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PNL: Week #5; Measurements and Vital Signs
Vital Signs
● Indicate the effectiveness of CS, RS, NS, ES
● VS quick and efficient way of monitoring a pt’s condition, identifying problems, or
evaluating responses to interventions
● *Basis for clinical problem solving
● Careful measurement techniques ensure accurate and consistent findings
● Temperature, Pulse, Reparations - (TPR) 36.5/72/16
● Blood Pressure, +/- pain - (BP) 124/82
● Oxygen Saturation - SpO2 96%
○ Nurse must considers the results of the VS with the knowledge of:
■ The person’s developmental stage - e.g., chronological age
■ Pt’s health status - e.g.Do they have infection?
■ Normal VS range values - e.g., normal HR and Pt’s baseline of HR
■ Pt’s baseline VS
Temperature Range 36 to 38
● Avg. Oral/Tympanic/Temporal 37
● Avg. Rectal 37.5
● Avg. Axillary 36.5
Pulse 60 to 100 beats/minute
Respiration 10 to 20 breaths/minute
Oxygen Saturation 95 to 100%
When to Measure VS:
● Baseline VS
● On admission/home care visit
● Before, during, after procedures/surgery
● BDA, blood product admin
● BDA, medications that affect CV, REsp, Temp control
● Accord to HCF’s policy/NP or MD order
● When patent’s general physical conditions change
● Before and after nursing interventions that may affect VS
● When pt reports nonspecific symptoms of physical distress
● When a pt leave for a day pass and returns
● ANY NURSE CONCERN!!
Guidelines for measuring VS
● Nurse selects appropriate method and location (site) e.g., arm, thigh, etc, and why?
● Select equipment that is functional and appropriate for the size and age of pt - e.g., 6
sizes for sphygmomanometer
, 2
● Explain to pt - e.g., informed consent (implied)
● Be aware of environmental factors
● ORganised, calm, and take time (step-by-step approach) to be accurate *double check
if requires
● Analyse the results: do further action need to be taken? Against normal baseline,
range VS? Need to document it? Need to contact a physician?
Body Temperature
● Diff b/t heat produced by body processes and amount lost to the external environment
● Core temp is slightly higher and more constant than surface temp
○ Rectal (Core)
○ Axilla (Surface)
● Normal adult range 36 to 38
Regulating Body Temp
● Generally receptors are on the skin
● If HOT:
○ Sweating
○ Vasodilation of bv - bld redistributed to surface vessels to promote heat loss
○ Inhibition of heat production
● Heat production:
○ Basal metabolism
○ Muscular activity (shivering)
○ Thyroxine and epinephrine (stimulating effects on metabolic rate)
○ Temp effect on cells
● If COLD:
○ Shivering increase
○ Sweating decreases
○ Vessels vasoconstrict
● Heat loss:
○ Radiation
○ Conduction/convection
○ Evaporation
Factors Affecting Body Temp
● Age
○ Newborns: 30% heat loss through head
○ Childhood: unstable temp regulation till puberty
○ Older Adults: deterioration in control mechanisms, poor vasomotor control,
reduce sweat gland activity, reduce metabolism, reduce amount of adipose
tissue
● Exercise: muscle activity; increase in blood supply and in carb and fat breakdown
● Hormone levels: progesterone levels low = d/c few tenth of degree
PNL: Week #5; Measurements and Vital Signs
Vital Signs
● Indicate the effectiveness of CS, RS, NS, ES
● VS quick and efficient way of monitoring a pt’s condition, identifying problems, or
evaluating responses to interventions
● *Basis for clinical problem solving
● Careful measurement techniques ensure accurate and consistent findings
● Temperature, Pulse, Reparations - (TPR) 36.5/72/16
● Blood Pressure, +/- pain - (BP) 124/82
● Oxygen Saturation - SpO2 96%
○ Nurse must considers the results of the VS with the knowledge of:
■ The person’s developmental stage - e.g., chronological age
■ Pt’s health status - e.g.Do they have infection?
■ Normal VS range values - e.g., normal HR and Pt’s baseline of HR
■ Pt’s baseline VS
Temperature Range 36 to 38
● Avg. Oral/Tympanic/Temporal 37
● Avg. Rectal 37.5
● Avg. Axillary 36.5
Pulse 60 to 100 beats/minute
Respiration 10 to 20 breaths/minute
Oxygen Saturation 95 to 100%
When to Measure VS:
● Baseline VS
● On admission/home care visit
● Before, during, after procedures/surgery
● BDA, blood product admin
● BDA, medications that affect CV, REsp, Temp control
● Accord to HCF’s policy/NP or MD order
● When patent’s general physical conditions change
● Before and after nursing interventions that may affect VS
● When pt reports nonspecific symptoms of physical distress
● When a pt leave for a day pass and returns
● ANY NURSE CONCERN!!
Guidelines for measuring VS
● Nurse selects appropriate method and location (site) e.g., arm, thigh, etc, and why?
● Select equipment that is functional and appropriate for the size and age of pt - e.g., 6
sizes for sphygmomanometer
, 2
● Explain to pt - e.g., informed consent (implied)
● Be aware of environmental factors
● ORganised, calm, and take time (step-by-step approach) to be accurate *double check
if requires
● Analyse the results: do further action need to be taken? Against normal baseline,
range VS? Need to document it? Need to contact a physician?
Body Temperature
● Diff b/t heat produced by body processes and amount lost to the external environment
● Core temp is slightly higher and more constant than surface temp
○ Rectal (Core)
○ Axilla (Surface)
● Normal adult range 36 to 38
Regulating Body Temp
● Generally receptors are on the skin
● If HOT:
○ Sweating
○ Vasodilation of bv - bld redistributed to surface vessels to promote heat loss
○ Inhibition of heat production
● Heat production:
○ Basal metabolism
○ Muscular activity (shivering)
○ Thyroxine and epinephrine (stimulating effects on metabolic rate)
○ Temp effect on cells
● If COLD:
○ Shivering increase
○ Sweating decreases
○ Vessels vasoconstrict
● Heat loss:
○ Radiation
○ Conduction/convection
○ Evaporation
Factors Affecting Body Temp
● Age
○ Newborns: 30% heat loss through head
○ Childhood: unstable temp regulation till puberty
○ Older Adults: deterioration in control mechanisms, poor vasomotor control,
reduce sweat gland activity, reduce metabolism, reduce amount of adipose
tissue
● Exercise: muscle activity; increase in blood supply and in carb and fat breakdown
● Hormone levels: progesterone levels low = d/c few tenth of degree
