer  Special form of electronic thermometer; inserted into auditory canal Slide 7 Slide 7 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Tympanic ThermometersAdvantages – may be more accurate than traditional thermometers, easy to use, suitable for all ages.Core temperature readings – shares blood supply with the hypothalamus More accurate readings in patients with rapid changes in temperature. Slide 8 Slide 8 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-2 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Disposable, single-use thermometer strip. Slide 9 Slide 9 Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-3 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Electronic thermometer. Slide 10 10 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-4 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Tympanic thermometer with probe cover inserted into auditory canal. Slide 11 11 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Temperature Pyrexia, Febrile, or Hyperthermia  When the temperature is above normal  Fever is actually a body defense; it will destroy invading bacteria. Classification of Fevers  Constant: remains elevated consistently  Intermittent: rises and falls  Remittent: temperature never returns to normal until the patient becomes well Hypothermia  An abnormally low body temperature Slide 12 12 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Signs and Symptoms of Elevated Body Temperature Thirst Anorexia Flushed, warm skin Irritability Glassy eyes/photophobia (sensitivity to light) Headache Elevated pulse and respiratory rates Restlessness or excessive sleepiness Increased perspiration Disorientation, progressing to convulsions in infants and children Slide 13 13 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Temperature Oral temperature is not obtained in the comatose or disoriented patient or in small infants. Rectal temperatures are contraindicated for patients with recent rectal surgery or certain conditions of the perineum. Axillary temperature is considered the least accurate method. Rectal readings are normally 1° F higher than oral, and axillary readings are 1° F lower than oral. Slide 14 14 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • StethoscopeAn instrument that is placed against the patient’s chest or back to hear heart and lung sounds Slide 15 15 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Auscultating Using theStethoscopeWhen assessing the apical heart rate, the nurse uses a stethoscope.Major Parts of the Stethoscope Earpieces  Should fit snugly and comfortably in the nurse’s ears Binaurals  Should be angled and strong enough that the earpieces remain firmly in the ears without discomfort Slide 16 16 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-6 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Parts of a stethoscope. Slide 17 17 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Auscultating Using theStethoscopeTubing Should be flexible and 12 to 18 inches long Can have single or dual tubesChestpiece Diaphragm: circular, flat-surfaced portion of the chest piece covered with a thin plastic disk Transmits high-pitched sounds created by the high- velocity movement of air and blood Bell: bowl-shaped chest piece, usually surrounded by a rubber ring. Transmits low-pitched sounds created by the low- velocity movement of blood. Slide 18 18 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Pulse Is a rhythmic beating or vibrating movement. The pulse is the regular, recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle of the heart as it contracts.The nurse notes the rate, rhythm, and volume of the pulse.Adult pulse rate is normally between 60 and 100 beats per minute. Slide 19 19 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-7 Pulse sites. Slide 20 20 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Factors Affecting Pulse RatesAgeExerciseFever, heatAcute pain, anxietyUnrelieved severe pain, chronic painMedicationsHemorrhagePostural changesMetabolismPulmonary conditions Slide 21 21 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • PulseTachycardia The pulse is faster than 100 beats per minute. It may result from shock, hemorrhage, exercise, fever, acute pain, and drugs.Bradycardia The pulse is slower than 60 beats per minute. It may result from unrelieved severe pain, drugs, resting, and heart block. Slide 22 22 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • PulseDysrhythmia Any disturbance or abnormality in a normal rhythmic pattern, specifically irregularity in the normal rhythm of the heartAny artery can be assessed for pulse rate, but the radial and carotid arteries are peripheral pulse sites that are easily palpated.The radial and apical locations are the most common sites for pulse rate assessment. Slide 23 23 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • AuscultationListen to sounds within the body to evaluate the condition of the heart, lungs, pleura, intestines or other organsTo listen to fetal heart tones Slide 24 24 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-9 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Point of maximum impulse is at fifth intercostal space. B, Assessing apical pulse. Slide 25 25 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Pulse Pulses on both sides of the peripheral vascular system should be assessed. Pulses are palpated using the pads of the index and middle fingers; only slight pressure is applied