Vital Signs
NRS 102
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General Survey
Physical appearance
Age
Sex
Level of consciousness
Skin color
Facial features
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General Survey
Body structure
Stature
Nutrition
Symmetry
Posture
Position
Body build, contour
Mobility
Gait
Range of motion
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General Survey
Behavior
Facial expression
Mood and affect
Speech
Dress
Personal hygiene
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Body Temperature
Physiology
Body temperature:
Temperature range:
Heat produced
Heat lost
98.6 F to 100.4 F or 36 C to 38 C
Temperature sites:
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Heat production
Heat loss
Skin temperature
regulation
Behavioral control
Thermoregulation
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Exercise
Hormonal level
Circadian rhythm
Environment
Temperature alterations
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Nursing Process
and Temperature
Assessment
Diagnosis
Planning
Implementation
Evaluation
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Assessment of Pulse
Sites
Use of stethoscope
Character of pulse
Nursing process and pulse determination
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Knowledge check!
Which patient would be most likely to present
with a pulse rate that is lower than normal?
A. A 70-year-old telephone salesman presenting
with dehydration.
B. A 20-year-old runner who had surgery 4 days
ago for a fractured leg.
C. A 67-year-old who presented with an
exacerbation of his COPD
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Respiration
Ventilation
Diffusion
Perfusion
Physiological control
Mechanics of breathing
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Assessment of Ventilation
Easy to assess
Respiratory rate
Ventilatory depth
Ventilatory rhythm
Diffusion and perfusion
Arterial oxygen saturation
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Assessing Respirations
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Measurements include:
Nursing diagnosis
Interventions
Planning
Evaluation
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Age
Stress
Ethnicity
Gender
Daily Variation
Medications
Activity, weight
Smoking
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Hypertension
More common than
hypotension
Thickening of walls
Loss of elasticity
Family history
Risk factors
Hypotension
90 mm Hg
Dilation of arteries
Loss of blood volume
Decrease of blood flow
to vital organs
Orthostatic/postural
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Vital Signs
Blood pressure
Systolic pressure
Diastolic pressure
Pulse pressure
Mean arterial pressure
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Slide 9-29
Equipment
Auscultation
Children
Ultrasonic stethoscope
Palpation
Lower extremity
Electronic blood pressure
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Knowledge check!
Significant elevation in blood pressure
measurements from one day to the next
could be attributed to:
A. A decrease in cuff size
B. An increase in cuff size
C. New onset of pain or anxiety
D. A and C
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Pulse oximeter
Allows indirect measurement of oxygen
saturation
SpO2 is a reliable estimate of SaO2
Measurement is affected if extremity is cold,
edematous or if nail polish is present
(interference with light transmission)
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Slide 9-35
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