Nursing Review: Vital Signs

Vital Signs

 Ø  Temperature (NV 36 – 37.5 C)

ü  Elderly people are at risk of hypothermia

ü  Hard work or strenuous exercise can increase body temperature

ü  Oral: most accessible 2-3 mins. * 15 minutes interval after ingestion of hot or cold drinks

ü  Rectal: most accurate 2-3 mins.

ü  Axillary: most safest 6-9 mins.

Ø  Pulse (NV 60-100 bpm)

   ü  Wave of blood created by contraction of the left ventricle of the heart

   ü  Radial: best site for adult

   ü  Brachial: best site for children

   ü  Apical: best site for 3 years old below

Ø  Respiration (NV 12/16-20)

Normal Breath Sound

Vesicular	Soft, low pitch	Lung periphery
Broncho-vesicular	Medium pitch	Larger airway blowing
Bronchial	Loud, high pitch	Trachea

Abnormal Breath Sound

Crackles	Dependent lobes	Random, sudden reinflation of alveoli fluids
Rhonchi	Trachea, bronchi	Fluids, mucus
Wheezes	All lung fields	Severely narrowed bronchus
Pleural Friction Rub	Lateral lung field	Inflamed Pleura

Ø  Blood Pressure (NV 120/80 mm/hg)

  ü  This is the force exerted by the blood against a vessel wall

  ü  The pressure rises with age.

  ü  A rest of 30 minutes is indicated before the blood pressure can be readily assessed 

             after stressful activity.

  ü  Interval of 30 minutes is needed after smoking or drinking caffeine.

  ü  After menopause, women generally have higher blood pressures than before.

  ü  Pressure is usually lowest early in the morning, when the metabolic rate is lowest, 

             then rises throughout the day and peaks in the late afternoon or early evening

Common Errors in Blood Pressure Assessment

Errors	Effect
Bladder cuff too narrow	Erroneously high
Bladder cuff too wide	Erroneously low
Arm unsupported	Erroneously high
Insufficient rest before the assessment	Erroneously high
Repeating assessment too quickly	Erroneously high
Cuff wrapped too loosely or unevenly	Erroneously low
Deflating cuff too quickly	Erroneously low systolic and high diastolic reading
Deflating cuff too slowly	Erroneously high diastolic reading
Failure to use the same arm consistently	Inconsistent measurements
Arm above level of the heart	Erroneously low
Assessing immediately after a meal or while client smokes	Erroneously high
Failure to identify auscultatory gap pressure	Erroneously low systolic pressure and erroneously low diastolic

Nursing Review: Nursing Process

ASSESSMENT PHASE Data Collection Organize Data Validate Data Document Data	Subjective Data  also referred to as symptoms or covert data Objective Data also referred to as signs or overt data, are detectable by an observer Primary source is the client Secondary source is family or anyone else that is not the client Methods of Data Collection Observing To observe is to gather data by using the sense. Interviewing Is a planned communication or a conversation with purpose Examining Is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
DIAGNOSIS PHASE Analyze Data Identify Health Problem Formulate Diagnostic Statements Diagnostic Statements Problem (P): statement of the client’s response. Etiology (E): factors contributing Signs and Symptoms (S): defining characteristics manifested by the client	Types of Nursing Diagnosis Actual diagnosis is a client problem that is present at the time of the nursing assessment. Risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors Wellness diagnosis Possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses .
PLANNING PHASE Prioritize problems Formulate goals Select actions Write nursing orders	Types of Planning Initial planning, admission assessment. Ongoing planning Discharge planning: M edications E xercise T reatment/therapy H ygiene O ut-patient follow up D iet/nutrition S exual activity/spirituality
INTERVENTION / IMPLEMENTATION Determining needs for assistance Putting into action the plan Supervising delegated care Documenting nursing activities	Types of Intervention   Independent   Dependent   Collaborative Cognitive or Intellectual Skills Such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient's needs. Interpersonal Skills Which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient Technical Skills Which includes knowledge and skills needed to properly and safely done the procedure
EVALUATION PHASE	Collecting data related to outcome Comparing data Drawing conclusion Continuing, modifying or  terminating the nursing care plan

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