Chapter 4 - VITAL SIGNS for Nursing 101
Discuss the importance of accurately assessessing vital signs.
1) They indicate basic body functioning
2) It is
... [Show More] appropriate to begin physical assessment by obtaining these data
3) Provide basis for problem solving
4) Enables identification of nursing diagnoses to implement planned interventions and to evaluate success when vital signs have returned to normal values.
Identify guidelines for vital signs measurement
1) Measure vital signs correctly
2) Understand and interpret the values
3) Communicate findings appropriately
4) Begin interventions as needed
Accurately assess Oral temperature assessment
- most accessible site; comfortable for patient; does not need any position changes
- do not use for patients who could be injured by thermometer, who are unable to hold thermometer properly, or who might bite down on thermometer.
- do not use for infants or small children
- do not use for disoriented or unconscious patients; patient who just had oral surgery; patients with trauma to face or mouth
- do not use in patients who breathe only with mouth open
- do not use in patients with history of convulsions or patients experiencing a chill
Accurately assess Rectal temperature assessment
- argued to be more reliable when oral temperature cannot be obtained
- use sensitivity because it is embarrassing
- do not use in patients after rectal surgery ; patients who have a rectal disorder such as tumors or hemorrhoids; or patients who cannot be positioned for proper thermometer placement such as those in traction
- there is risk of body fluid exposure, and lubrication is required
Accurately assess Axillary temperature assessment
- safe method because it is noninvasive
- least accurate
Accurately assess Tympanic Temperature Assessment
- noninvasive, accurate, safe
- provides core reading; lessens need to handle newborns, which aids in preventing heat loss
- excessive cerumen has the possibility to interfere with accurate reading;
- continuous measurement of temperature is not possible
- new disposable probe cover necessary for each patient.
Describe the procedure for determining the respiratory rate
1) Prepare hand hygiene, introduce self to patient, identify the patient (takes away patient anxiety)
2) Explain procedure (seeks cooperation and assistance from patient [Show Less]