Licensed Vocational Nursing Program s1

BAKERSFIELD COLLEGE LICENSED VOCATIONAL NURSING PROGRAM

1ST SEMESTER FUNDAMENTALS

SCIENTIFIC BASIS FOR NURSING PRACTICE

CHAPTER 32 - VITAL SIGNS - T,P,R

INTRODUCTION

Vital sign assessment, along with other physiological measurements, helps to provide a data base for a client’s physiological status. It is important for the nurse to understand the relationship between vital signs and the body’s response to changes in levels of wellness in order to initiate appropriate nursing interventions when a client’s health status changes.

OBJECTIVES

Upon completion of this unit, the student will be able to:

A. Theory 1. Define and appropriately use the terms associated with the assessment of vital signs. 2. Explain the principles and mechanisms of thermoregulation. 3. Discuss the rational for a nursing care plan for a client with a fever. 4. Explain the physiology for the normal regulation of pulse and respiration. 5. List some factors that normally cause variations in body temperature, pulse, or respiration. 6. Identify normal vital sign values for adults. 7. Identify normal body temperature in an adult on the Celsius scale.

B. Laboratory 1. Identify the reason for each step that is taken to assess a client’s oral, rectal, and axilary temperature. 2. Review how to properly use a stethoscope. 3. Identify the reason for each step that is taken to assess a client’s pulse and respiration. 4. Review the different types of clinical thermometers that are being used in the settings. 5. Describe at least four client conditions that contraindicate taking an oral temperature. 6. Describe at least three client conditions that contraindicate taking a rectal temperature. 7. Read a clinical thermometer accurately. 8. Review the procedure for assessing body temperature, (a) oral, (b) axilary, (c) rectal. 9. Review the procedure for assessing the radial pulse. 10. Demonstrate how to take an apical-radial pulse. 11. Define pulse deficit. 12. List the 5 arteries commonly used for assessment of pulse. 13. Locate the PMI and demonstrate how to assess the apical pulse. 14. Locate the pulse at all the artery sites listed in your text. 15. Review and demonstrate the procedure for counting a pulse at all the identified sites. 16. State the rationale for assessing a client’s respirations without making the client aware of the procedure. 17. Recognize the early signs of hypoxia. 18. Review the procedure for assessing respirations. 19. Demonstrate proper use of a pulse oximeter.

ASSIGNMENT

A. Read Chapter 32- Potter & Perry pgs. 502- 535 and Review Questions for TPR.

B. Study Guide for Chapter 32 – omit section on blood pressure

 Chapter 32Vital Signs T, P, R

 Guidelines for Measuring Vital Signs  Establish a baseline for future assessments.  Be able to understand and interpret values.  Appropriately delegate measurement.  Communicate findings.  Ensure equipment is in working order.  Accurately document findings.

 Body Temperature Physiology  Body temperature:  Heat produced  Heat lost  Temperature range:  98.6° F to 100.4° F or 36° C to 38° C  Temperature sites:  Oral, rectal, axillary, tympanic membrane, temporal artery, esophageal, pulmonary artery

 Body Temperature Regulation

 Factors Affecting Body Temperature

 Nursing Process and Temperature  Assessment  Diagnosis  Planning  Implementation  Evaluation

 Pulse, Physiology, and Regulation  The indicator of circulatory status  Electrical impulses originate from the sinoatrial (SA) node.  Cardiac output, heart rate, stroke volume  Mechanical, neural, and chemical factors regulate ventricular contraction and stroke volume.

 Assessment of Pulse  Sites  Use of stethoscope  Character of pulse  Nursing process and pulse determination

 Respiration  Ventilation  Diffusion  Perfusion  Physiological control  Mechanics of breathing  Assessment of Ventilation  Easy to assess  Respiratory rate  Ventilatory depth  Ventilatory rhythm  Diffusion and perfusion  Arterial oxygen saturation

 Nursing Process and Respiratory Vital Signs  Measurements include:  Respiratory rate, pattern, depth, SpO2, ventilation, diffusion, perfusion  Nursing diagnosis  Interventions  Planning  Evaluation

 Health Promotion and Vital Signs  Monitor vital signs.  Include age-related factors.  Include environmental and activity factors.