NURS301 Vitals Flashcards
Nurse responsibilities and measuring Vital Signs
- Measure, interpret significance of vitals, and make decisions about care
- Know normal ranges of vitals
- Know pt history and other therapies that may affect vitals
- Know pt baseline for comparison
Baseline
The initial set of vitals
Vital Signs include
T =Temperature
P =Pulse (over 60 seconds, HR)
RR =Respirations (over 60 seconds) BPM
BP =Blood Pressure
When do you measure vitals every 15 mins
Upon admission post cardiac catheterization beginning blood transfusion after surgery beginning chemo neurovascualr checks/MS changes
When do you measure vitals every 30 minutes
after first set of Cardiac Cath VS
If a change of status occurs
When do you measure vitals every hour?
All ICU patients
All Critical Care patients
When do you measure vitals every 2 hours?
Some cardiac medication monitoring
When do you measure vitals every 4 hours?
Routine VS assessment
Core Temperature
Controlled by hypothalamus
heat generated by organs and tissues inside the body
Skin Temperature
quick rise and fall of heat in response to environmental conditions
Normal Core Temperature
96.2-100.9 degrees F
Factors affecting temperature
age, exercise, hormones, sleep cycles, stress, smoking, eating, certain medications
How do Nurses Measure Temperature?
Glass+Mercury=GOLD STANDARD
Electronic Digital=most used
infrared tympanic
forehead strip
Axillary temp (AX) is how different than Oral Temp (PO) by how much?
AX is 1 degree below PO
Rectal Temp (PR) is how different than Oral Temp (PO)?
PR is 1 degree higher than PO
