What is the difference in vital signs for pediatric patients vs. adult patients?
Peds have HIGHER RR & HR than adults, and LOWER BP than adults
Changes in vital signs can…
be based on environmental temperature, physical exertion, or effects of illness.
Consider a clients condition when assessing vital signs by…
- Determining when, where, how, and by whom vitals will be measured.
- Keep assessment frequency to a minimum (increase assessment if patients condition worsens)
- Nurse is responsible for judging if increased frequency of assessment is necessary.
When taking considerations for vital signs, the nurse should assess client status by…
- clients baseline, time of admission, and routine.
- review of/change in condition
- before, during, and after certain meds and/or blood administration.
- a physician order or in prep for physician exam.
- facility standard/policy
- before, during, and after an invasive procedure.
When will delegating vital sign measurements be acceptable?
- if client is stable
- before delegating, nurse must review V/S data
- a nurse CANNOT delegate apical pulse measurement
What vital sign is interrelated with INCREASED TEMPERATURE?
INCREASED HEART RATE;
INCREASED REPIRATORY RATE;
INCREASED BLOOD PRESSURE
What vital sign is interrelated with INCREASED BLOOD PRESSURE?
INCREASED HEART RATE;
INCREASED RESPIRATORY RATE
Normal range in adults for Pulse rate
60-100 beats per minute
Normal Temperature range in adults
Oral & Tympanic: 37C/96.8F
Rectal: 37.5C/99.5F
Axillary: 36.5C/97.7F
Normal range for Respirations
12-20 breaths per minute
Normal Pulse oximetry
over 95%
normal BP
120/80
Normal pulse pressure
30-50 mm Hg;
Pulse pressure is calculated by subtracting your diastolic blood pressure measurement from your systolic blood pressure measurement.
When compared to adults, which vital signs in infants and children differ?
- Pulse and RR HIGHER
- BP LOWER
- Brachial and apical pulse= best sites
- RR less regular
Priority nursing diagnoses include…
- Risk for imbalanced body temp
- ineffective thermoregulation
- activity intolerance
- anxiety
- decreased cardiac output
- deficient or excess fluid volume
- impaired gas exchange
- acute pain
- ineffective peripheral tissue perfusion
- risk of injury
temperature is the measurement of the difference between…
heat production and heat loss
Which part of the brain regulates the body’s temperature?
hypothalamus
any temperature below 97.6 F and/or higher than 100.6 F is…
an abnormal reading
Any temp measured below 96 or over 104 on a patient who appears normal means the nurse has an…
incorrect reading
Deep tissue (core body) temperature is…
constant
What kind of temperature is dependent on blood flow to the skin?
surface body temperature
Examples of Radiation heat loss (heat transferred b/t 2 objects w/o direct contact) include…
- cool surgical room while client’s skin is exposed
- temp in patient’s room warmer than the skin, body absorbs heat through radiation.
- removing patient’s clothing promotes radiant heat loss.
Examples of conductive (heat transferred from one object to another through direct contact) heat loss includes…
person using a fan to cool down
Heat loss due to evaporation includes…
perspiration
