Foundations of Nursing 6th ed. (Exam 7) Ch.4 -
Vital Signs
Guidelines for obtaining/measuring vital signs
-measure vital signs correctly
-understand and interpret the values
-Communicated findings appropriately
-begin interventions as needed
BOX 4-1, p.59
-nurse who cares for the patient is ideally the one to assess vital signs
-make sure equipment is in proper working condition
-use standard precautions & make sure equipment is clean
-beware of patient's normal range of vital signs
-know patient's medical history, therapies & medications prescribed
-keep environmental factors that have potential to affect vital signs to minimum
-approach the patient in calm, caring manner while demonstrating proficiency in handling supplies
-use organized, systemic approach
-nurse & physician decide the frequency of vital sign measurement
-evaluate the results of vital sign measurement
-verify & communicate significant changes in vital sign
-nurse or health care personnel measure vital signs before primary provider examine the patient
,-report abnormalities in vital signs to the physician
Indication of basic body function
-Temperature
-Pulse
-Respirations
-Blood Pressure
-Pain
FLACC scale
used for infants
-face
-legs
-activity
-crying
-consolability
Wong-baker scale
Used for children Pain rating scale. Face scale
,Factors affecting body temperature
Normal range: 97F - 99.6F
-Age (state of health, varies among neonate, infancy, puberty, and older adults)
-Exercise (activity level)
-Hormonal influences (hormonal changes during ovulation, menstrual cycle & menopause cause body
temperature fluctuations)
-Diurnal influences (change throughout the day, lowest between 1am-4am, peaks around 4pm-6pm)
-Stress: physical/emotional (raises body temperature)
-Environment (can raise/lower body temp, the changes depend on the extent of exposure, air humidity,
and the presence of convection currents)
-Ingestion of hot/cold liquids (cause variations in oral temperature readings)
-Smoking cigarettes/cigar (alters body temperature measurement)
(BOX 4-4, p.62)
Temperature extremes
Can't go below 93.2 or above 105
, Core temperature
Temperature of the deep tissue of the body; it remains relative constant unless a person is expose to
severe extremes in environmental temperature
Surface Temperature
Temperature of the skin; it often varies in response to the environment
How to record vital signs?
Location of temperature reading (must be documented with each temperature reading!)
-Oral = O with a circle around it (98.6F)
-Tympanic = T with a circle around it (98.6F)
-Axillary = A or Ax with a circle around it (97.6F)
-Rectal = R with a circle around it (99.5F)
BP reading
-final /O may be added (120/80/0) if the beat is clearly heart until the end
-ap = apical pulse
Report
-report any abnormal findings to the nurse manager or physician
-record the nurses' notes for any accompanying or precipitating signs & symptoms
-document any interventions initiated
Vital Signs
Guidelines for obtaining/measuring vital signs
-measure vital signs correctly
-understand and interpret the values
-Communicated findings appropriately
-begin interventions as needed
BOX 4-1, p.59
-nurse who cares for the patient is ideally the one to assess vital signs
-make sure equipment is in proper working condition
-use standard precautions & make sure equipment is clean
-beware of patient's normal range of vital signs
-know patient's medical history, therapies & medications prescribed
-keep environmental factors that have potential to affect vital signs to minimum
-approach the patient in calm, caring manner while demonstrating proficiency in handling supplies
-use organized, systemic approach
-nurse & physician decide the frequency of vital sign measurement
-evaluate the results of vital sign measurement
-verify & communicate significant changes in vital sign
-nurse or health care personnel measure vital signs before primary provider examine the patient
,-report abnormalities in vital signs to the physician
Indication of basic body function
-Temperature
-Pulse
-Respirations
-Blood Pressure
-Pain
FLACC scale
used for infants
-face
-legs
-activity
-crying
-consolability
Wong-baker scale
Used for children Pain rating scale. Face scale
,Factors affecting body temperature
Normal range: 97F - 99.6F
-Age (state of health, varies among neonate, infancy, puberty, and older adults)
-Exercise (activity level)
-Hormonal influences (hormonal changes during ovulation, menstrual cycle & menopause cause body
temperature fluctuations)
-Diurnal influences (change throughout the day, lowest between 1am-4am, peaks around 4pm-6pm)
-Stress: physical/emotional (raises body temperature)
-Environment (can raise/lower body temp, the changes depend on the extent of exposure, air humidity,
and the presence of convection currents)
-Ingestion of hot/cold liquids (cause variations in oral temperature readings)
-Smoking cigarettes/cigar (alters body temperature measurement)
(BOX 4-4, p.62)
Temperature extremes
Can't go below 93.2 or above 105
, Core temperature
Temperature of the deep tissue of the body; it remains relative constant unless a person is expose to
severe extremes in environmental temperature
Surface Temperature
Temperature of the skin; it often varies in response to the environment
How to record vital signs?
Location of temperature reading (must be documented with each temperature reading!)
-Oral = O with a circle around it (98.6F)
-Tympanic = T with a circle around it (98.6F)
-Axillary = A or Ax with a circle around it (97.6F)
-Rectal = R with a circle around it (99.5F)
BP reading
-final /O may be added (120/80/0) if the beat is clearly heart until the end
-ap = apical pulse
Report
-report any abnormal findings to the nurse manager or physician
-record the nurses' notes for any accompanying or precipitating signs & symptoms
-document any interventions initiated
