NSG 3100 Exam 2 Galen

Purpose of vital signs Vital signs are a basic but very important component of physiologic assessment of the patient . They are used to monitor the functioning of body systems. Assessment of vital signs allows the nurse to detect changes in the health status of the patient, identify early warning signs of life - threatening health conditions , evaluate the effectiveness of interventions. Alterations in vital signs Sudden alterations in vital signs or values outside the normal range are indicators of a priority situation for the nurse. Further assessments and emergency measures should be initiated as indicated by the patient's status. The primary care provider is notified of alterations in vital signs. Situations that require vital sign assessment On the admission: To baseline As part of physical assessment During inpatient stay as monitoring Any change in health status Before and after sx or invasive procedures to establish baseline and monitoring effects Before and after admission of medication or interventions that could change health status in respiratory, cardiac, or thermal regulations systems To detect improvement in patient condition Before discharge or transfer to another unit delegating tasks UAP May take vital signs as long as the nurse initially assess the patient to determine they are medically stable. UAP may measure, record, and report V/S RN must initially assess patient RN must interpret V/S RN must ensures that the UAP knows the proper technique and knows what V/S to report immediately RN must report abnormal V/S to physician RN must double check vital signs to verify abnormal data. Types of Vital Signs temperature, pulse, respiration, blood pressure and pain. Temperature (T) The measurable heat of the human body Pulse (P) the detectable rhythmic expansion of an artery that occurs with the pumping action of the beating heart. Pulse rate is the number of heartbeats per minute Respiration (R) Breaths per minute, one respiration = inhalation AND expiration Blood pressure (BP) The measurable pressure of blood in the systemic arteries. Pain Subjective Scale of 0-10 (What patient says it is) Normal Temperature rate for adults ages 18-65 97.6 - 99.5 A person who maintains a normal body temperature is: Afebrile Factors Affecting Temperature Age, Hormone, Exercise, Stress, circadian Rhythms, Environment and Smoking. Temperature Regulation When the body becomes too cold it is called Hypothermia: Shivering increases heat production, sweating is inhibited to decrease heat loss, Vasoconstriction decreases heat loss. What is Hyperthermia? Elevated body temperature Nursing Interventions for Hyperthermia 1st assess and determine cause Remove excess blankets Adequate nutrition and fluids to meet increase metabolic demand Reduce physical activity to limit heat production Administer antipyretics Provide oral hygiene to keep mucous membranes moist. Provide cool sponge baths, cooling blankets, or packs.