General Status and Vital Signs

What are the steps of the overall framework of care?

1. introduce yourself as you walk into the room
2. tell the patient why you are in the room
3. ask them how they are doing and listen intently
4. what is their chief complaint? assess pain
5. take vital signs
6. physical assessment
7. Exit the room after giving the patient a summary, telling when you will be back, giving call bed, bed in low position

factors to observe of general status

physical development, body build, nutritional status, apparent age (compared to stated), skin condition, color, dress, hygiene, posture, level of consciousness, behaviors, body movement, affect (emotion), speech

when do you take vitals?

1. on admission
2. as ordered from provider
3. change in patient status
4. LOC change or unresponsive
5. before, during, and after a procedure
6. before certain medications
7. when you think something is wrong
8. before calling a provider

what does delegation of vital signs look like?

RN can delegate to LNA, CNA, LPN, or MA but the RN remains responsible, must interpret the data, and reports directly to the provider

What affects patient temperature?

metabolism, hormones, exercise, and shivering

afebrile or normothermic definition

no fever, core temperature is 36-38 C

febrile or hyperthermia definition

temperature is higher than 38-38.3 C

hypothermia definition

temperature is lower the 36 C

When measuring heart rate, what 3 factors are you assessing?

Speed, rhythm, and amplitude

assessing heart rate

normal = 60-100 bpm

bradycardia = <60 bpm

tachycardia = >60 bpm

Assessing heart rhythm

does it follow a pattern? regular or irregular

assessing amplitude of heart

0 = absent

\+1 = weak or diminished

\+2 = normal

\+3 = increased or strong

\+4 = full and bounding

what is blood pressure

the amount of pressure in the arteries when the ventricles of the heart contract and relax

what factors can affect blood pressure?

cardiac output, peripheral vascular resistance, arterial elasticity or hardness, blood volume, blood viscosity

important factors of patient history for BP

* any BP medication or allergies
* family history BP
* smoking
* exercise
* diet
* ethnicity

what is respiratory rate?

how many full respiratory cycles (inhale/exhale) there are in one minute

When measuring respirations, what are 3 factors you’re assessing?

rate, depth, and rhythm

rhythm of respirations

do they follow a pattern? if its irregular, monitor it over a full minute

depth of respirations

are their breaths shallow or deep? Are they equal on both sides

what is SPO2?

pulse oxygen saturation; its an indirect measurement of arterial blood oxygenation

what factors affect SPO2 level?

hemoglobin level, cool extremities, and poor circulation