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Vital Signs and Validation and Documentation of Data Study in the Book - General Survey
4 Major Vital Signs
Body Temperature, Respiratory rate, Pulse Rate, Blood Pressure
Body Temperature
heat produced and Heat lost metabolism
Core Temperature
deep tissues, oral, rectal
Surface Temperature
Skin
Radiation
transfer of heat from the surface of one object to the surface of another without contact
Conduction
transfer of heat from one surface to another, direct transfer by conduct Example: cloth and fever
Convection
dissipation of heat by air currents. Example: exposure of skin towards the electric fan
Evaporation
vaporization of moisture from the skin
Pyrexia
body temperature above normal range
Hyperpyrexia
Very high fever 41degrees C above
Hypothermia
subnormal core body below 36 degree C
Fibril
with fever
Intermittent fever
temperature fluctuates (normal/subnormal)
Remittent Fever
within a wide range over a 24 hrs period remains above normal range (always high/low)
Relapsing
elevated for a few days ( days where in you are sick or not)
Constant/ Continuous
constantly high
Oral
most accessible and convenient, allow 15 mins to elapse. Under the tongue
Rectal
most accurate measurement (core temp). Insert by 0.5 to 1.5 inches. 2-5 mins
Axillary
Safest and non-invasive method
Tympanic
useful for toddlers, core temperature
Forehead
less accurate, use infrared sensor to pick up infrared radiation that the body produce.
Pulse Rate
a wave of blood created by contraction of the left ventricle of the heart
Bradycardia
slow pulse
Tachycardia
fast pulse
Rhythm
pattern interval of beats
Volume (Amplitude)
strength of pulse
Respiration
act of breathing, inhalation, or inspiration, exhalation, expiration
Diffusion
exchange of Gas
Delfusion
flow of blood for transport gases
Ventilation
movement of gases in and out of the lungs
Normal Respiratory Rate Newborn
30-60 bpm
Normal Respiratory Rate Adult
12-20 bpm
Eupnea
normal respiratory rate
Tachypnea
quick respiratory rate
bradypnea
slow respiratory rate
Apnea
cessation
Dyspnea
difficult and labored breathing
Orthopnea
ability to only breathe in a upright position
Blood Pressure
measure of the pressure, every blood flow through the arteries
Systolic
pressure of blood contraction of ventricles
Diastolic
pressure of the ventricles when at rest
Pulse Pressure
difference between the systolic and diastolic pressure
Hypertension
abnormally high blood pressure over 140 mmHg systolic and above 90 mmHg diastolic
Hypotension
Abnormally low below 100/60 mmHg
Orthostatic Hypotension
a drop in systolic pressure
Korotkoff Sound
the sound you hear in taking Blood pressure
Oxygen Saturation
value to the percent of all hemoglobin in blood
Pulse Oximeter
non invasive device
Validation of Data
the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate
Cues
are subjective and objective data that can be directly observed by the nurse.
Inferences
nurses’ interpretation or conclusion based on the cues
Documentation
process of preparing a record reflecting the assessment data and both the client’s health status and response to care.
Health Information Technology
the use of communication and information technology healthcare to improve the effectiveness and efficiency of health services
Health Information Systems
to integrate data collection, processing, reporting, and use of information in public health facilities.
Narrative
requires documentation of all activities surrounding the care provided and the clients response to the procedures
S.O.A.P.
use an interdisciplinary approach, problems are identified and listed. Each member of the team then charts relevant information about each problem.
S.O.A.P.I.E
problems can be quickly identified. The members share in the interventions, implementation, and evaluation of outcomes. Team collaboration.
Focus
identifies the conduct or purpose of the narrative a condition, nursing diagnosis, behavior, signs of symptoms, an acute change.
FDAR
includes all wellness aspects
Note
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