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Vital Signs ppt notes page
Temperature Alterations
Make sure to review definitions of heatstroke and heat
exhaustion.
Hypothermia
Mild 91.5 to 96.8
Moderate 86.1 91.4
Severe 80.6 86.0
Profound 101.8 degrees. Dehydration andfebrile seizures more
common with infants > 6 mos and < 3 yrs of age. Seizures
rarely occur afterage 5. Important to stress liquids and oral
intake.
Elderly tend to run a lower temp. Important to know what is the
normal temp. Temp of 100.4 may bewithin normal range, but in
elderly may indicate fever.
Cultures may be ordered. Usually give meds after the culture is
drawn.
Pulse
Pulse increase can be affected by blood pressure and temp
also.
Factors affecting pulse: age, autonomic nervous system,
medications.
Assessment of the PulseDiscuss parts of stethoscope. Bell is for
low-pitched sounds. Diaphragm is for high-pitched sounds
.
Rate Tachycardia hr >100bpm Bradycardia - < 60bpm
Rhythm Dysrhythmia irregular, early, late, or missed beat
Pulse deficit pulse wave is not transmitted to extremities.
Requires two nurses, one assessesperipheral pulse while other
assesses apical pulse and then compare rates. The difference
betweenapical and radial rate is the pulse deficit.
Strength normal, weak, thready, bounding
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Equality equal between extremities. Never palpate carotid
bilaterally at the same time.
May use Doppler if unable to palpate pulse.
Physiological Control
High levels of O2 in COPD patients can lead to respiratory
depression
Assessment of Respirations
Rate assess without clients knowledge of action.
Rhythm Men and children tend to be diaphragmatic breathers.
Women tend to use thoracic musclesmore. Labored respirations
require use of accessory muscles. Infants breathing more
irregularly.
Depth deep, normal, or shallow.
Blood Pressure
Adult BP range systolic:
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What is the purpose of taking vital signs
o Allows to establish a database of values, assists in goal
setting, assists in aility to
see how pt is reponding to treatment and progress
What are factors affecting vital signs?
Age, gender. drugs, meds, emotional, status, pain, stress,
infection, time of day, time of monthWhat is thermoregulation
receptors into temp regulatory center (hypothalamus) then if hot
orcold send message to body's vascular, metaolic, muscular, skin
adjustmentsWhat is a vasuclar change in thermoregulation if hot=
red cheeks vasularization if cold= lips
blue Metabolic changes in thermoregulation? more
norephrinephrine to increase metabolismSkeletal muscle
thermoreguation shivering if cold Skin of thermoregulation Sweat
glands andgoosbumps Normal values for temperature? 98.6 +/- 1.8 F
What is pyrogen? A fever What aresites to monitor temperature?
forehead, ears, armpit, rectum, subglinal
