Vital Signs 2 Power Point Flashcards
Vital signs are used to
monitor patient’s condition, identify problems, and ______ to intervention
evaluate response
Guidelines for Measuring Vital Signs
Measuring is your responsibility
Equipment use; ensure it is working properly
Know patient’s usual range and medical Hx
Control environmental factors
Use systematic approach
Collaborate to decide frequency
Used for administering medications
Analyze results, identify significant findings
Instruct patient in vital sign assessment
Early Signs and Symptoms of Hypoxia
Restlessness Headache Visual Disturbances Confusion or change in behavior Tachypnea Tachycardia Hypertension Dyspnea Anxious face
Advanced symptoms of hypoxia
Hypotension
Bradycardia
Metabolic acidosis (production of lactic acid)
Unresponsiveness/Coma
Cyanosis
Chronic hypoxia
Polycythemia Clubbing of fingers and toes Peripheral edema Right-sided heart failure Chronic PO2 less than 55mmHg O2 saturation less than 87% Elevated Po2 (respiratory acidosis)
Hypertension or Hypotension Thickening of walls Loss of elasticity Family history Risk factors
Hypertension
More common than hypotension
Hypertension or Hypotension Systolic <90 mm Hg Dilation of arteries Loss of blood volume Decrease of blood flow to vital organs Orthostatic/postural
hypotension
A pain assessment is a ____ symptom and the frequency ordered in parameters is _____ scale. Reassess, use to measure efficacy of interventions.
subjective
0-10
Age-Related Changes That Affect Thermoregulation
Inefficient vasoconstriction
Decreased cardiac output
Diminished subcutaneous tissue and muscle mass
Decreased peripheral circulation
Delayed and diminished shivering
Diminished ability to acclimatize to heat
Functional Consequences Affecting Thermoregulation
Compromised ability to respond to hot or cold environments
Increased susceptibility to hypothermia and hyperthermia
Lower baseline temperature
Diminished febrile response to infections
Dulled perception of environmental temperatures
Nursing Interventions to Promote Healthy Thermoregulation
Maintaining healthy environmental conditions
Teaching about measures to protect from hypothermia
Teaching about measures to prevent hyperthermia
Instituting comfort measures
Recording Vital Signs
Record values on electronic or paper graphic.
Record in nurses’ notes any accompanying or precipitating symptoms.
Document interventions initiated on the basis of vital sign measurement.
If a vital sign is outside anticipated outcomes, write a variance note to explain, along with the nursing course of action.
In the nurse’s variance note, address possible causes of a fever.
If a vital sign is outside anticipated outcomes, write a ______ to explain, along with the nursing course of action.
variance note
