Vital signs are vital

Sample lecture notes: Module II – Objectives 1-7

Rationale – signs of life

Guides course of actions Detects changes in health status Accuracy is “vital” Part of nursing assessment Viewed in relation to other data

Documentation and reporting

Responsibility of nurse “Abnormals” MUST be dealt with Methods and formats vary

Computer Written Charts

Temperature

Reflect Infection & inflammation Show balance in thermoregulation

(or imbalance) Measuring

Scale “C” or “F”

Tools for temp measuring

Glass Electronic Tympanic Disposable strips

Routes

Oral Rectal Axillary Core

Pulse

Reflects Heart contractions Defined by rate, rhythm, and strength Normal adult:

<60 = bradycardia >100 = tachycardia

Characteristics

Variable measuring locations Brachial Radial Apical Total nine locations

Pulse specifics

Rate – changes with stress Rhythm – normal is “regular” Quality – strong or weak

Important to note if changed (remember – vital signs are analyzed in

relation with other data)

Respirations

Body must receive oxygen and release carbon dioxide

Primarily an involuntary act Normal is a quiet easy respiration

Tools

Stealth Stethoscope Visual Occasionally tactile Environment

Blood pressure

Relates information about the client’s cardiovascular system Blood volume Peripheral vascular resistance

Tools

Sphygmomanometer Stethoscope Doppler

Guides to measuring

Usually brachial artery Under constant conditions Millimeters of mercury (mmHG) Right size Right place Right use of equipment Right environment

Hints

Palpate first Wait 30 – 60 sec If changing position, wait 2 minutes for

circulation to equalize

The sounds of pressure

Korotkoff sounds (5) Systolic Diastolic Know normals Chart according to policy (2 or 3)

Review

Vital signs are valuable in assessing life Know “normal”

Look for relationships Document findings and report changes Select right tools for accurate collection Delegate with follow-up

Conclusion

Questions ?

Concerns?

Confusion?

THE END