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Chapter 31
Vital Signs
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Guidelines
• Nurse’s responsibility/delegation
• Equipment
• Knowledge of client’s range
• Knowledge of client’s history and current status
• Environmental factors
• Systematic approach
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Guidelines (cont'd)
• Approach with the client
• Frequency of assessment
• Assessment for medications
• Analysis and verification of results
• Communication of results
• Teaching
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Temperature
• Body temperature
• Physiology– Regulation: neural and vascular control– Heat production
• Basal metabolic rate
• Shivering
• Nonshivering thermogenesis
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Temperature (cont'd)
• Physiology– Heat loss
• Radiation
• Conduction
• Convection
• Evaporation
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Temperature (cont'd)
• Physiology– Skin and temperature regulation
• Behavioral control
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Temperature (cont'd)
• Factors affecting temperature– Age– Exercise– Hormone level– Circadian rhythm– Stress– Environment
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Temperature (cont'd)
• Temperature alterations– Pyrexia (fever)– Hyperthermia
• Heatstroke
• Heat exhaustion– Hypothermia
• Frostbite
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Temperature (cont'd)
• Assessment– Sites– Thermometers
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Temperature (cont'd)
• Nursing diagnoses– Risk for imbalanced body temperature – Hyperthermia– Hypothermia– Ineffective thermoregulation
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Temperature (cont'd)
• Planning– Goals and outcomes– Setting priorities– Continuity of care
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Temperature (cont'd)
• Implementation– Prevention of alterations– Interventions for fever– Interventions for hyperthermia– Interventions for hypothermia
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Temperature (cont'd)
• Evaluation– Changes in body temperature
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Pulse
• Physiology and regulation– Stroke volume– Cardiac output– Mechanical, neural, and chemical
factors
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Pulse (cont'd)
• Assessment– Sites
• Radial
• Apical
• Other peripheral sites– Use of a stethoscope
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Pulse (cont'd)
• Character of the pulse– Rate– Rhythm– Strength– Equality
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Pulse (cont'd)
• Nursing diagnoses– Activity intolerance– Decreased cardiac output– Ineffective tissue perfusion
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Respiration
• Physiological control– Oxygen– Carbon dioxide
• Mechanics of breathing– Inspiration– Expiration– Tidal volume
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Respiration (cont'd)
• Assessment– Rate– Ventilatory depth– Ventilatory rhythm– Arterial oxygen saturation
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Respiration (cont'd)
• Nursing diagnoses– Activity intolerance– Ineffective airway clearance– Ineffective breathing pattern– Impaired gas exchange– Ineffective tissue perfusion
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Blood Pressure
• Physiology– Cardiac output– Peripheral resistance– Blood volume– Viscosity– Elasticity
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Blood Pressure (cont'd)
• Influencing factors – Age– Stress– Ethnicity– Gender– Diurnal variation– Medications– Other
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Blood Pressure (cont'd)
• Alterations– Hypertension– Hypotension
• Orthostatic hypotension
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Blood Pressure (cont'd)
• Measurement– Equipment
• Manual and automatic– Auscultation– Palpation– Sites– Children– Self-measurement
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Blood Pressure (cont'd)
• Nursing diagnoses– Anxiety– Decreased cardiac output– Deficient/Excess fluid volume– Risk for injury– Acute pain– Ineffective tissue perfusion
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Additional Nursing Interventions
• Client teaching
• Reporting and recording