Nursing Fundamentals Vitals & Client

Vital Signs

Vital Signs

Clinical measurements that include B/P, Pulse, Body Temp, Respiration, Oxygen Saturation

Vital signs provide a baseline of data that can be used as a

comparison to future findings

Vital signs identify trends, patterns that can indicate

Possible change in a clients condition

Vital signs can guide

Treatment decisions and nursing interventions

Blood pressure

A measurement of the force, pressure of circulating blood on the interior walls of the blood vessels

Normal B/P Range for adults

120/80

High B/P Range (Stage 1)

130/80 or 139/89

High B/P Range (Stage 2)

140/90

High B/P Range (Stage 3 Medical Emergency)

140/90

Pulse

Rhythmic dilation of the arteries that occurs with the beating of the heart

Average pulse rate for adults

60-100 bpm

Factors that affect heart rate

Fitness level, age, pregnancy, medications, emotions, body positions and air temperatures

Fitness effects on pulse rate

Lower resting H/R indicates better cardiovascular fitness and heart function.

Average H/R or pulse for well-trained athletes

Resting heart rate is 40 BPM

Pregnancy effect on pulse rate

Higher than average H/R

Medication effect on pulse rate

Thyroid medication can increase H/R, beta-blockers can lower it

Emotion effect on pulse rate

Stress, anxiety or happiness can increase H/R

Body positioning and pulse rate

Sitting up can cause your pulse to increase a little

Air temp and pulse

Higher temps & humidity can increase heart rate

Body Temperature

The balance of heat produced by the body and the heat lost to the environment

Normal body temp range

97-99 OR 36.1-37.2

Conduction

Heat is transferred thru physical contact between the body & another object

Convection

Heat is transferred to air or water

Radiation

Heat is transferred thru infrared radiation

Evaporation

Heat is transferred from a liquid state to a gaseous state

Respiratory rate

The number of breaths taken per minute

The body loses heat through

conduction and convection

Normal respiratory rate

12-20 BPM

Infant normal Respiratory rate

30-60 BPM

Elderly normal respiratory rate

Less than 28 BPM

Tachypnea

Respiratory rate is too fast

Bradyonea

Respiratory rate is too slow

Tachypnea can be caused by

Lung disease, hyperventilation

Oxygen saturation

Estimated amount of oxygen bound to the hemoglobin molecule in red blood cells, indicating amount of oxygen being transported to body tissues

Systolic BP

Max amount of pressure exerted when the heart contracts and forces blood into the aorta

Diastolic BP

Min. amount of pressure exerted when the heart is relaxed

Hypertension

BP above the expected reference range

A client should be diagnosed w/ stage 1 hypertension when their systolic pressure is

130-139 mm Hg or 80-89 mm Hg

Interventions for Hypertension

Exercise, stress reduction techniques, low-sodium diet, weight loss

Interventions for Hypotension

Fluid increase, upright posture, medication evaluation, risk of falling, extreme temps, dehydration

Grading pulses

0,+1,+2,+3 and +4

A 0 pulse is

absent/nonpalpable

+1 pulse is

weak/diminished

+2 pulse is

normal

+3 pulse is

increased and strong

+4 pulse is

bounding

Interventions for fever & hyperthermia

Encourage fluids, remove excess clothing, tepid bath, cool environment, antibiotics or antipyretics

Inspiration

intake of air by lungs in order to oxygenate body tissues and support cellular function

Expiration

Expels carbon dioxide from the lungs

Client education

an ongoing, goal-driven, interactive process that provides clients w/ new info

Client education goals

Health promotion, restoration of health and adaption to permanent illness or injury

Health Promotion

Any activity that works to improve a client’s hea

Restoration of health

Any activity that works to improve the health of a client w/ an illness or injury

Adaptation to permanent illness or injury

Assisting a client to adapt their life to accommodate permanent health alterations

Cognitive

Thinking domain-thinking through information and able to comprehend it

Affective

The feeling domain involves the client’s feelings regarding values, attitudes and beliefs

Psychomotor

Doing domain, physical or mental activites required to learn skills

Relevance

The client understanding of why they should be learning the info being provided

Motivation

Client’s ability to engage in the learning process by deciding when, where and how they will learn

Factors in promoting learning

Perceived benefits, enhanced health literacy, ongoing client participation, nonjudgmental support, quiet low stimulus environment, repetition

Factors that hinder learning

Fear, anxiety, depression, lack of motivation, timing

Client health literacy

Client’s ability to obtain, read and understand basic health info.

Health information should be presented at what reading level

6 grade

Feedback

Helpful information provided to the learner to aid in improvement. It shows understanding of the material

Elements of an effective teaching plan

Assessment—Analysis—Planning—Implementation—Evaluation