over the artery to avoid obliterating the pulse. Apical pulse represents the actual beating of the heart. When auscultated, the “lubb-dubb” heard represents one cardiac cycle, or heartbeat. Pulse deficit: difference between the radial and apical rates; signifies that the pumping action of the heart is faulty. Slide 26 26 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • PulseNursing Interventions for patient with abnormal pulse Assess peripheral pulses Observe s/s of abnormal tissue perfusion Assess for related data Observe other signs and symptom Assess pulse deficit Slide 27 27 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-8 (From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.) Taking an apical/radial pulse. Slide 28 28 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • RespirationsThe taking in of oxygen, its utilization in the tissues, and the giving off of carbon dioxide; the act of breathing. Internal Respirations The exchange of gas at the alveolar level External Respirations Breathing movements that can be observed by the nurse; inspiration and expiration Slide 29 29 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • INSPIRATION AND EXPIRATIONINSPIRATION Inhaling air with oxygen into the lungs EXPIRATION Exhaling air with carbon dioxide out of the lungs Slide 30 30 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Factors Influencing RespirationDisease or illnessStressFeverAgeGenderBody positionMedicationsExerciseAcute PainSmokingBrain Stem Injury Slide 31 31 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Respirations Assessment includes the rate, depth, rhythm, and quality. The normal rate for an adult is between 12 and 20 per minute.  Tachypnea  Rapid respiratory rate; exercise and fever increase respiratory rate  Bradypnea A slow respiratory rate, below 12 per minute The depth of respiration is determined by the amount of air taken in with inhalation. Slide 32 32 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-10 Patterns of respirations. Slide 33 33 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • RespirationsAssessment includes the rate, depth, rhythm, and quality. (continued) The rhythm of respiration should be regular and uninterrupted.Dyspnea Breathing with difficultyApnea A lack of spontaneous respirationsCheyne-Stokes respirations An abnormal pattern of respiration; alternating patterns of apnea and deep, rapid breathing. Slide 34 34 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Blood PressureThe pressure exerted by the circulating volume of blood on the arterial walls, veins, and chambers of the heart. Systolic  The higher number; represents the ventricles contracting Diastolic  The second number; represents the pressure within the artery between beats Pulse Pressure  Difference between the systolic and diastolic Slide 35 35 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Blood Pressure Normal blood pressure in the adult is 120/80 mm Hg. Hypertension  Sustained elevated blood pressure is above 140/90 mm Hg. Hypotension  Blood pressure is below normal. Orthostatic Hypotension  A drop of 25 mm Hg in systolic pressure and a drop of 10 mm Hg in diastolic pressure when moving from lying to sitting or sitting to standing. Slide 36 36 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Factors Influencing Blood PressureAgeAnxiety, fear, pain, emotional stressMedicationsHormonesDiurnal (happening daily)RaceGender Slide 37 37 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Conditions Causing Alterations in Blood PressureHemorrhageIncreased Intracranial PressureAcute painEnd-stage renal diseasePrimary essential hypertensionGeneral anesthesiaExercise postural changeSmoking Slide 38 38 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Blood PressureSphygmomanometer A device for measuring the arterial blood pressure Consists of an inflatable cuff and a gauge The cuff is inflated around the patient’s arm to compress the artery; then it is slowly deflated while the nurse listens at the brachial artery with a stethoscope and hears pulsating sounds.  Korotokoff sounds: The first sound heard is the systolic pressure; the point at which the last sound is heard is the diastolic pressure. Slide 39 39 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-11 (From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants [6th ed.]. St. Louis: Mosby.) Aneroid manometer and cuff. Slide 40 40 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-12 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) Wall-mounted aneroid sphygmomanometer. Slide 41 41 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-17 Electronic sphygmomanometer. Slide 42 42 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-14 (From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) Doppler stethoscope over brachial artery to measure blood pressure. Slide 43 43 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-13 (From Potter, P.A., Perry, A.G. [2005]. Fundamentals of nursing. [6th ed.]