NR 224 Week 2 Supplemental Assignment; Vital Signs

NR224 EdaptWeek2 2626360884321VitalSigns Introduction to VitalSigns Vitalsigns serve as astarting pointin assessing the overalfunctioning ofthe body andare asnapshotofapointin time that reffects the immediate status ofabaseline ortrends ofthe values overtime. Vitalsigns include the measurementoftemperature, pulse, respirations, bloodpressure, andO2 saturation. There are normaly five vitalsigns thatare measured: temperature, pulse, respirations, bloodpressure, andpain. Oxygen saturation is also frequently included. The nurse mustbe able to do the fo lowing: Measure vitalsigns correctly. Use the equipmentneededforvitalsign measurements correctly. Understandwhatthe vitalsigns te lyou aboutthe client. Be organizedanduse asystematic approach when measuring vitalsigns. Delegate vitalsign measurements to otherhealthcare providers. Analyze andinterprettrends overtime. Respondto changes in vitalsigns quickly andappropriately. Communicate anddocumentfindings accurately. Vitalsigns alone are notenough to evaluate body functioning ordetermine problem-solving steps. Vitalsigns are one setofclues usedinco laboration with otherphysiologicalmeasurements andassessmentfindings forthe basis ofproblem solving and indication ofbasic body functioning. AbnormalVitalSigns The client’s baseline range ofvitalsigns, which may ormay nottypicaly run inthe normalrange, incomparison to currentfindings. The client’s health history, therapies, andprescribedandover-the-countermedications as these may predictably affect one ormore vitalsigns; the impactofvitalsign measurements on medication administration, andvice versa. Some medications are only given when aparticularvitalsign is within aparticularrange. Andsome medications are contraindicatedwhen certain vitalsigns are withinacertain range. Environmentalfactors may falsely affectvitalsigns (such as the effectofawarm, humidroom on the client's temperature). Ensure thatthe vitalsign equipmentis working correctly priorto measurementinorderto provide accurate findings, andselectthe correctequipmentforthe client’s condition andcharacteristics (such as age andsize). An acute episode ofanxiety can cause the physiologic response ofan increasedpulse rate. A lowheartrate means the body is receiving less blood/perfusion, which can cause decreasedcardiac output. Ineffective, rapidrespirations resultin adecrease inserum oxygen andimpairedgas exchange. A clientwho has hadasurgicalprocedure is likely to be in acute pain, which impacts vitalsign results. A decreasedpulse oximetry indicates insufficientoxygenin the bloodand, therefore, ineffective peripheraltissue perfusion. VitalSigns With Pediatric Clients The client’s age, gender, activity, medication, andhealth status inffuence theirvitalsigns. Comparedwith adults, ininfants andchildren: pulse andrespirations run higher bloodpressure runs lower brachialandapicalpulse are the bestsites forassessing pulse respirations tendto be less regularin infants Vitalsigns inolderadults are inffuencedby aging. Delegating VitalSigns Vitalsignmeasurements are the nurse’s responsibility. However, when appropriate, nurses may delegate them to unlicensed nursing assistantpersonnelafterthe nurse has determinedthatthe client’s condition is stable. The nurse mustreviewthe vital sign dataanduse nursing knowledge to fo lowthe nursing process basedon the dataobtained. The skilofapicalpulse measurementcannotbe delegated. The nurse completes the vitalsigns upon admission to establish baseline vitalsigns andto assess the client’s stability before delegating. Determining ClientHealth by Monitoring VitalSigns Recalfrom previous knowledge that: Vitalsigns andotherphysiologicalmeasurements oftenprovide the basis forproblem solving. Carefultechnique ensures accurate findings. Temperature, pulse, respirations, bloodpressure, andoxygensaturation are usualy assessedatthe same time atset intervals. The ability to obtain accurate measurements ofvitalsigns is criticalbecause vitalsigns are an indication ofbasic body functioning. Itis appropriate to begin the physicalassessmentby obtaining this data. The skils requiredto measure vitalsigns are simple, butthe simplicity shouldneverreduce the criticalvalue ofthe task. Changes in vitalsigns signalachange in physiologicalfunction andcan change basedon many factors, such as: environmentaltemperature physicalexertion effects ofilness Assessmentofvitalsigns provides: cues foridentifying nursing diagnoses, implementing plannedinterventions, andevaluating outcomes monitoring ofaclient’s condition, identification ofproblems, andevaluation ofintervention responses datausedto determine aclient’s health status andneedformedicalornursing