Mosby items and derived items © 2005 by Mosby, Inc. Chapter 31 Vital Signs.

Mosby items and derived items © 2005 by Mosby, Inc.

Chapter 31

Vital Signs


Guidelines

• Nurse’s responsibility/delegation

• Equipment

• Knowledge of client’s range

• Knowledge of client’s history and current status

• Environmental factors

• Systematic approach


Guidelines (cont'd)

• Approach with the client

• Frequency of assessment

• Assessment for medications

• Analysis and verification of results

• Communication of results

• Teaching


Temperature

• Body temperature

• Physiology– Regulation: neural and vascular control– Heat production

• Basal metabolic rate

• Shivering

• Nonshivering thermogenesis


Temperature (cont'd)

• Physiology– Heat loss

• Radiation

• Conduction

• Convection

• Evaporation



• Physiology– Skin and temperature regulation

• Behavioral control



• Factors affecting temperature– Age– Exercise– Hormone level– Circadian rhythm– Stress– Environment



• Temperature alterations– Pyrexia (fever)– Hyperthermia

• Heatstroke

• Heat exhaustion– Hypothermia

• Frostbite



• Assessment– Sites– Thermometers



• Nursing diagnoses– Risk for imbalanced body temperature – Hyperthermia– Hypothermia– Ineffective thermoregulation



• Planning– Goals and outcomes– Setting priorities– Continuity of care



• Implementation– Prevention of alterations– Interventions for fever– Interventions for hyperthermia– Interventions for hypothermia



• Evaluation– Changes in body temperature


Pulse

• Physiology and regulation– Stroke volume– Cardiac output– Mechanical, neural, and chemical

factors


Pulse (cont'd)

• Assessment– Sites

• Radial

• Apical

• Other peripheral sites– Use of a stethoscope


Pulse (cont'd)

• Character of the pulse– Rate– Rhythm– Strength– Equality


Pulse (cont'd)

• Nursing diagnoses– Activity intolerance– Decreased cardiac output– Ineffective tissue perfusion


Respiration

• Physiological control– Oxygen– Carbon dioxide

• Mechanics of breathing– Inspiration– Expiration– Tidal volume


Respiration (cont'd)

• Assessment– Rate– Ventilatory depth– Ventilatory rhythm– Arterial oxygen saturation


Respiration (cont'd)

• Nursing diagnoses– Activity intolerance– Ineffective airway clearance– Ineffective breathing pattern– Impaired gas exchange– Ineffective tissue perfusion


Blood Pressure

• Physiology– Cardiac output– Peripheral resistance– Blood volume– Viscosity– Elasticity


Blood Pressure (cont'd)

• Influencing factors – Age– Stress– Ethnicity– Gender– Diurnal variation– Medications– Other



• Alterations– Hypertension– Hypotension

• Orthostatic hypotension



• Measurement– Equipment

• Manual and automatic– Auscultation– Palpation– Sites– Children– Self-measurement



• Nursing diagnoses– Anxiety– Decreased cardiac output– Deficient/Excess fluid volume– Risk for injury– Acute pain– Ineffective tissue perfusion


Additional Nursing Interventions

• Client teaching

• Reporting and recording

Mosby items and derived items © 2005 by Mosby, Inc. Chapter 31 Vital Signs.

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