. St. Louis: Mosby.) The sounds during blood pressure measurement can be differentiated into five Korotkoff phases. Slide 44 44 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Blood PressureAssessment of Blood Pressure in the Lower Extremities Occasionally, the upper extremities may be inaccessible, so blood pressure must be measured in the lower extremities. The popliteal artery, located behind the knee, is the site for auscultation. The cuff must be wide and long enough to allow for the larger girth of the thigh and is positioned with the bladder over the posterior aspect of the midthigh. Slide 45 45 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-15, A (A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) A, Lower-extremity blood pressure cuff positioned above popliteal artery at midthigh. Slide 46 46 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-15, B (A, From Elkin, M.K., Perry, A.G., Potter, P.A. [2004]. Nursing interventions and clinical skills. [3rd ed.]. St. Louis: Mosby.) B, Location of the popliteal artery and placement of the cuff. Slide 47 47 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Blood pressure readingDo not apply cuff to arm when: Catheter is in an antecubital fossa and fluids are infusing Arteriovenous shunt is in place Breast or axillary surgery has been performed on that side Arm or hand has been traumatized or diseased. A lower arm cast or bulky bandage is in place. Slide 48 48 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Blood PressureAutomatic Measurement Devices Many automatic devices can determine blood pressure automatically. Once the cuff is applied, the nurse can program the device to obtain and record blood pressure readings at preset intervals.Self-Measurement Portable home devices Stationary automated machines Slide 49 49 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Height and WeightHelps assess normal growth and developmentAids in proper drug dosage calculationMay be used to assess the effectiveness of drug therapy, such as diureticsSignificant loss of weight may be a sign of an underlying disease Slide 50 50 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-16 (Photo courtesy Critikon, Inc., Tampa, Fla.) Automatic blood pressure monitor. Slide 51 51 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Height and WeightHeightPatient should remove shoes and stand erect. A measuring stick or tape may be attached vertically to the weight scales or wall. Standing scales may have a metal rod, which is attached to the back of the scale and swings out over the top of the patient’s head. Slide 52 52 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Height and WeightWeight Types of scales  Standing scales  Chair scales; lift scales  Used for patients who cannot stand Patients should be weighed at the same time of day, on the same scale, and in the same type of clothing to allow an objective comparison of subsequent weighing. Patient should void before weighing. Slide 53 53 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Figure 11-18 (From Sorrentino, S.A. [2004]. Mosby’s textbook for nursing assistants. [6th ed.]. St. Louis: Mosby.) Types of scales. A, Standing scale. B, Chair scale. C, Lift scales. Slide 54 54 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • When Vital Signs Are Assessed Temperature, pulse, respirations, and blood pressure are usually assessed at the same time at set intervals. A set of vital signs is taken when the patient is admitted to the facility and then as prescribed by the physician or as policy dictates. Example: every 4 hours; once a shift; weekly Slide 55 55 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • When Vital Signs Are Assessed The more ill the patient, the more frequently vital signs are taken. Vital signs are interrelated. A rise in temperature of 1° F may cause an increase in pulse rate of 4 beats per minute. Respiratory rate and blood pressure readings increase with a rise in temperature. Blood pressure falls because of hemorrhage, the pulse and respirations increase and the temperature usually decreases. Slide 56 56 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Recording Vital SignsGraphic Flow Sheet Used for charting vital signs R indicates a rectal temperature Ax indicates an axillary temperature Blood pressures are always written with the systolic first and the diastolic beneath.  Example: 120/80 Apical pulse is indicated with an “ap” after next to the number.  Example: 78 ap Slide 57 57 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Recording Vital SignsAny abnormal findings are reported to the nurse- manager or physician immediately.Any accompanying or precipitating signs and symptoms such as chest pain, vertigo, shortness of breath, flushing, and diaphoresis should be recorded as well.The nurse documents any interventions initiated as a result of vital sign measurement, such as tepid sponging. Slide 58 58 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Pain as the Fifth Vital SignMonitor pain along with vital signsJCAHO requirements for pain controlAssessing and managing pain is a major nursing responsibilityCollection of subjective and objective data Slide 59 59 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Nursing ProcessAssessment Normal daily fluctuations Factors likely to interfere with accuracy of vital sign reading Medications that may influence vital signs Factors that influence vital signs Conditions that precipitate fever, such as infections Pertinent laboratory values Previous baseline vital signs from patient’s record Slide 60 60 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.
  • Nursing ProcessNursing Process Fluid volume deficient Hyperthermia Hypothermia Body temperature, risk for imbalance Gas exchange, impaired Slide 61 61 Slide Mosby items and derived items © 2006, 2003, 1999, 1995, 1991 by Mosby,© 2005 by Elsevier Inc. Elsevier items and derived items Inc.